我国三城市流产后计划生育服务的影响因素分析及服务质量的综合评价
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摘要
[研究目的]
一、总目的
对我国三城市流产后计划生育服务质量的影响因素进行探索(简称“影响因素探索”),并对三城市的流产后计划生育服务质量进行综合评价(简称“质量综合评价”),为优质的流产后计划生育服务的进一步开展提供参考。
二、具体目的
(一)利用重复流产率、避孕措施落实、性与生殖健康知识水平及服务满意度四大类国际上常用的流产项目评估指标的影响因素分析结果,结合构建的妇女流产后避孕行为影响因素的验证性因子分析SEM,从流产后计划生育服务质量提高的目的(防止非意愿妊娠的发生,降低流产率和重复流产率)出发,探索影响流产后计划生育服务质量的因素,并提出相应的对策。
(二)在WHO优质流产后计划生育服务框架的基础上,利用综合评分法、蛛网图模型法和聚类分析法对北京、上海、郑州三地区的29家医院的流产后计划生育服务质量进行综合评价,探索性地综合评估我国流产后计划生育服务质量的优势和不足,并验证几种综合评价方法在流产后计划生育服务质量评估方面的适用性,为流产后计划生育服务质量的评估提供参考。
[研究方法]
一、资料来源
本研究是在欧盟FP6中国流产后计划生育服务研究数据基础上的再分析、再挖掘。数据基本情况如下
采用分层随机化的方法,在北京、上海、郑州三个城市选择了29家医院。在这29家医院中,共调查流产妇女3132人。流产妇女的纳入标准为：①到选定的医院寻求流产服务；②年龄<25岁；③早期妊娠；④能在半年后随访,随访方式可以为反诊或是电话随访；⑤愿意参加本调查。排除标准为：不愿参加本研究者或不能坚持随访者。
二、研究方法
在服务质量影响因素探索方面,本文综合运用了传统经典的统计方法及现代统计学方法。使用的经典统计分析方法主要包括描述性分析、χ2检验、Logistic回归及多元线性回归等。使用的现代统计学方法是新一代统计学三大进展中的最突出代表：SEM。
在服务质量综合评价方面,主要在WHO的优质流产后计划生育服务框架的基础上,探索性的采用了综合评价法中的综合评分法、蛛网图评价法和聚类分析法,对服务质量进行了综合评估。
在本研究数据的统计分析及综合评价中,主要采用SPSS17.0软悠扬；在SEM构建的过程中,首先采用SPSS17.0软件对数据进行插补,在数据插补完成后采用AMOS软件进行SEM的构建；在综合评价中的蛛网图评价法中,采用了Microsoft Office软件进行了模型图的构建。
[研究结果]
一、影响因素探索部分
(一)国际上常用的四大类流产项目评估指标的影响因素分析
1.重复流产
(1)流产妇女的妊娠原因
未避孕(64.0%)和避孕失败(36.0%)是本次调查中3132名流产妇女的主要妊娠原因。妇女不避孕的主要原因是“在没有准备好避孕药具的情况下进行了同房”(43.3%)和“因为知道但不想使用避孕方法”(34.6%)。绝大多数避孕失败的发生是在使用短效的现代避孕措施(避孕套39.2%、紧急避孕药20.1%、口服避孕药12.4%)中和传统的避孕措施(安全期29.7%,体外射精20.1%)中,在使用长效避孕措施(宫内节育器1.5%)中发生避孕失败的较少。
(2)重复流产的影响因素
多因素Logistic回归分析发现,知识得分和性生活时间与重复流产的发生有关,与知识得分<60分的妇女相比,知识得分≥60分的妇女重复流产的发生相对较少(OR95%CI：0.694(0.498-0.969)；在性生活时间方面,与性生活时间<1年的相比,性生活时间≥1年的妇女发生重复流产的可能越大(OR95%CI：29.44(15.327-56.548))。
2.性与生殖健康知识
多因素Logistic回归分析发现,年龄和出生地是性与生殖健康知识水平的影响因素,与年龄<22岁的妇女相比,年龄≥22的妇女,在性与生殖健康知识方面及格率越高(OR95%CI:1.625(1.164-2.270));与出生在农村的妇女相比,出生在城镇(OR95%CI：1.800(1.241-2.611))和城市(OR95%CI：1.554(1.102-2.190))的妇女性与生殖健康知识方面及格率越高。
3.避孕措施
(1)流产妇女避孕措施的使用情况
流产前和流产后,妇女使用的主要的避学措施均为避孕套(前：77.5%,后：78.2%)和体外射精(前：11.6%,后：7.7%)。
(2)流产妇女避孕药具选择时各因素的考虑情况
在避孕药具的选择时,妇女最关注的为避孕措施的安全性(74.6%)和有效性(70.0%),最不关注的为避孕药具的价格(10.5%)。
(3)流产后首次性生活避孕措施落实的影响因素
多因素Logistic回归分析发现,婚姻状况、男方是否关心避孕问题、男女年龄差距和性生活时间与流产后首次性生活时避孕措施的落实情况相关。与男方不关心避孕问题的相比,男方关系避孕问题的妇女流产后首次性生活时避孕措施的落实率高(OR95%CI：1.413(1.102-1.812))；与性生活时间<1年的相比,性生活时间≥1年的妇女流产后首次性生活时避孕措施的落实率高(OR95%CI：1.382(1.076-1.774))；与已婚的妇女相比,未婚的妇女流产后首次性生活时避孕措施的落实率低(OR95%CI：0.66(0.498-0.875))；与男女年龄差距<2岁的相比,男女年龄差距≥2的妇女流产后首次性生活时避孕措施的落实率低(OR95%CI：0.749(0.593-0.946))。
