人工流产及流产后关爱服务的现状分析

人工流产后关爱服务(PAC)是一项标准化的服务流程,是对流产后的女性进行的关爱服务,其目的是有效降低重复流产率、保护女性的生殖健康、提升女性的生活质量。目前在我国流产后关爱服务还未完全落到实处,因此需要在各个医院和社区开展的相关活动,推进APC服务的发展。     

未婚人工流产女性生殖健康知识知晓现状调查及其影响因素分析

摘要 目的：探究未婚人工流产女性生殖健康知识知晓现状,并分析其影响因素。方法：随机选取2018年3月~2021年5月期间在同济大学附属第一妇婴保健院计划生育科终止妊娠的未婚女性486例作为研究对象。其中,拒绝调查者21例,实际调查465例,应答率95.68%（465/486）,数据清理后有效问卷459份,有效率为98.71%（459/465）。调查未婚人工流产女性生殖健康知识知晓现状,未婚人工流产女性生殖健康知识知晓情况的危险因素采用单因素及多因素Logistic回归分析。结果：研究对象中,女性生殖健康知识知晓总分最低分17分,最高分为92分,平均（65.74±10.82）分;得分大于80分者179例,优良率为39.00%（179/459）。得分在80分及其以下的女性280例。未婚人工流产女性生殖健康知识知晓情况与年龄、女方文化程度、父母婚姻状况、流产次数、工作性质、居住地、恋爱经历、男方文化程度有关（P<0.05）。而与家庭月收入、更换工作次数无关（P>0.05）。年龄、男方文化程度工作性质、居住地、女方文化程度、流产次数、父母婚姻状况是未婚人工流产女性生殖健康知识知晓情况的影响因素（P<0.05）。结论：未婚人工流产女性生殖健康知识知晓水平一般,受到年龄、女方文化程度、父母婚姻状况等多种因素影响,应针对其影响因素特点加强生殖健康知识的宣教,以降低人工流产的风险。     

Public health in inner London.

One of Sir Bernard Tomlinson''s aims in his inquiry into London''s health services was to advise the secretary of state for health on the future balance of primary and secondary health care "taking account of the health needs of Londoners." Sir Bernard, however, also made it clear that "we have not seen it as part of our remit to carry out a comprehensive needs assessment for the whole of London," but concluded that the extremes of health need found in London were "unparalleled in the rest of England." Dr Jacobson highlights some of the major determinants of health inequality in inner London and assesses the extent to which the proposed solutions are likely to meet these needs.     

Iron Status and Reproduction in US Women: National Health and Nutrition Examination Survey, 1999-2006

Women experience significant changes in iron status throughout their reproductive lifespans. While this is evident in regions with high rates of malnutrition and infectious disease, the extent of reproductive-related changes is less well known in countries with low rates of iron deficiency anemia, such as the United States. The goal of this study is determine the relationship between women''s reproductive variables (pregnancy, parity, currently breastfeeding, regular menstruation, hormonal contraceptive use, and age at menarche) and iron status (hemoglobin, ferritin, transferrin receptor, and % transferrin saturation) using an anthropological framework for interpreting the results. Data from women aged 18–49 were taken from the 1999–2006 US NHANES, a nationally representative cross-sectional sample of US women. Using multiple imputation and complex survey statistics, women''s reproductive variables were regressed against indicators of iron status. Pregnant women had significantly poorer iron status, by most indicators, than non-pregnant women. All biomarkers demonstrated significantly lower iron levels with increasing parity. Women who were having regular periods had iron indicators that suggested decreased iron levels, while women who used hormonal contraceptives had iron indicators that suggested increased iron levels. Despite relatively good iron status and widespread availability of iron-rich foods in the US, women still exhibit patterns of iron depletion across several reproductive variables of interest. These results contribute to an ecological approach to iron status that seeks to understand variation in iron status, with the hopes that appropriate, population-specific recommendations can be developed to improve women''s health.     

