A qualitative exploration of perceptions and experiences of contraceptive use, abortion and post-abortion family planning services (PAFP) in three provinces in China

This study was carried out in three provinces of China in 2013. These three provinces represented different areas of socio-economic development within the country: Zhejiang, a highly developed province located in the eastern coastal area, had a GDP per capita of 68,593Yuan (about 11,075 US$) in 2013. Hubei, with a medium level of development, located in central area of China had a GDP per capita of 42,686 Yuan (about 6892 US$) in 2013. Yunnan, a relatively poor and undeveloped province, had a GDP per capita of 25,157 Yuan (about 4062 US$) in 2013 and 33% of its population are ethnic minority groups. Within each province, one city and one rural county were selected, with representation across the sample of: relatively rich and poor cities/counties; ethnic minorities (one county); rural-to-urban migrants (one city). In each city, three facilities were selected for participant recruitment: one level-2 hospital (medium sized hospital) and two level-3 hospitals (one general or comprehensive hospital at city level and one maternal and child health hospital at city level). In each rural county, two facilities were selected: one level-1 hospital (township hospital), and one level-2 hospital (county level). In Zhejiang province, in the rural setting, one Maternal and Child Health institute and one level-2 hospital were selected as these two institutions provide the majority of abortion services in the area. We recruited service users and their partners for in-depth interviews via facility records.

Twenty-nine in-depth interviews (IDIs) were undertaken with women who had experienced abortion between 1 and 6 months prior to the interview. A purposive sample of women was selected at different levels of hospitals by using the abortion register to include maximum variation amongst interviewees. Factors taken into consideration were age, marital status, and residency status (migrant or permanent urban resident (see Table 1 for participant characteristics). Interviews sought to explore, from the women’s perspectives, the circumstances of the abortion, experiences of care received, future reproductive and contraceptive plans and influences on these, and perceptions of the acceptability of planned PAFP services. Thirteen in-depth interviews were also undertaken with male partners of a sub-sample of these women. These men were invited for interview following an informed consent process with their partners who gave permission for the research team to request an interview. It was important to include these men, since literature suggests they may be influential on contraceptive uptake [22] (see Table 2 for breakdown of numbers).

To capture broader views on abortion, six focus group discussions (FGDs) were carried out with community members from different social groups: including unmarried and married women and men, urban residents and rural-to-urban migrants (see Table 3 for breakdown of numbers). These FGDs were used to explore the social context for FP and abortion, including: acceptability of pre-marital sex and pregnancy; perceptions, knowledge and attitudes towards FP and abortion; perceptions of abortion providers; desired sources and media for FP information; and perceptions of appropriateness. See Table 4 for a summary of data collection methods.

Semi-structured topic guides were used in interviews and FGDs. Three research teams were formed and each team consisted of one senior, one middle-level and one junior researcher. Topic guides were developed and discussed collaboratively among team members before being piloted and implemented. All interviews were tape-recorded with the consent of interviewees. All IDIs and FGDs were conducted in a private room to avoid interruption from outside. Each IDI lasted for approximately 30 to 40 min and Each FGD lasted for about 1 h. Each team checked the contents of respective interviews. To ensure the quality of the interviews, interviewers repeated the summary of interview to interviewees to check the answers after the interview was done. After the interview, a stenographer transcribed the whole interview verbatim based on recordings. Another team member double checked the text of each interview.

All the recorded files were managed systematically by assigning a unique identification number to each interview so as to ensure the anonymity of the respondent. Data were analysed using a framework approach [23] as follows. Transcripts were read and re-read separately by the investigators to identify emerging themes. Data were coded according to predetermined analytical categories and organized into themes and subthemes. Summary matrices were developed for every category of respondents in each province by comparing, contrasting and synthesizing information within and across cases. The thematic framework was used to classify and organize data according to key themes and concepts categories.

Ethical approval was obtained from the Liverpool School of Tropical Medicine Research Ethics Committee, and the Institutional Review Boards of the School of Public Health, Fudan University, National Institute for Research in Family Planning, and the Chongqing Medicine University Ethics Committee, China. Oral, informed consent was obtained from all participants of IDIs and FGDs. All IDIs and FGDs were recorded with respondents’ consent.