(4)各类避孕措施使用的影响因素
影响避孕套、口服避孕药、IUD、紧急避孕药、传统/现代避孕措施、短效/长效避孕措施使用的多因素Logistic回归分析结果见汇总表ST-I。
(二)妇女流产后避孕行为影响因素的验证性因子分析SEM构建结果
采用AMOS17.0拟合的SEM结果见图SF-1,图中所有的路径系数均为标准化后的路径系数。模型的拟合结果显示χ2=841.782(P<0.05),GFI=0.969, AGFI=0.949, PGFI=0.596,尽管P值小于0.05,但由本研究拟合的GFI、AGFI和PGFI非常理想,所以认为模型对数据的拟合程度较高。SEM分析结果显示,性与生殖健康知识、个体因素、社会经济地位、社会支持等潜变量均会通过直接和/或间接的途径来影响妇女流产后的避孕行为。
注：
1.为简洁明了,本表只汇总了多因素分析有意义的变量：
2.口服避孕药单因素分析没有P<0.05的变量,因此不进行多因素分析,故在本表中未纳入口服避孕药的结果；
3.自变量赋值：年龄：1=<22岁(ref),2=≥22岁；男性年龄分组：1=<24岁(ref),2=≥24岁；性生活时间：1=<1年(ref)2=≥1年；其余自变量:0=否(ref),1=是
4.因变量赋值避孕套(0=不使用；1=使用)；宫内节育器(0=不使用；1=使用)；紧急避孕药(0=不使用；1=使用)；传统/现代避孕措施(0=传统；1=现代)；短效/长效避孕措施(0=短效：1=长效)。
二、质量综合评价部分
综合评分法结果显示,我国三城市的流产后计划生育服务质量在人际关系(82.17分)和服务的连续性(82.66分)方面相对较好,在服务时机(57.67分)、避孕方法的选择(62.85分)、技术力量(57.26分)方面的能力次之,在宣教和咨询方面的能力最弱(48.46分)：上海、北京、郑州三地区的综合得分分别为72.33、61.84和57.32分。
蛛网图评价法结果显示,三城市的服务质量在WHO优质流产后计划生育服务框架的六个方面有很好的一致性。
聚类分析结果显示,纳入研究的29家医院的流产后计划生育服务质量总体可分高、中、低三类,各类中的医院数目分别为9、12和8家。
[研究结论]
一、影响因素探讨部分
探讨流产后计划生育服务质量的影响因素,提高流产后计划生育服务质量的目的是降低流产及重复流产的发生率。非意愿妊娠是流产和重复流产发生的根源,要解决流产和重复流产问题,需要从非意愿妊娠发生的主要原因来入手。因此,提高流产后计划生育服务的质量,解决流产和重复流产问题,主要需从优化避孕药具提供网络、改变妇女“不想使用避孕方法”的态度和解决避孕失败问题三大方面来进行。
提高年轻化、未育化的流产人群的避孕药可及性,是避孕药具网络优化的一大切入点；改变流产妇女“不想使用避孕方法”的态度,不仅需要提高流产妇女的性与生殖健康知识水平,还需要改善外界环境的影响,如增加男方在避孕节育和流产服务中的参与等；要解决“避孕失败”问题,需要通过宣教、咨询等各种措施,来提高流产妇女的避孕相关知识水平和避孕技能,来减少安全期和体外射精等传统避孕方法的使用,提高各类短效现代避孕措施的正确使用率和坚持使用率,增加长效现代避孕措施的使用率。
妇女流产后避孕行为影响因素的SEM构建结果显示,妇女流产后避孕行为的改变,受到多种因素共同作用的影响。因此,要改变妇女流产后的避孕行为,不能仅仅依靠一种因素的改变。而是要协调采用多种措施,综合提高流产后的计划生育服务质量,以达到预防非意愿妊娠发生,进而达到降低流产率和重复流产率的目的。
二、质量综合评价部分
从WHO的优质流产后计划生育服务框架的六方面来看,我国三城市的流产后计划生育服务质量在人际关系和服务的连续性方面相对较好,在服务时机、避孕方法的选择、技术力量方面的能力次之,在宣教和咨询方面的能力最弱。三城市的服务质量在WHO优质流产后计划生育服务框架的六方面有很好的一致性。
综合评分法和聚类分析法两种评估结果的一致性,不仅验证了本研究中质量综合评价结果的可靠性和稳定性,同时说明了两种方法在医院流产后计划生育服务质量的综合评价上是适用的。
Objectives
General objectives
To explore the influential factors of the post-abortion family planning services and comprehensively evaluate the quality of post-abortion family planning service of three cities, to raise suggestions for the further development and providing high quality post abortion family planning services.