Illegal abortion and reproductive injustice in the Pacific Islands: A qualitative analysis of court data

The Oceania region is home to some of the world's most restrictive abortion laws, and there is evidence of Pacific Island women's reproductive oppression across several aspects of their reproductive lives, including in relation to contraceptive decision-making, birthing, and fertility. In this paper we analyse documents from court cases in the Pacific Islands regarding the illegal procurement of abortion. We undertook inductive thematic analysis of documents from eighteen illegal abortion court cases from Pacific Island countries. Using the lens of reproductive justice, we discuss the methods of abortion, the reported context of these abortions, and the ways in which these women and abortion were constructed in judges' summing up, judgements, or sentencing. Our analysis of these cases reveals layers of sexual and reproductive oppression experienced by these women that are related to colonialism, women's socioeconomic disadvantage, gendered violence, limited reproductive control, and the punitive consequences related to not performing gender appropriately.     

Child spacing and two child policy in practice in rural Vietnam: cross sectional survey.

OBJECTIVE: To explore the reproductive pattern of women in rural Vietnam in relation to the existing family planning policies and laws. DESIGN: Cross sectional survey with question-naires on reproductive history. SETTING: Tien Hai, a district in Red River Delta area, where the population density is one of the highest in Vietnam. SUBJECTS: 1132 women who had at least one child under 5 years of age in April 1992. MAIN OUTCOME MEASURES: Birth spacing and probability of having a third child. RESULTS: The mean age at first birth was 22.2 years. The average spacing between the first and the second child was 2.6 years. Mothers with a lower educational level, farmers, and women belonging to the Catholic religion had shorter spacing between the first and second child and also a higher probability of having a third child. In addition, women who had no sons or who had lost a previous child were more likely to have a third child. CONCLUSION: Most families do not adhere to the official family planning policy, which was introduced in 1988, stipulating that each couple should have a maximum of two children with 3-5 years'' spacing in between. More consideration should be given to family planning needs and perceptions of the population, supporting the woman to be in control of her fertility. This may imply improved contraceptive services and better consideration of sex issues and cultural differences as well as improved social support for elderly people.     

The World Health Organisation. Interview with the director general. Interview by Fiona Godlee.

Dr Hiroshi Nakajima was elected director general of WHO in 1988. Born in Japan, he trained as a psychiatrist before joining WHO in 1973. He was WHO''s regional director for the Western Pacific from 1979 to 1988. His term of office has been marked by criticism of his management style and allegations of misuse of WHO''s funds. I spoke to him at WHO''s headquarters in Geneva in July. I have presented the interview in the form of questions and answers. It would be misleading, however, not to make clear that in doing so I have transcribed conversation which was at times extremely difficult to follow. I feel that it is important to emphasise this in the context of an interview with an international leader, one of whose primary tasks must be to communicate his views on health to people across the world. The interviews gave me first hand experience of the difficulties in communication that staff, diplomats, and others, including Japanese leaders, have consistently commented on since Dr Nakajima took office.     

The effect of paternal investment on female fertility intention in South Korea

Life history theory views reproduction as an outcome of resource allocation. The allocation of resources such as parental investments of time, energy and material resources involves trade-offs between number of offspring and timing of reproduction. Within the framework of mammalian parental investment, the outstanding feature of human reproduction is the high level of paternal care. Although empirical evidence suggests that human paternal investment may have evolved as a reproductive strategy to reduce infant and child mortality rates, the effects of actual paternal investment, including allocating time to child care, on female reproductive decisions have received relatively little attention. We examined the trade-off from two perspectives using a representative sample of married South Korean women aged 20–44 in 2005 (n=977). First, paternal investment in domestic labor, including child care and housework, was expected to be associated with women's preference regarding future reproduction. Second, relative paternal investment was expected to increase women's preference for future reproduction, especially among employed women. We found that increased paternal investment in child care and housework remarkably enhanced women's intention to have a second child, especially among employed women. In addition, although family members provide a low percentage of child care in South Korea, such help is likely to be a useful resource for second childbirth among employed women. Somewhat expectedly, older age and longer time since first birth had negative effects on women's second-child intention. There is growing evidence that, in the lowest fertility societies, paternal investment may be an essential resource for promoting future reproductive behavior of women, especially employed women.     