Concerns about potential health risks associated with the use of specific contraceptives emerged as an important influence on contraceptive choices. Some participants drew on their own experiences (mainly negative), and others expressed perceptions based on the experiences of people they knew. Many, however, referred to common-sense notions, expressed as ‘just what I think’, or the social diffusion of knowledge (‘I have heard’). OCs in particular were commonly described as ‘harmful to health’, which was often explicitly related to their hormonal nature. Common specific harms perceived were irregular menstruation or bleeding, and future infertility or delayed fertility after discontinuing use. Less commonly mentioned fears included gaining weight and experiencing ‘stomach problems’. Few in either FGDs or interviews spoke from personal experience about OCs, and generally stated this as ‘common-sense’. Only one unmarried woman said she had heard OCs were not bad for health from her friends.

(IDI with woman service user, Zhejiang, high GDP context).

(FGD with married migrant women, Zhejiang, high GDP context).

Concerns about IUDs centred on a perception of them as invasive to the body; they were referred to by more than one participant as ‘foreign matter’ and several women expressed the perception that the IUD might be ‘expelled’ from the body. These fears were prompted by both the experiences of others within their social network, and ‘common sense’ norms.

A number of women, both in individual interviews and FGDs, reported experiencing problems with the use of IUDs, including physical discomfort, abdominal pain, and menstrual/bleeding problems, which sometimes led to them having the device removed. Two women had experienced a pregnancy with the IUD in situ, one of which was ectopic. One woman had previously experienced cervicitis and therefore felt an IUD was not suitable for her.

Less clear norms emerged regarding condoms. Several married women in IDIs described a general feeling of condoms being ‘not good’, ‘not good for the womb’ or ‘not clean’ especially if used repeatedly or in the long term, but were not able to articulate any reasons for this. One married woman described condoms as ‘not safe’ (i.e. not effective). However, two women expressed positive feelings about condoms, saying that they were good and were ‘hygienic’.

(IDI with married woman, service user Hubei, medium GDP context).

The above quote illustrates how participants narrated weighing up the relative potential for harm from different methods, as well as the commonly held perception of oral contraceptives as especially harmful.

Some participants also expressed an awareness of potential negative impacts of using Emergency Contraceptives, which were considered to be a contraceptive method by some female respondents, particularly unmarried women:

(IDI with unmarried woman, service user, Yunnan, low GDP context).

Our results provide important insights into the perceptions and experiences of women undergoing unintended pregnancy and subsequent abortion, their contraceptive decision-making, and missed opportunities in the delivery of post abortion family planning (PAFP) to appropriately address their FP needs. Interviews revealed participants’ perceptions that changing social norms of pre-marital sexual activity, are linked to increased numbers of abortions. Available evidence suggests that young, unmarried and migrant women are disproportionately represented among women seeking abortions [8, 18]. Our study elucidated some of the social mechanisms underpinning this evidence in the Chinese context. According to our study, social norms and perceptions about suitability and safety, as well as gendered norms about decision-making on contraceptive methods contribute to greater challenges for these groups of women. For example, in line with a number of studies internationally, long-acting methods may be perceived as appropriate only after child-bearing (within marriage in the Chinese context), and young women often rely on their partner for information about contraceptives and/or willingness to purchase and use condoms. Participants perceived that stigma was a barrier to young, unmarried women’s and men’s ability to negotiate FP information and services [24]. The need to develop more inclusive, ‘youth-friendly’ services to address stigma, among other barriers has been well established internationally [25, 26]. In China, research has shown that work also needs to be done with parents and other ‘gatekeepers’ to address ambivalent and/or negative attitudes towards improving sexual and reproductive health education among young people [27, 28].

International literature suggests that concerns about side effects and health risks are a common reason for non-use of contraceptive methods by sexually active couples who do not intend a pregnancy: analyses of Demographic and Health Surveys (DHS) in 51 and 35 low and middle income countries respectively found that this reason accounted for non-use for between 23 and 35% of married women [22] and 37.3% of sexually active women aged 15–49 [29]. Similarly a systematic review of the evidence from ‘developed’ countries regarding desirable and undesirable qualities of long-acting reversible contraception (LARC) identified concern about side effects as a common perceived negative quality of LARC [30], whilst qualitative research identified misconceptions about IUDs and other LARC as a factor in low utilisation among young women in Australia [31] Our data from women of varying ages and backgrounds suggest that relatively high levels of anxiety about contraceptive methods are a contributing factor in China, including widespread concerns about side-effects (particularly from oral contraceptives, but also IUDs), effects on future fertility, and reliability. The context for this is very low availability of person-centred counselling on contraceptive methods that explains the relative advantages and disadvantages of a range of modern methods in the specific situation of the individual client. For example, the general orientation of FP counselling towards encouraging IUD use can mean that those women who have experienced side effects or difficulties with IUDs are not enabled to identify an alternative method that meets their needs through FP counselling. Moreover, clients who have experienced the failure of their existing method (for example pregnancies with IUD in situ, or, more often, related to inconsistent use of a method) are generally not facilitated to reflect on this and the implications for future contraceptive use through existing counselling. For young unmarried people, reliable and easily accessible sources of information and options for modern methods are even more limited. The combination of limited information and choices with anxieties about side effects also underlies the widespread use of unreliable methods, such as the ‘rhythm’ method, and the regular use of emergency contraceptives. Our data also revealed that commercialisation of reproductive technologies influenced participants’ perceptions of product quality, potentially undermining local and public provision of FP services such as distribution of free condoms.