Detailed objectives
1. From the factor ananlysis of the four major categories evaluation indicators of international abortion projects, rate of the repeat induced abortions, implementing of the contraception, knowledge level of the sexual and reproductive health and women's satisfaction, combined with the build of women post-abortion contraceptive behavior influencing factors confirmatory factor analysis SEM, from the purposes of improving the quality of post-abortion family planning services(to prevent the occurrence of unwanted pregnancy, reduce the rate of abortion and repeat abortion), departure to explore the influential factors of post-abortion family planning service quality, and propose appropriate countermeasures.
2. Based on the quality post-abortion family planning services framework of WHO, integrated scoring, the spider diagram modeling, and cluster analysis were used to evaluate the quality of post-abortion family planning services in29hospitals in Beijing, Shanghai, Zhengzhou, to abortionthe strengths and weaknesses of the post abortion family planning services, and verify the applicability of several comprehensive evaluation methods in the assessment of the quality post-abortion family planning services, to provide a reference for the quality assessment of the post-abortion family planning services.
Methods:
1. The source of the data:
The present study is a re-analysis and re-excavation of a former study. The data of the present study is from the EU-China FP6Projdet:The Study of Post-abortion Family Planning Services of China. Details of the data are as follows:
29hospitals were selected from the three cities, Beijing, Shanghai and Zhengzhou, by using stratified randomization method.3132abortion women were investigated form the29hospitals. The inclusion criteria of abortion women were (1) to seek abortion services in the selected hospitasl;(2) age<25years old;(3) early pregnancy;(4) could be followed up after six months, anti-clinic or telephone follow-up;(5) willing to participate in this survey. The exclusion criteria were: women do not want to participate in the research and those who could not adhere to the follow-up.
2. Research methods
Both classic statistical analysis methods and modern statistical methods were used the influential factors analysis of the quality post-abortion family planning services. The classic statistical analysis methods used were including the descriptive analysis, chi-square test, Logistic regression and the multiple-linear regression. The modern statistical method used was SEM, the most prominent method in the new generation of three statistical progresses.
Based on the quality post-abortion family planning services framework of WHO. integrated scoring, the spider diagram modeling, and cluster analysis were used to evaluate the quality of post-abortion family planning services. Microsoft Office software was used for the construction of the spider diagram.
Results
1. Influential factors analysis of the quality post-abortion family planning services
1.1The factor ananlysis of the four major categories evaluation indicators of international abortion projects
1.1.1Repeat abortion
(1) Causes of pregnancy among abortion women
Without contraception and contraception failure were the two main reasons for the3132abortion women. The two main reasons for abortion women did not taken contraceptives were "did not prepare any contraceptive measures"(43.3%) and "being afriaid of troubles"(34.6%). Most the contraception failure were happended during using short-acting contraceptives (condom:39.2%, emergency contraceptive pill:20.1%, and oral contraceptive pill:12.4%) and traditional contraceptives (rhythm:29.7%, withdrawl:20.1%), while contraception failure were rarely happened during using long-acting contraceptives such as IUDs(1.5%).
(2) Influencing factors of repeated abortion
Multivariate logistic regression shows that, knowledge score and time of sexual life were the influencing variables for repeated abortion. Compared to women socored <60, women scored≥60more less likely to have have repated abortion(OR95%CI:0.694(0.498-0.969); Compared to women had sex life<1year, women had sex life≥1year more likely to have repated abortion (OR95%CI:29.44(15.327-56.548)).
1.1.2Knowledge score of sexual and reproductive health
Multivariate Logistic regression showed that, age and place of birth were the influential factors of the knowledge score. Compared with women<22, women≥22more likely to achive higher scores(OR95%CI:1.625(1.164-2.270)); Compare with women born in rural areas, women born in town (OR95%CI:1.800(1.241-2.611)) and urban areas more likely to achive higher scores.
1.1.3Contraceptives
(1) Distribution of the abortion contraception used by abortion women
Condom and withdrawl are the two main contraceptives used by women under going abortion, the proportion used were77.5%11.6%before abortion and78.2%and7.7%after abortion respectively.
(2) Abortion women's considerations when chosing contraptives
The effectiveness (74.6%) and safety (70.0%) of the contraceptives were the top two aspects that women undergoing abortion were concerned, while the cost the contraceptives (10.5%) were the least fouced aspect.
(3) Influencing factors of the cotraception during the first intercourse after abortion.
Mulit-variable logisteic regression showed that, marital status, whether the man is concerned about contraception, the age gap between men and women and the sexual life time were realted to the contraceptives during the first intercourse taken after abortion. Compared to the male partner does not care about contraception, abortion women with male partner of caring about contraception more likely to take contraceptives during the first intercourse after abortion(OR95%CI:1.413(1.102-1.812)); compared to women had sex life<1year, wome had sex life≥1year more likely to take contraceptives during the first intercourse after abortion(OR95%CI:1.382(1.076-1.774)); compared with married women, unmarried women less likely to take contraceptives during the first intercourse after abortion (OR95%CI:0.66(0.498-0.875)); comepared with the age gap between men and women<2years, women of with the age gap between men and women≥2years less likely to take contraceptives during the first intercourse after abortion (OR95%CI:0.749(0.593-0.946)).
