Abortion seems popular among young, unmarried women.

Abortion numbers were perceived as high by all participants, who thought this was linked to changes in socio-cultural norms. In particular, an increase in abortions among young, unmarried women was seen as a major reason for high numbers of abortions. This was attributed by the majority of participants across all three provinces, in rural and urban areas, to the increasing acceptability of premarital sex as part of changing social attitudes:

ZJ People are very casual towards premarital sex. It is very common today and does not attract people’s attention. In particular, parents today are not as strict as our parents in old days. Premarital sex is more acceptable today than before. This is certainly a sign of social development.

(IDI with Policy maker, HB province)

Participants, particularly in YN and ZJ province, saw pre-marital sex as leading to abortion due to young, unmarried people being less likely to use contraception. Lack of understanding or awareness of contraception was one of the main perceived reasons for this:

The younger the age is, the less likely they will protect themselves, especially for students or those under 20—situations get a little better for those above 25.

(IDI with manager, YN province)

Most couples use emergency contraceptives because they fear being pregnant… Most of them [young unmarried women seeking induced-abortion] did not use any contraception method. They always think they would not get pregnant.

(FGD with FP service providers, ZJ province)

Some participants also perceived young people to have ‘casual’ attitudes towards abortion, asserting that young people use abortion as a contraceptive method. Some health managers in HB and YN felt that the rise in abortion rates was not acceptable and a number of service providers from all provinces perceived an increase in ‘misleading propaganda’, for example in relation to advertisements for abortion under anaesthetization:

Many private hospitals, TV programs and newspapers over-advertise ‘painless abortion’ which misleads many young people. Young people think that it only takes 3 minutes and it’s simple without any pain. They regard it as a “kind” of contraception.

(IDI with health manager, HB province)

So easy! All that you need to do is a short sleep!

(IDI with service provider, YN Province)

Furthermore, participants across all provinces perceived that abortions were common among rural-to-urban migrants, the majority of whom are relatively young, and unmarried. Low educational level was also an important perceived reason for lack of knowledge on contraception.

Unmarried people, especially the young people, are the main abortion users. Among those unmarried people there are a large number of internal migrants.

(FGD with health service providers, ZJ Province)

Gaps in contraceptive information and provision [for marginalised groups].

The majority of participants across all three provinces perceived family planning services as widely accessible. Services described included the availability of a range of contraceptive methods at ‘family planning stations’ and hospitals, including IUD insertion and removal, condoms, contraceptive pills, and male and female sterilization. Other types of contraception were sometimes reported as being available at family planning stations (such as Norplant) or at tertiary hospitals (such as contraceptive foam). The majority of service stakeholders across all three provinces reported that these services were available free of cost or reimbursable through health insurance to married couples, but that services were limited for migrants, young, unmarried people and ethnic minorities.

Most participants in all provinces acknowledged that the majority of family planning services are neither targeted at, nor easily accessible to unmarried people. Oral contraceptives and/or condoms were said by some to be available without charge for unmarried people at health facilities, and condoms were reported to be distributed for free to migrant workers by some participants (e.g. in HB), but the availability varied within and between provinces. Furthermore, payment is required for all other services.

For married people, they mainly access contraception through hospital and pharmacy. I’m not quite familiar with unmarried people. I think it will be more difficult considering the tradition and psychological issues……For the migrant population, it will be more difficult compared with local residents. I think they don’t know where to get contraception.

(IDI with health manager, HB Province)

Some service stakeholders, across all three provinces, emphasized the lack of effective contraceptive education provided to young people either from their families or through their schools. Participants perceived that family planning education in middle schools was discouraged by the authorities:

When we communicate with the young junior middle school students, we find that they are completely confused about knowledge of contraception and their parents can’t find an appropriate way to communicate with them. … No media introduces correct methods of contraception to the public. Free contraceptive pills or condoms are mostly provided for married people by Family Planning institutes. In fact, it is very important to provide Family Planning services for the unmarried people, because there are a lot of complications of abortion, which are likely to affect their fertility in their future life.

(FGD with health service providers, ZJ Province)

In HB and YN province some service stakeholders mentioned that married women are usually targeted for services, and some identified that this leads to a problematic lack of focus on men’s responsibilities:

Most male partners think contraception is women’s responsibility. It’s not their problem.

(FGD with health service providers, HB Province)

Actually it is more important to carry out education for men, since in many cases, [unintended pregnancy] results from men’s unwillingness to use condoms.

(IDI with health manager, YN Province)

In YN Province, some participants perceived difficulties experienced by ethnic minorities in accessing services related to communication with providers, especially for older people who are less likely to speak standard Mandarin.