Our findings revealed the significant influence of gendered power relations on contraceptive use and non-use. Limited evidence from China suggests that while attitudes have become more accepting of sexual permissiveness for unmarried people, women remain at a disadvantage in terms of social norms guiding such behaviour [32, 33]. For example, a study exploring Beijing women’s experience of coerced sex and virginity loss highlighted how the cultural shift in attitudes towards sex may leave some women in a very precarious position, given the pressure they feel from society to act as ‘traditional’ women and the pressure from their partners and boyfriends to be sexually available. A number of the women in this study were forced to have abortions following coercive sexual encounters [33]. Our findings show how unequal gender relations impact not only on the sexual encounter itself, but on whether and what type of contraception is used. While there was general consensus in our data that women and men should make joint decisions about contraceptive use, there were a number of examples illustrating women’s relative lack of power to use a method they preferred, or to use contraception at all; for example where women reported that their partners sometimes refused to use condoms. Evidence from other contexts demonstrates how gendered power dynamics impact on contraceptive use. For example, recent data collected in Sub-Saharan Africa revealed covert use of contraceptive methods due to male resistance, perceived or otherwise, to contraceptive use [34]. Analyses of DHS data from 35 and 51 low and middle income countries respectively found that partner opposition was given as a reason for non-use of contraception by 22.4% of sexually active women who did not desire a pregnancy [29] and between 11 and 27% of married women who did not desire a pregnancy [22]. Increasingly, interventions aim to engage men in reproductive decision-making based on evidence that joint decision-making is more likely to promote contraceptive use among couples [35, 36]. Our study suggests that it is important to involve male partners in PAFP in China and to facilitate reflection on communication about contraception within post-abortion counselling.

Finally, related to the existing provision of counselling, our study illustrates a range of limitations for effective communication between service users and service providers about their FP experiences and future options. While studies have shown that low levels of SRH knowledge affects vulnerable groups in particular [19‐21], our findings demonstrate how communication barriers with providers related to FP knowledge and decision-making affect women of all ages and backgrounds. Many participants received some information regarding contraceptive methods, and some reported being able to use this information to adopt more effective contraceptive behaviour. However, only one woman explicitly described having experienced a discussion that she perceived as increasing her general knowledge about contraception. The lack of in-depth person-centred counselling also meant that patients with facing medical and/or social challenges to using a method they found acceptable did not receive support in considering how to deal with these challenges. Women who had experienced complications with more ‘accepted’ types of contraception, such as IUD, were placed in a particularly difficult position, with little opportunity to discuss their specific needs. Furthermore, even where participants reported being able to apply the information they received, they rarely described receiving in depth counselling about these decisions, for example, to discuss ways in which they could improve their correct and consistent use of condoms. WHO guidelines emphasise the importance of informed decision-making in the provision of contraceptive information, advice and services that respect human rights. Among other aspects, health workers should provide non-directive and comprehensive counselling that allows clients to make autonomous decisions about their contraceptive use, without coercion or misinformation [37]. Despite the existence of such guidelines, research on post-abortion contraceptive services demonstrates the challenges of conveying information about contraceptive methods in a sensitive manner at a time that is already difficult for women (and their partners). A study in the UK found that some health workers feel they must guide women towards a particular ‘choice’ of contraceptive method [38] while a study in Nepal found that health workers made judgments about the suitability of certain methods for certain groups of women, therefore biasing clients’ ability to make informed and autonomous decisions [39]. Addressing such challenges in China will require a shift in attitudes and skills of providers as well as the allocation of resources to enable them to spend sufficient time with clients [40].