(4) Influencing factors of the use of various contraceptives
The multivariate logistic regression analysis results of the influencing factors of the use of condoms, oral contraceptives, IUDs, emergency contraception, traditional/modern contraceptive measures. and the use of short-acting/long-acting contraceptive measures were summarized in the Summary Table ST-1.
Notes:
1. Only the statistically significant variables were summarized in the above summary table.
2. No statistically signficnat variable was found in the univariate analysis of the oral contraceptive. Therefore, oral contracptive was not included in the above table.
3. Assignment of the independent variables: Age:1=<22years (ref),2=≥22years of age; Age of the male partner:1=<24years old (ref),2=≥24years old; Time of sex life:1=<1year (ref)2=≥1year;The argument of the rest independent variables:0=No (ref),1=Yes
4. Dependent variable assignment Condoms (0=not used;1=used); Intrauterine device (0=not used;1=used); Emergency contraception (0=not used;1=used) Traditional/modern contraceptive measures (0-traditional;1=modern); Short-acting/long-acting contraceptive measures (0=short-acting;1=long-term
1.2The contraction of women post-abortion contraceptive behavior influencing factors confirmatoryfactor analysis SEM
The SEM was construted by using AMOS17.0, see Fiugre SF-1. All path coefficients of the SEM were standardized path coefficients. Model fitting results were χ2=841.782(P<0.05), GFI=0.969, AGFI=0.949, PGFI=0.596. Althoght the P value is less than0.05, the fitting indicators GFI, AGFI, and PGFI were ideal, thus the defauted model fits the sampling data. The outcome of SEM analysis showed that the four latent variables, knowledge on sex and reproductive, individual facters, social economic status and social support were all have affects on the contraceptive behaviors of women after abortion through direct and/or indirect ways.
Fiugure SF-1Women Post-abortion Contraceptive Behavior Influencing Factors Confirmatoryfactor Analysis SEM
2. Comprehensive evulation of the service quality
Integrated score results showed that the quality of family planning services in the three cities in China after abortion is relatively good in interpersonal relationships (82.17points) and continuity through likage of services (82.66points), followed by the choice of methods (62.85points), the timing (57.67points) and the technical competence (57.26points), while information and consulting were the weakest aspect (48.46points). The scores achived by Shanghai, Beijing, Zhengzhou were72.33.61.84and57.32respectively.
The spider diagram evaluation results showed, in six elements of the WHO quality post-abortion family planning services framework, the service quality of the three cities were in good agreement.
The result of cluster analysis showed that, total29hospitals were clustered into3groups by their service quality, and there were9,12and8in each group respectively.
Conclusions
1. Conculusions of the part of influential factors analysis
The purposes of exploring the influential factors of post-abortion family planning service quality, is to improving the quality of post-abortion family planning services. And then, reduce the rate of abortion and repeated abortion. Unwanted pregnancy is the source of abortion and reapeated abortion. Thus, to address the issue of abortion and repeated abortion should be started from the causes of unwanted pregnancy. Therefore, improving the quality of post-abortion family planning services, to address the issues of abortion and repeat abortion, could be addressed by so loving the following thress problems:optimizing the contracptives service network, changing womens'myth attitude "did not want to use contraceptives", and solving the problem of abortion failure.
Increasing the abortion women's accessibility to the contraceptives is a breakthrough point of contraceptives service network optimization. Changing the attitude of not want to use contraptives, not only need further raising of the knowledge level of abortion women, but should give more attention to the outside environmental factors such as male partenrs'support. Diminishing the use of traditional contraceptives such as rhythm and withdrawl, increasing the currect and consistant use of short-acting modern contraceptives, and rasing the use of long-acting modern contraceptives were the main ways of solving the problem of contraception failure.
The outcome of the women post-abortion contraceptive behavior influencing factors confirmatoryfactor analysis SEM showed that, the behaviors of contraception of women after abortion were impacted by many combimed aspects. Therefore, to change the cotracption behavior of women after abortion, not rely solely on one single factor. But to coordinate and integrate a variety of measures, to improve the quality of post-abortion family planning services, to prevent the occurance of unwanted pregnancies, thereby achieving the purpose of reducing the rate of abortion and repeated abortion.
2. Conculusions of the part of quality assessment
From the six elements of quality post-abortion family planning services framework of WHO, the quality of family planning services in the three cities in China after abortion is relatively good in interpersonal relationships and continuity through likage of services, followed by the choice of methods, the timing and the technical competence, while information and consulting was the weakest aspect. The service qualities of the three cities were in good agreement.
The results consistency of the two comprehensive evaluation method, comprehensive scoring method and cluster analysis, not only verified the reliability and stability of the quality of evaluation results in the present study, but also indicated that the two methods is applicable in using to evaluate the services quality of post-abortion family planning.