It's difficult to communicate with ethnic minorities. Young people are OK—they have basically completed secondary education—yet those above 40 are less likely to speak mandarin. There are 13 ethnic minorities YNhere, and they speak different dialects.

(IDI with manager, YN province)

Distance to family planning stations for remote rural populations was also seen as a physical barrier to accessing services. A minority of policy makers also mentioned a lack of FP services for HIV positive women and lack of choice of contraceptive methods for service users.

Extent of PAFP provision is varied and limited.

Participant views on the current extent of PAFP provision varied between provinces. For example service stakeholders from HB perceived that PAFP services exist fairly widely with most facilities providing some form of family planning information as part of abortion services. In ZJ, FP service providers from an urban tertiary hospital reported they have been trained for PAFP and perceived that they are providing the service well. However, participants reported that PAFP is not available in urban secondary hospitals. FP service providers in rural ZJ regarded themselves as providing PAFP services; however, they were not able to describe a standardized procedure for PAFP service provision. No participant from YN reported PAFP provision in rural areas.

Our hospitals mainly focus on medical services. Doctors do not provide much health education and consulting in the hospitals. After surgery, we mainly inform patient about the medical issues, [and say] little about contraception.

(IDI with manager, ZJ Province)

The majority of participants in YN and ZJ and a minority in HB perceived current PAFP services provided as limited. These perceived limitations were due to lack of detailed national guidelines for PAFP, lack of motivation among FP service providers, lack of financial and human resources, and limited time commitment for following up of service users. These issues are described more detail below.

Positive perceptions of PAFP in principle.

In HB and tertiary hospitals of urban ZJ, almost all participants among policy makers, managers and service providers mentioned that there are currently positive attitudes among doctors towards PAFP. These were framed in terms of both willingness and a sense of duty. Support was also perceived from hospitals, some of which are already engaged in providing some of form of post abortion care [PAC].

A number of these service stakeholders also perceived that the potential positive impacts would include social benefits, such as a reduction in numbers of abortions and an increase in women’s awareness of how to protect themselves. In HB province, a range of potential institutional benefits were perceived by policy makers, managers and service providers including improvement of technical skills, improvement of services, and enhanced safety of services through standardization of PAFP. Some HB facility managers mentioned that these benefits could potentially enhance hospitals’ reputations, which could in turn attract greater number of patients and therefore lead to increased income at those hospitals.

In 2011, we started systematic and standard PAFP. We allocated a special consultation room for PAFP. Before we also provided a similar service but at that time there was no specific term like ‘PAFP’… The core idea of PAFP is care after abortion that does not simply focus on abortion, but emphasizes contraceptive use after the abortion to prevent repeated induced abortion.

(FGD with service providers, HB Province)

Providing PAFP still faces challenging.

However, some service providers in HB and ZJ Provinces discussed their experiences of the challenges of providing PAFP, reporting that some clients did not ‘comply’ with advice given; clients were characterized as lacking in knowledge and understanding. Unmarried women were seen as particularly difficult to contact for follow-up counseling:

We feel it is hard to reach the target of [successfully following up] 80% [of women after abortion]. Lots of women give a false name and a false telephone number to us. They do not want their boyfriend to know [about the abortion] or it was due to an extra-marital affair… however, we are still carrying out follow-up, although we are sometimes blamed by the clients.

(IDI with service providers, ZJ Province)

In addition, the institutional and cultural confusion about how to ‘manage’ sexually active young people was expressed by most participants of three provinces in discussing the challenges of carrying out PAFP. Participants expressed unease about discussing contraceptives with young people and many did not view this as primarily the responsibility of abortion-service providers, emphasizing that more contraceptive education was required at schools.

If it is a married woman of childbearing age, which means she has a family and insurance, then you can implement PAFP according to the requirements. She should be provided with instruction, I agree, and the effect [of information on conceptive use] will be better. But if it is a student standing before you, how you are supposed to provide instruction? Are you going to give her a scolding or look down upon her? What kind of method is good for her? How to change her behavior and improve her health? We have no idea at present!

(IDI with policy maker, YN province)

It is not only our responsibility [to provide reproductive health education to young people]… Education should be provided before sexual behavior happens… School should give reproductive health education to students in junior middle school or even earlier.

(FGD with service providers, ZJ Province)

The need for a policy support.

Many policy makers and service providers in all three provinces emphasized the need for policy support. A common perception amongst service stakeholders was that policy support for PAFP services would be needed in the form of regulation and guidelines mandating their provision. Both service providers and policy makers expressed the need to include PAFP service delivery in the indices used by the Health Bureau to assess facility performance.