Making family planning accessible in resource-poor settings

It is imperative to make family planning more accessible in low resource settings. The poorest couples have the highest fertility, the lowest contraceptive use and the highest unmet need for contraception. It is also in the low resource settings where maternal and child mortality is the highest. Family planning can contribute to improvements in maternal and child health, especially in low resource settings where overall access to health services is limited. Four critical steps should be taken to increase access to family planning in resource-poor settings: (i) increase knowledge about the safety of family planning methods; (ii) ensure contraception is genuinely affordable to the poorest families; (iii) ensure supply of contraceptives by making family planning a permanent line item in healthcare system''s budgets and (iv) take immediate action to remove barriers hindering access to family planning methods. In Africa, there are more women with an unmet need for family planning than women currently using modern methods. Making family planning accessible in low resource settings will help decrease the existing inequities in achieving desired fertility at individual and country level. In addition, it could help slow population growth within a human rights framework. The United Nations Population Division projections for the year 2050 vary between a high of 10.6 and a low of 7.4 billion. Given that most of the growth is expected to come from today''s resource-poor settings, easy access to family planning could make a difference of billions in the world in 2050.     

The impact of aging on innate and adaptive immunity in the human female genital tract

Mucosal tissues in the human female reproductive tract (FRT) are primary sites for both gynecological cancers and infections by a spectrum of sexually transmitted pathogens, including human immunodeficiency virus (HIV), that compromise women''s health. While the regulation of innate and adaptive immune protection in the FRT by hormonal cyclic changes across the menstrual cycle and pregnancy are being intensely studied, little to nothing is known about the alterations in mucosal immune protection that occur throughout the FRT as women age following menopause. The immune system in the FRT has two key functions: defense against pathogens and reproduction. After menopause, natural reproductive function ends, and therefore, two overlapping processes contribute to alterations in immune protection in aging women: menopause and immunosenescence. The goal of this review is to summarize the multiple immune changes that occur in the FRT with aging, including the impact on the function of epithelial cells, immune cells, and stromal fibroblasts. These studies indicate that major aspects of innate and adaptive immunity in the FRT are compromised in a site‐specific manner in the FRT as women age. Further, at some FRT sites, immunological compensation occurs. Overall, alterations in mucosal immune protection contribute to the increased risk of sexually transmitted infections (STI), urogenital infections, and gynecological cancers. Further studies are essential to provide a foundation for the development of novel therapeutic interventions to restore immune protection and reverse conditions that threaten women''s lives as they age.     

Economic Status,Education and Empowerment: Implications for Maternal Health Service Utilization in Developing Countries

Background

Relative to the attention given to improving the quality of and access to maternal health services, the influence of women''s socio-economic situation on maternal health care use has received scant attention. The objective of this paper is to examine the relationship between women''s economic, educational and empowerment status, introduced as the 3Es, and maternal health service utilization in developing countries.

Methods/Principal Findings

The analysis uses data from the most recent Demographic and Health Surveys conducted in 31 countries for which data on all the 3Es are available. Separate logistic regression models are fitted for modern contraceptive use, antenatal care and skilled birth attendance in relation to the three covariates of interest: economic, education and empowerment status, additionally controlling for women''s age and residence. We use meta-analysis techniques to combine and summarize results from multiple countries. The 3Es are significantly associated with utilization of maternal health services. The odds of having a skilled attendant at delivery for women in the poorest wealth quintile are 94% lower than that for women in the highest wealth quintile and almost 5 times higher for women with complete primary education relative to those less educated. The likelihood of using modern contraception and attending four or more antenatal care visits are 2.01 and 2.89 times, respectively, higher for women with complete primary education than for those less educated. Women with the highest empowerment score are between 1.31 and 1.82 times more likely than those with a null empowerment score to use modern contraception, attend four or more antenatal care visits and have a skilled attendant at birth.