一、总目的
对我国三城市流产后计划生育服务质量的影响因素进行探索(简称“影响因素探索”),并对三城市的流产后计划生育服务质量进行综合评价(简称“质量综合评价”),为优质的流产后计划生育服务的进一步开展提供参考。
二、具体目的
(一)利用重复流产率、避孕措施落实、性与生殖健康知识水平及服务满意度四大类国际上常用的流产项目评估指标的影响因素分析结果,结合构建的妇女流产后避孕行为影响因素的验证性因子分析SEM,从流产后计划生育服务质量提高的目的(防止非意愿妊娠的发生,降低流产率和重复流产率)出发,探索影响流产后计划生育服务质量的因素,并提出相应的对策。
(二)在WHO优质流产后计划生育服务框架的基础上,利用综合评分法、蛛网图模型法和聚类分析法对北京、上海、郑州三地区的29家医院的流产后计划生育服务质量进行综合评价,探索性地综合评估我国流产后计划生育服务质量的优势和不足,并验证几种综合评价方法在流产后计划生育服务质量评估方面的适用性,为流产后计划生育服务质量的评估提供参考。
[研究方法]
一、资料来源
本研究是在欧盟FP6中国流产后计划生育服务研究数据基础上的再分析、再挖掘。数据基本情况如下
采用分层随机化的方法,在北京、上海、郑州三个城市选择了29家医院。在这29家医院中,共调查流产妇女3132人。流产妇女的纳入标准为：①到选定的医院寻求流产服务；②年龄<25岁；③早期妊娠；④能在半年后随访,随访方式可以为反诊或是电话随访；⑤愿意参加本调查。排除标准为：不愿参加本研究者或不能坚持随访者。
二、研究方法
在服务质量影响因素探索方面,本文综合运用了传统经典的统计方法及现代统计学方法。使用的经典统计分析方法主要包括描述性分析、χ2检验、Logistic回归及多元线性回归等。使用的现代统计学方法是新一代统计学三大进展中的最突出代表：SEM。
在服务质量综合评价方面,主要在WHO的优质流产后计划生育服务框架的基础上,探索性的采用了综合评价法中的综合评分法、蛛网图评价法和聚类分析法,对服务质量进行了综合评估。
在本研究数据的统计分析及综合评价中,主要采用SPSS17.0软悠扬；在SEM构建的过程中,首先采用SPSS17.0软件对数据进行插补,在数据插补完成后采用AMOS软件进行SEM的构建；在综合评价中的蛛网图评价法中,采用了Microsoft Office软件进行了模型图的构建。
[研究结果]
一、影响因素探索部分
(一)国际上常用的四大类流产项目评估指标的影响因素分析
1.重复流产
(1)流产妇女的妊娠原因
未避孕(64.0%)和避孕失败(36.0%)是本次调查中3132名流产妇女的主要妊娠原因。妇女不避孕的主要原因是“在没有准备好避孕药具的情况下进行了同房”(43.3%)和“因为知道但不想使用避孕方法”(34.6%)。绝大多数避孕失败的发生是在使用短效的现代避孕措施(避孕套39.2%、紧急避孕药20.1%、口服避孕药12.4%)中和传统的避孕措施(安全期29.7%,体外射精20.1%)中,在使用长效避孕措施(宫内节育器1.5%)中发生避孕失败的较少。
(2)重复流产的影响因素
多因素Logistic回归分析发现,知识得分和性生活时间与重复流产的发生有关,与知识得分<60分的妇女相比,知识得分≥60分的妇女重复流产的发生相对较少(OR95%CI：0.694(0.498-0.969)；在性生活时间方面,与性生活时间<1年的相比,性生活时间≥1年的妇女发生重复流产的可能越大(OR95%CI：29.44(15.327-56.548))。
2.性与生殖健康知识
多因素Logistic回归分析发现,年龄和出生地是性与生殖健康知识水平的影响因素,与年龄<22岁的妇女相比,年龄≥22的妇女,在性与生殖健康知识方面及格率越高(OR95%CI:1.625(1.164-2.270));与出生在农村的妇女相比,出生在城镇(OR95%CI：1.800(1.241-2.611))和城市(OR95%CI：1.554(1.102-2.190))的妇女性与生殖健康知识方面及格率越高。
3.避孕措施
(1)流产妇女避孕措施的使用情况
流产前和流产后,妇女使用的主要的避学措施均为避孕套(前：77.5%,后：78.2%)和体外射精(前：11.6%,后：7.7%)。
(2)流产妇女避孕药具选择时各因素的考虑情况
在避孕药具的选择时,妇女最关注的为避孕措施的安全性(74.6%)和有效性(70.0%),最不关注的为避孕药具的价格(10.5%)。
(3)流产后首次性生活避孕措施落实的影响因素
多因素Logistic回归分析发现,婚姻状况、男方是否关心避孕问题、男女年龄差距和性生活时间与流产后首次性生活时避孕措施的落实情况相关。与男方不关心避孕问题的相比,男方关系避孕问题的妇女流产后首次性生活时避孕措施的落实率高(OR95%CI：1.413(1.102-1.812))；与性生活时间<1年的相比,性生活时间≥1年的妇女流产后首次性生活时避孕措施的落实率高(OR95%CI：1.382(1.076-1.774))；与已婚的妇女相比,未婚的妇女流产后首次性生活时避孕措施的落实率低(OR95%CI：0.66(0.498-0.875))；与男女年龄差距<2岁的相比,男女年龄差距≥2的妇女流产后首次性生活时避孕措施的落实率低(OR95%CI：0.749(0.593-0.946))。
