This study was aimed to determine the proportion of women who received PAC among abortion patients and the possible factors that may be associated with PAC utilization in Guangzhou, China. The degree of PAC counseling before they leave the health care facilities was found 42.1% which seems to be lower than a previous European framework project done in three cities of China[9]. The prevalence rate was even lower than the studies conducted in the middle region hospitals (71.8%), wet region hospitals (58.4%) and east region hospitals (43.1%) in China[10], 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 the health care system. Since 2010, a very small proportion of public hospitals were included in a project to pilot the provision of post-abortion FP services, generally known as ‘the PAC project’[7]. However, PAC provision has not yet been integrated into the Chinese health system. The majority of women seeking an abortion, therefore, were often unaware of the benefits of FP services, thereby deeming it as an inappropriate occasion for accepting PAC counseling. Moreover, some service providers have perceived difficulties for migrant women to access PAC services due to non-transferrable health insurance and different welfare policies between provinces. Additionally, PAC providers recognized their inadequate knowledge on reproductive health and poor counseling skill may limit it’s practice.
In this study, unmarried women were seem 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[11]. However, a cross-sectional facility data from 30 provinces of China found only 31% of PAC service users were unmarried[12]. Considering the fact, it could be concluded that unmarried women had a good awareness of reproduction and contraception. Moreover, in Guangzhou, the government at all levels has taken initiatives to educate young and unmarried people regarding reproductive health knowledge including explicit attention to discussing ambivalent attitudes towards their sexuality and developing youth-friendly stance in counseling. The efforts have also been made to overcome certain barriers with large migrant populations. On the other hand, schools have also played an important part in this field. Additionally, the seek for PAC services suggests contraceptive methods have not been appropriately used to avoid unintended pregnancies. Developing critical thinking on cultural and ethical dimensions attached to adolescent sexuality may be effective here.
The odds ratio of using PAC was higher among those women who had local household registration as compared with migrants. Less than 20% of migrant women received PAC, suggesting under-utilization 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. Henceforth, additional studies are required 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 comparable with previous studies conducted in Ethiopia, suggesting that FP utilization is associated with a decrease in repeated IA[11]. It implied that post-abortion period is the appropriate time to provide reproductive health knowledge. However, the rigid workload of PAC providers in China may prevent them from spending prolonged durations on elaborating details of contraception with each abortion woman. Moreover, the training on PAC providers was not sufficient, and thus their knowledge related to PAC was much lower than their self-evaluation. Therefore, efforts should be made to improve counseling skills, which would increase the practice of PAC effectively.
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. A similar study from three cities in China revealed that a couple’s joint decision on the use of PAC services appeared to show better compliance of FP methods[13]. This may be explained by their being 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 counseling together, while in most of the hospitals, male partners were just given some materials regarding reproductive knowledge. Our study supported other findings that women perceived men’s participation in contraception as a support for them[14-15]. 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 the health care system. 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, the self-reported questionnaires administered to the women covered sensitive issues. This could lead some women to respond in a way they believed was more acceptable. Secondly, the causal relationship between variables and PAC utilization can not be drawn due to the cross-sectional nature of our study. Thirdly, the findings might not be representative of abortion patients in China, since participants were recruited from Guangzhou, China.