Our study aimed at determining the proportion of women who received PAC among abortion clients and possible factors that may associate with PAC utilization in Guangzhou, China. The magnitude of PAC counseling before they leave the health care facilities was 42.1% which is lower than a European framework project done in three cities of China[9]. The prevalence rate was even lower than the studies conducted in Southern Ethiopia (61.5%)[10], Pakistan (72.9%)[11] and Brazil (97.4%)[12]. This variation of PAC utilization could be due to the Chinese socio-cultural context, as well as the huge migration from rural areas to cities following rapid economic development. FP services, an integral component of PAC, are provided through the national network of FP clinics, which are almost independent of health care system. Since 2010, a very small proportion of public hospitals were included in a project to pilot provision of post-abortion FP services, generally known as ‘the PAC project’[7]. However, PAC provision has not yet been integrated into Chinese health system. The majority of women seeking abortion therefore were often unaware of the benefits of FP services, thereby deeming it as an inappropriate occasion for accepting PAC counseling. Another possible reason may be related to the limited access for migrant women. Due to non-transferrable health insurance and different welfare policies, service stakeholders perceived difficulties for migrants to access FP services. The other explanations could be ascribed to respondents’ level of awareness, religious beliefs, misconceptions about contraceptive and FP services and low counseling skills among different study settings.
Unmarried women were two times more likely to utilize PAC as compared to married women. This finding was consistent with a study in Ethiopia that married women were less prone to adopt PAC[13]. However, another study found that married women were more likely to use PAC than unmarried women[10]. It indicated that unmarried women had good awareness of reproduction and contraception. In Guangzhou, governments at all levels have taken initiatives to educate young, unmarried people on reproductive health knowledge including explicit attention to discussing ambivalent attitudes towards their sexuality and developing youth-friendly stance in counseling; efforts to overcome barriers with large migrant population. On the other hand, school’s roles also played an important part. However, seeking PAC suggests contraceptive methods have not been appropriately used to avoid unintended pregnancies. Training to develop critical thinking on cultural and ethical dimensions attached to sexuality among unmarried people may be effective here.
The odds of using PAC were higher among women who had local household registration than those without. Less than 20% of migrant women received PAC, suggesting underutilization of free FP counseling. This could be due to the lack of access to local health insurance and maternal insurance. As a result, a proportion of migrants had used private clinics which are often poorly regulated and unlicensed and tended to overstate the advantage of abortion without providing PAC. Further study is needed to understand the motivation of PAC use among migrants.
In this study, knowing fertility could return within 10-14 days was found to be significantly associated with PAC utilization. This finding was in line with studies conducted in Ethiopia documents at which FP utilization is associated with decreased repeat IA[13]. It implied that post-abortion period is the right time to introduce reproductive and contraceptive advice because women are more ready to receive messages. However, due to high contraceptive failure, popular use of contraception has not helped to reduce IA. This could be due to inadequate counseling skills of providers. In China, the rigid workload of PAC providers may prevent them from spending prolonged durations on elaborating details of contraception with each abortion woman. On the other hand, the training on FP was not sufficient, and thus their knowledge related to PAC was much lower than their self-evaluation. Efforts should be made to improve counseling skills, which would increase the effective practice of modern contraceptives.
Our survey suggested that women whose husbands or partners were the main deciders on PAC use were less likely to receive PAC as compared to the participants who decide themselves. The same studies from Egypt and Nigeria concluded that women who failed to receive PAC are because of disapprovals from their husbands[14-15]. This may be explained by their being not involved in PAC. Men are usually not allowed to access the department of gynecology in China. In some hospitals, male partners were eventually allowed into counseling rooms, thus couples could get advices together, while in other hospitals, male partners were just given some materials regarding reproductive knowledge. A number of studies suggest the importance of male involvement in women’s use of contraceptives[16-17]. Future research could explore whether targeting and including male partners in the provision of PAC could have impact on improving PAC utilization among abortion clients.
A few policy implications can be drawn from this study to improve the provision of PAC. Firstly, low utilization rate of PAC in public hospitals warrants increased attention from public health authorities to either develop PAC guidelines or new national policies incorporating PAC into health care institutions. Detailed policy provisions are needed to ensure the systematic implementation of PAC. Secondly, PAC should improve it’s coverage for migrants. This should include enhanced public education programs for young and unmarried migrants, improved access to free guidance and counseling. Thirdly, it’s essential for providers to gain additional knowledge about PAC and develop youth and migrant friendly attitudes. Including male partners in the provision of PAC is also needed.
There are several limitations in this study. Firstly, given the sensitivity of the topic, women might feel shy to reveal private information. This may lead some women to report in a more acceptable way due to the stigma associated with it. Secondly, the causal relationship between variables and PAC utilization can not be drawn due to the cross-sectional nature of our study, though the results could provide useful implications for the improvement of PAC. Thirdly, the generalization of the findings would be limited as the recent integration of FP into health care institutions could provide great opportunity for close observation of other districts of Guangzhou.