Conclusions/Significance

Efforts to expand maternal health service utilization can be accelerated by parallel investments in programs aimed at poverty eradication (MDG 1), universal primary education (MDG 2), and women''s empowerment (MDG 3).     

Assessing the correlates of desired family size in Shaanxi,China

Abstract

This exploratory analysis of factors associated with Chinese women's fertility desires uses data on married women between the ages of 18 and 35 who live in Shaanxi Province, China. Analyses using an economic framework found that both rural and urban couples who intended to sign, or who had already signed, the one‐child certificate reported wanting significantly fewer children. However, in rural areas (where 80 per cent of the provincial population lives), education level, living arrangements, participation in an arranged marriage, attitudes regarding the ideal age for marriage, and knowledge of the reasons for the government's fertility policies appear to play a relatively larger role in shaping fertility preferences.     

The Potential of Medical Abortion to Reduce Maternal Mortality in Africa: What Benefits for Tanzania and Ethiopia?

Background

Unsafe abortion is estimated to account for 13% of maternal mortality globally. Medical abortion is a safe alternative.

Methods

By estimating mortality risks for unsafe and medical abortion and childbirth for Tanzania and Ethiopia, we modelled changes in maternal mortality that are achievable if unsafe abortion were replaced by medical abortion. We selected Ethiopia and Tanzania because of their high maternal mortality ratios (MMRatios) and contrasting situations regarding health care provision and abortion legislation. We focused on misoprostol-only regimens due to the drug''s low cost and accessibility. We included the impact of medical abortion on women who would otherwise choose unsafe abortion and on women with unwanted/mistimed pregnancies who would otherwise carry to term.

Results

Thousands of lives could be saved each year in each country by implementing medical abortion using misoprostol (2122 in Tanzania and 2551 in Ethiopia assuming coverage equals family planning services levels: 56% for Tanzania, 31% for Ethiopia). Changes in MMRatios would be less pronounced because the intervention would also affect national birth rates.

Conclusions

This is the first analysis of impact of medical abortion provision which takes into account additional potential users other than those currently using unsafe abortion. Thousands of women''s lives could be saved, but this may not be reflected in as substantial changes in MMRatios because of medical abortion''s demographic impact. Therefore policy makers must be aware of the inability of some traditional measures of maternal mortality to detect the real benefits offered by such an intervention.     

Consensus finally achieved on resuscitative interventions.

A joint policy statement on the resuscitation of patients is published in this issue of CMAJ. Dr. John Williams, the CMA''s director of ethics and legal affairs, discusses how it differs from the joint statement published last year.     

Economic crisis and national attitudes: experimental evidence from Spain

We argue that existing approaches to development, including the women in development [WID] and gender and development [GAD] perspectives, fall short in their treatment of culture, and that a new paradigm, which we term 'Women, Culture and Development' [WCD], represents a way forward. Linking the fields of feminist studies, cultural studies and critical development studies, a WCD framework highlights culture as lived experiences and structures of feeling, attends to the relationship between production and reproduction in women's lives, and centres women's agency and struggles. A multi-ethnic and multiracial feminist approach to development studies, and an explicit engagement with culture can shift economistic and overly structural analyses to highlight the experiences, identities, practices and representations of Third World women. We illustrate the potential of a WCD paradigm with discussions of the environment and sexuality, and conclude with a sketch of the future visions and political possibilities of this approach.     

The Link between Inequality and Population Health in Low and Middle Income Countries: Policy Myth or Social Reality?