(4)各类避孕措施使用的影响因素
影响避孕套、口服避孕药、IUD、紧急避孕药、传统/现代避孕措施、短效/长效避孕措施使用的多因素Logistic回归分析结果见汇总表ST-I。
(二)妇女流产后避孕行为影响因素的验证性因子分析SEM构建结果
采用AMOS17.0拟合的SEM结果见图SF-1,图中所有的路径系数均为标准化后的路径系数。模型的拟合结果显示χ2=841.782(P<0.05),GFI=0.969, AGFI=0.949, PGFI=0.596,尽管P值小于0.05,但由本研究拟合的GFI、AGFI和PGFI非常理想,所以认为模型对数据的拟合程度较高。SEM分析结果显示,性与生殖健康知识、个体因素、社会经济地位、社会支持等潜变量均会通过直接和/或间接的途径来影响妇女流产后的避孕行为。
注：
1.为简洁明了,本表只汇总了多因素分析有意义的变量：
2.口服避孕药单因素分析没有P<0.05的变量,因此不进行多因素分析,故在本表中未纳入口服避孕药的结果；
3.自变量赋值：年龄：1=<22岁(ref),2=≥22岁；男性年龄分组：1=<24岁(ref),2=≥24岁；性生活时间：1=<1年(ref)2=≥1年；其余自变量:0=否(ref),1=是
4.因变量赋值避孕套(0=不使用；1=使用)；宫内节育器(0=不使用；1=使用)；紧急避孕药(0=不使用；1=使用)；传统/现代避孕措施(0=传统；1=现代)；短效/长效避孕措施(0=短效：1=长效)。
二、质量综合评价部分
综合评分法结果显示,我国三城市的流产后计划生育服务质量在人际关系(82.17分)和服务的连续性(82.66分)方面相对较好,在服务时机(57.67分)、避孕方法的选择(62.85分)、技术力量(57.26分)方面的能力次之,在宣教和咨询方面的能力最弱(48.46分)：上海、北京、郑州三地区的综合得分分别为72.33、61.84和57.32分。
蛛网图评价法结果显示,三城市的服务质量在WHO优质流产后计划生育服务框架的六个方面有很好的一致性。
聚类分析结果显示,纳入研究的29家医院的流产后计划生育服务质量总体可分高、中、低三类,各类中的医院数目分别为9、12和8家。
[研究结论]
一、影响因素探讨部分
探讨流产后计划生育服务质量的影响因素,提高流产后计划生育服务质量的目的是降低流产及重复流产的发生率。非意愿妊娠是流产和重复流产发生的根源,要解决流产和重复流产问题,需要从非意愿妊娠发生的主要原因来入手。因此,提高流产后计划生育服务的质量,解决流产和重复流产问题,主要需从优化避孕药具提供网络、改变妇女“不想使用避孕方法”的态度和解决避孕失败问题三大方面来进行。
提高年轻化、未育化的流产人群的避孕药可及性,是避孕药具网络优化的一大切入点；改变流产妇女“不想使用避孕方法”的态度,不仅需要提高流产妇女的性与生殖健康知识水平,还需要改善外界环境的影响,如增加男方在避孕节育和流产服务中的参与等；要解决“避孕失败”问题,需要通过宣教、咨询等各种措施,来提高流产妇女的避孕相关知识水平和避孕技能,来减少安全期和体外射精等传统避孕方法的使用,提高各类短效现代避孕措施的正确使用率和坚持使用率,增加长效现代避孕措施的使用率。
妇女流产后避孕行为影响因素的SEM构建结果显示,妇女流产后避孕行为的改变,受到多种因素共同作用的影响。因此,要改变妇女流产后的避孕行为,不能仅仅依靠一种因素的改变。而是要协调采用多种措施,综合提高流产后的计划生育服务质量,以达到预防非意愿妊娠发生,进而达到降低流产率和重复流产率的目的。
二、质量综合评价部分
从WHO的优质流产后计划生育服务框架的六方面来看,我国三城市的流产后计划生育服务质量在人际关系和服务的连续性方面相对较好,在服务时机、避孕方法的选择、技术力量方面的能力次之,在宣教和咨询方面的能力最弱。三城市的服务质量在WHO优质流产后计划生育服务框架的六方面有很好的一致性。
综合评分法和聚类分析法两种评估结果的一致性,不仅验证了本研究中质量综合评价结果的可靠性和稳定性,同时说明了两种方法在医院流产后计划生育服务质量的综合评价上是适用的。
Objectives
General objectives
To explore the influential factors of the post-abortion family planning services and comprehensively evaluate the quality of post-abortion family planning service of three cities, to raise suggestions for the further development and providing high quality post abortion family planning services.