We will assess the work plan and the feasibility for relevant hospitals. I think if possible we can add content of PAFP services to their work plans, and evaluate at the end of every year.

(IDI with policy maker, HB province)

There must be a policy to include PAFP services as part of assessment content. Only doing this can PAFP services become routine work.

(FGD with service providers, ZJ Province)

[If there is] no policy, [then there are] no guidelines and no assessment. The hospitals don’t have motivation as well as pressure to provide PAFP.

(IDI with policy maker, HB province)

A number of service stakeholders also perceived the need for more detailed clinical guidelines and standards and a clear regulation structure to accompany policy, to address concerns about assuring the quality of services.

Policy makers and service providers from all three provinces referred to the merging of the Ministry of Health and the Family Planning Commission (MHFPC) as an important opportunity for developing PAFP services. It was suggested that these previously separate institutions could now work together more effectively in this area by playing complementary roles; for example FP institutions could work on organization, awareness raising and follow-up, whilst health institutions could provide technical expertise. Some participants linked the opportunity to the possibility of sharing resources and the fact that the FP sector was fully funded by the government in contrast to health facilities, which receive only limited government funding and are therefore required to generate income through service provision.

The state population and family planning committee has been merged with the ministry of health. This will provide us some opportunities. At least, this is beneficial for the integration of family planning service provision. In the near future, township and village family planning stations or family planning offices can provide free contraceptives, and our health facilities can integrate this into our services and enhance the content of our services. I do think it’s feasible.

(IDI with policy maker, ZJ Province)

Financial and human resource considerations.

In addition to the importance of a policy mandate the majority of service stakeholders stressed that the financial implications of developing PAFP services need consideration. Although one manager anticipated that improvements in service quality through extending PAFP would actually increase institutional earnings due to attracting more patients, some service providers and managers feared that implementing PAFP would ultimately lead to a reduction in abortion service volume, which would reduce their own earnings, since these are linked to hospital income generation.

If the quality of service is improved, [the hospital] will attract more patients. When the service quality becomes better, institutional earnings will be naturally increased.

(IDI with hospital manager, HB Province)

Our service providers think PAFP is a burden. First it will increase workload, and this kind of workload is not related to economic benefit. Second, if PAFP is effective, the amount of abortions will decrease and our salary will decrease because the health system [here] is mainly a market economy. That’s why we don’t really care about this PAFP……There isn’t any support in terms of policy, technology, and finance. China medical association came to develop the guideline, but they didn’t provide financial support.

(IDI with hospital manager, HB province)

The majority of service providers in all three provinces perceived that expansion of PAFP services would substantially increase their workloads and saw this as a likely obstacle to the feasibility of implementation. Those already providing PAFP reported that it had led to increased workloads:

Participant a: [Since the provision of PAC,] workload is larger.

Participant b: Our work is more intensive than before. It makes me busy. We have to tell them [about conceptive use] before the abortion and also after the abortion, plus follow-up.

(FGD with service providers, ZJ Province)

Similarly the majority of hospital and departmental managers and policy makers perceived the need for increased human resources to provide PAFP services.

There must be human resource quotas for PAFP services. The hospital should give our department as least 2 staff members that focus on provision of PAFP services. If we have these 2 people, the hospital will give us financial support for their salary. Free PAFP services will certainly increase our burden. This thing is not difficult to implement with human resources and funds.

(IDI with service manager, YN province)

Another issue mentioned by a number of service stakeholders in all three provinces was the importance of motivating providers through an incentive structure. This was expressed in slightly different ways across different service stakeholder groups: for example, some stated the need for PAFP to be included in the set of performance indicators for individual providers within facilities and thus linked to income. Others perceived the need for improved pay.

Many stakeholders, particularly policy makers and managers, were also concerned about skills and training for abortion service providers, both in technical knowledge on FP and communication and counselling skills, and the availability of appropriate educational materials to give to clients. However, some health managers in HB referred to PAFP as “not technically difficult”.

Hospital service providers focus on clinical services. Now they have to provide individualized counselling, their interpersonal communication skill should be improved. They need training.

(IDI with policy maker, ZJ Province)

Finally, policy makers and managers in HB and YN provinces also mentioned the importance of physical spaces dedicated to the provision of PAFP services, though some saw these as not essential:

It will be best if special IEC is done in a dedicated venue, but it requires provision of both human resource and funding. However, when such conditions are not matched, a conscientious doctor who is trained sufficiently in this aspect can do it well too, even if there is no dedicated venue.

(IDI with service manager, YN province)