An influential policy idea states that reducing inequality is beneficial for improving health in the low and middle income countries (LMICs). Our study provides an empirical test of this idea: we utilized data collected by the Demographic and Health Surveys between 2000 and 2011 in as much as 52 LMICs, and we examined the relationship between household wealth inequality and two health outcomes: anemia status (of the children and their mothers) and the women'' experience of child mortality. Based on multi-level analyses, we found that higher levels of household wealth inequality related to worse health, but this effect was strongly reduced when we took into account the level of individuals'' wealth. However, even after accounting for the differences between individuals in terms of household wealth and other characteristics, in those LMICs with higher household wealth inequality more women experienced child mortality and more children were tested with anemia. This effect was partially mediated by the country''s level and coverage of the health services and infrastructure. Furthermore, we found higher inequality to be related to a larger health gap between the poor and the rich in only one of the three examined samples. We conclude that an effective way to improve the health in the LMICs is to increase the wealth among the poor, which in turn also would lead to lower overall inequality and potential investments in public health infrastructure and services.     

A system worth saving.

The country will mark Canada Health Day on May 12, so CMAJ asked Dr. Michael Gordon to reflect on Canada''s health care system and the changes it has seen and will see. The special day, cosponsored by the Canadian Public Health Association, is designed to highlight "the need for better communication between health professionals and the communities they serve." In this article, Gordon reflects on the dangers facing Canada''s medicare system and the need to protect it from the inroads threatened by privatization.     

"Don't let others design your future", new CMA president tells physicians. Interview by Nancy Robb.

Dr. Judith Kazimirski of Nova Scotia becomes the CMA''s 126th president during the association''s annual meeting in Sydney, NS, this month. She says her priority for the next year is to help the CMA play a lead role as the debate intensifies about the future of health and health care in Canada. "The time is right for a very public debate about what people want their system to be, what problems they''re having, and how reform is moving ahead," she says, "and physicians have a critical leadership role to play."     

A closer look at reproductive technology and postmenopausal motherhood.

Although reproductive technologies have been aimed at young, infertile women, evidence suggests that postmenopausal women are also taking advantage of them. Dr. Eike-Henner Kluge asserts in an article in CMAJ (1994; 151; 353-355) that there are ethical reasons to deny older women access to these technologies. Kluge''s comparison of postmenopausal women to prepubescent girls is fallacious. His assertion that older parents harm children by denying them a "normal" childhood is not supported by any empiric data. Kluge''s distinction between medical intervention, in offering reproductive technologies to a woman in her reproductive years, and "improving on nature", by offering these technologies to postmenopausal a woman is spurious. Unless technologies that are expensive and minimally successful, such as in-vitro fertilization, are denied to everyone, there are no grounds for denying them to postmenopausal women.     

Women's Empowerment and Contraceptive Use: The Role of Independent versus Couples' Decision-Making,from a Lower Middle Income Country Perspective

Introduction

There is little available evidence of associations between the various dimensions of women''s empowerment and contraceptive use having been examined - and of how these associations are mediated by women''s socio-economic and demographic statuses. We assessed these phenomena in Pakistan using a structured-framework approach.

Methods

We analyzed data on 2,133 women who were either using any form of contraceptive or living with unmet need for contraception. The survey was conducted during May - June 2012, with married women of reproductive age (15–49 years) in three districts of Punjab. The dimensions of empowerment were categorized broadly into: economic decision-making, household decision-making, and women''s mobility. Two measures were created for each dimension, and for the overall empowerment: women''s independent decisions, and those taken jointly by couples. Contraceptive use was categorized as either female-only or couple methods on the basis of whether a method requires the awareness of, or some support and cooperation from, the husband. Multinomial regression was used, by means of Odds Ratios (OR), to assess associations between empowerment dimensions and female-only and couple contraceptive methods.

Results

Overall, women tend to get higher decision-making power with increased age, higher literacy, a greater number of children, or being in a household that has superior socio-economic status. The measures for couples'' decision-making for overall empowerment and for each dimension of it showed positive associations with couple methods as well as with female-only methods. The only exception was the measure of economic empowerment, which was associated only with the couple method.

Conclusion

Couples'' joint decision-making is a stronger determinant of the use of contraceptive methods than women-only decision-making. This is the case over and above the contribution of women''s socio-demographic and economic statuses. Effort needs to be made to educate women and their husbands equally, with particular focus on highly effective contraceptive methods.