Detailed objectives
1. From the factor ananlysis of the four major categories evaluation indicators of international abortion projects, rate of the repeat induced abortions, implementing of the contraception, knowledge level of the sexual and reproductive health and women's satisfaction, combined with the build of women post-abortion contraceptive behavior influencing factors confirmatory factor analysis SEM, from the purposes of improving the quality of post-abortion family planning services(to prevent the occurrence of unwanted pregnancy, reduce the rate of abortion and repeat abortion), departure to explore the influential factors of post-abortion family planning service quality, and propose appropriate countermeasures.
2. Based on the quality post-abortion family planning services framework of WHO, integrated scoring, the spider diagram modeling, and cluster analysis were used to evaluate the quality of post-abortion family planning services in29hospitals in Beijing, Shanghai, Zhengzhou, to abortionthe strengths and weaknesses of the post abortion family planning services, and verify the applicability of several comprehensive evaluation methods in the assessment of the quality post-abortion family planning services, to provide a reference for the quality assessment of the post-abortion family planning services.
Methods:
1. The source of the data:
The present study is a re-analysis and re-excavation of a former study. The data of the present study is from the EU-China FP6Projdet:The Study of Post-abortion Family Planning Services of China. Details of the data are as follows:
29hospitals were selected from the three cities, Beijing, Shanghai and Zhengzhou, by using stratified randomization method.3132abortion women were investigated form the29hospitals. The inclusion criteria of abortion women were (1) to seek abortion services in the selected hospitasl;(2) age<25years old;(3) early pregnancy;(4) could be followed up after six months, anti-clinic or telephone follow-up;(5) willing to participate in this survey. The exclusion criteria were: women do not want to participate in the research and those who could not adhere to the follow-up.
2. Research methods
Both classic statistical analysis methods and modern statistical methods were used the influential factors analysis of the quality post-abortion family planning services. The classic statistical analysis methods used were including the descriptive analysis, chi-square test, Logistic regression and the multiple-linear regression. The modern statistical method used was SEM, the most prominent method in the new generation of three statistical progresses.
Based on the quality post-abortion family planning services framework of WHO. integrated scoring, the spider diagram modeling, and cluster analysis were used to evaluate the quality of post-abortion family planning services. Microsoft Office software was used for the construction of the spider diagram.
Results
1. Influential factors analysis of the quality post-abortion family planning services
1.1The factor ananlysis of the four major categories evaluation indicators of international abortion projects
1.1.1Repeat abortion
(1) Causes of pregnancy among abortion women
Without contraception and contraception failure were the two main reasons for the3132abortion women. The two main reasons for abortion women did not taken contraceptives were "did not prepare any contraceptive measures"(43.3%) and "being afriaid of troubles"(34.6%). Most the contraception failure were happended during using short-acting contraceptives (condom:39.2%, emergency contraceptive pill:20.1%, and oral contraceptive pill:12.4%) and traditional contraceptives (rhythm:29.7%, withdrawl:20.1%), while contraception failure were rarely happened during using long-acting contraceptives such as IUDs(1.5%).
(2) Influencing factors of repeated abortion
Multivariate logistic regression shows that, knowledge score and time of sexual life were the influencing variables for repeated abortion. Compared to women socored <60, women scored≥60more less likely to have have repated abortion(OR95%CI:0.694(0.498-0.969); Compared to women had sex life<1year, women had sex life≥1year more likely to have repated abortion (OR95%CI:29.44(15.327-56.548)).
1.1.2Knowledge score of sexual and reproductive health
Multivariate Logistic regression showed that, age and place of birth were the influential factors of the knowledge score. Compared with women<22, women≥22more likely to achive higher scores(OR95%CI:1.625(1.164-2.270)); Compare with women born in rural areas, women born in town (OR95%CI:1.800(1.241-2.611)) and urban areas more likely to achive higher scores.
1.1.3Contraceptives
(1) Distribution of the abortion contraception used by abortion women
Condom and withdrawl are the two main contraceptives used by women under going abortion, the proportion used were77.5%11.6%before abortion and78.2%and7.7%after abortion respectively.
(2) Abortion women's considerations when chosing contraptives
The effectiveness (74.6%) and safety (70.0%) of the contraceptives were the top two aspects that women undergoing abortion were concerned, while the cost the contraceptives (10.5%) were the least fouced aspect.
(3) Influencing factors of the cotraception during the first intercourse after abortion.
Mulit-variable logisteic regression showed that, marital status, whether the man is concerned about contraception, the age gap between men and women and the sexual life time were realted to the contraceptives during the first intercourse taken after abortion. Compared to the male partner does not care about contraception, abortion women with male partner of caring about contraception more likely to take contraceptives during the first intercourse after abortion(OR95%CI:1.413(1.102-1.812)); compared to women had sex life<1year, wome had sex life≥1year more likely to take contraceptives during the first intercourse after abortion(OR95%CI:1.382(1.076-1.774)); compared with married women, unmarried women less likely to take contraceptives during the first intercourse after abortion (OR95%CI:0.66(0.498-0.875)); comepared with the age gap between men and women<2years, women of with the age gap between men and women≥2years less likely to take contraceptives during the first intercourse after abortion (OR95%CI:0.749(0.593-0.946)).
(4) Influencing factors of the use of various contraceptives
The multivariate logistic regression analysis results of the influencing factors of the use of condoms, oral contraceptives, IUDs, emergency contraception, traditional/modern contraceptive measures. and the use of short-acting/long-acting contraceptive measures were summarized in the Summary Table ST-1.
Notes:
1. Only the statistically significant variables were summarized in the above summary table.
2. No statistically signficnat variable was found in the univariate analysis of the oral contraceptive. Therefore, oral contracptive was not included in the above table.
3. Assignment of the independent variables: Age:1=<22years (ref),2=≥22years of age; Age of the male partner:1=<24years old (ref),2=≥24years old; Time of sex life:1=<1year (ref)2=≥1year;The argument of the rest independent variables:0=No (ref),1=Yes
4. Dependent variable assignment Condoms (0=not used;1=used); Intrauterine device (0=not used;1=used); Emergency contraception (0=not used;1=used) Traditional/modern contraceptive measures (0-traditional;1=modern); Short-acting/long-acting contraceptive measures (0=short-acting;1=long-term
1.2The contraction of women post-abortion contraceptive behavior influencing factors confirmatoryfactor analysis SEM
The SEM was construted by using AMOS17.0, see Fiugre SF-1. All path coefficients of the SEM were standardized path coefficients. Model fitting results were χ2=841.782(P<0.05), GFI=0.969, AGFI=0.949, PGFI=0.596. Althoght the P value is less than0.05, the fitting indicators GFI, AGFI, and PGFI were ideal, thus the defauted model fits the sampling data. The outcome of SEM analysis showed that the four latent variables, knowledge on sex and reproductive, individual facters, social economic status and social support were all have affects on the contraceptive behaviors of women after abortion through direct and/or indirect ways.
Fiugure SF-1Women Post-abortion Contraceptive Behavior Influencing Factors Confirmatoryfactor Analysis SEM
2. Comprehensive evulation of the service quality
Integrated score results showed that the quality of family planning services in the three cities in China after abortion is relatively good in interpersonal relationships (82.17points) and continuity through likage of services (82.66points), followed by the choice of methods (62.85points), the timing (57.67points) and the technical competence (57.26points), while information and consulting were the weakest aspect (48.46points). The scores achived by Shanghai, Beijing, Zhengzhou were72.33.61.84and57.32respectively.
The spider diagram evaluation results showed, in six elements of the WHO quality post-abortion family planning services framework, the service quality of the three cities were in good agreement.
The result of cluster analysis showed that, total29hospitals were clustered into3groups by their service quality, and there were9,12and8in each group respectively.
Conclusions
1. Conculusions of the part of influential factors analysis
The purposes of exploring the influential factors of post-abortion family planning service quality, is to improving the quality of post-abortion family planning services. And then, reduce the rate of abortion and repeated abortion. Unwanted pregnancy is the source of abortion and reapeated abortion. Thus, to address the issue of abortion and repeated abortion should be started from the causes of unwanted pregnancy. Therefore, improving the quality of post-abortion family planning services, to address the issues of abortion and repeat abortion, could be addressed by so loving the following thress problems:optimizing the contracptives service network, changing womens'myth attitude "did not want to use contraceptives", and solving the problem of abortion failure.
Increasing the abortion women's accessibility to the contraceptives is a breakthrough point of contraceptives service network optimization. Changing the attitude of not want to use contraptives, not only need further raising of the knowledge level of abortion women, but should give more attention to the outside environmental factors such as male partenrs'support. Diminishing the use of traditional contraceptives such as rhythm and withdrawl, increasing the currect and consistant use of short-acting modern contraceptives, and rasing the use of long-acting modern contraceptives were the main ways of solving the problem of contraception failure.
The outcome of the women post-abortion contraceptive behavior influencing factors confirmatoryfactor analysis SEM showed that, the behaviors of contraception of women after abortion were impacted by many combimed aspects. Therefore, to change the cotracption behavior of women after abortion, not rely solely on one single factor. But to coordinate and integrate a variety of measures, to improve the quality of post-abortion family planning services, to prevent the occurance of unwanted pregnancies, thereby achieving the purpose of reducing the rate of abortion and repeated abortion.
2. Conculusions of the part of quality assessment
From the six elements of quality post-abortion family planning services framework of WHO, the quality of family planning services in the three cities in China after abortion is relatively good in interpersonal relationships and continuity through likage of services, followed by the choice of methods, the timing and the technical competence, while information and consulting was the weakest aspect. The service qualities of the three cities were in good agreement.
The results consistency of the two comprehensive evaluation method, comprehensive scoring method and cluster analysis, not only verified the reliability and stability of the quality of evaluation results in the present study, but also indicated that the two methods is applicable in using to evaluate the services quality of post-abortion family planning.
引文
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