计划生育/生殖健康权利的促进及其对计划生育优质服务质量的影响研究
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摘要
[研究背景]
计划生育作为我国的基本国策,是我国社会发展过程中特定人口及国情下必然的和历史的选择,计划生育服务是我国生殖健康服务领域的核心问题。1994年开罗国际人口与发展大会之后,我国政府接受了国际社会关于生殖健康及其权利的概念。计划生育工作在服务领域和内容方面从单纯的控制人口转变为计划生育、人口与健康相结合,从简单的行政管理转向优质服务与科学管理相结合,系统地逐步认识并贯彻着从计划生育到生殖健康的服务实践。以妇女为中心的生殖健康在整个生殖健康领域占有突出地位。随着人类社会全面、快速的进步以及人们的认识和实践的不断深入,尤其是1995年世界妇女大会以来、保护和尊重妇女的生殖健康权利逐渐成为各国政府在生殖健康工作领域、以至整个国家全面工作中高度关注的问题。近年来,国内、外在生殖健康领域做了大量的研究和实践,争取、维护人类生殖健康权利的努力还在进程中,还需要更多的调查研究和反思。
我国生殖健康服务实践以计划生育为核心,以《中华人民共和国人口与计划生育法》为代表的一系列法律、法规已形成促进妇女计划生育/生殖健康权利实现的良好的支持环境。“以人为本”成为加强人口和计划生育工作、形成和完善人性化管理和服务机制的核心理念,全国范围内已普遍开展计划生育优质服务。在优质服务中推行的知情选择帮助了服务对象安全和有尊严地表达了他们自己的生殖目标、改善了计划生育服务质量,并在这些努力中进一步赋权于中国妇女。然而,充分实现妇女计划生育/生殖健康权利仍然面临着严峻的挑战：一方面,在个人权利、当前利益与国家的政策、长远利益之间,仍然存在需要进一步协调的矛盾,而且随着我国社会持续发展和经济改革的不断深化,群众“求公平、求维权、求和谐”的愿望和需求更为迫切。另一方面,计划生育服务队伍的服务水平还比较低,服务理念还不够完善,尚不能全面、科学地理解和实践“以人为本”的计划生育优质服务。服务人员对“服务对象在计划生育方面享有的基本权利”存在漠视或理解不够,贯彻落实“服务对象的权利”的意识和技能缺乏；同时,广大育龄妇女缺乏在计划生育方面享有的基本权利的认知、不能主动参与服务和维护自身权利。因此,要解决以上问题,迫切需要从服务对象的计划生育/生殖健康权利的视角重新审视计划生育/生殖健康服务,需要政策层面的大力倡导和强化服务提供方依法行政的意识；提高计划生育服务人员的相关认识、服务意识和技能；需要进一步对广大群众、尤其是育龄妇女开展计划生育/生殖健康权利相关的宣传、教育、倡导和综合咨询服务。
[研究目的]
探讨目前我国育龄妇女计划生育/生殖健康权利的实现状况、制定针对性的干预方案,在试点地区对计划生育服务方和育龄妇女开展性与生殖健康及权利的维护与促进的干预活动,评价干预效果,从维护和促进育龄妇女计划生育/生殖健康权利的角度探索进一步深化计划生育优质服务的进路。
[研究方法]
本研究为流行病学社区干预研究,采用定性和定量相结合的方法收集资料。在中国的内蒙、重庆、广东、河南4个项目试点地区,各选择条件相似的两个县,随机分为干预县和对照县。选定的干预县在常规计划生育服务工作基础上,对育龄妇女实施基于社区的以计划生育/生殖健康权利知识宣教和相应的综合咨询服务为主的综合干预方案；同时,对选定的干预县计划生育服务提供方(管理人员和服务人员)实施贯彻服务对象计划生育/生殖健康权利的政策倡导和性与生殖健康权利知识宣教和对服务人员进行相关咨询服务技能培训为主的综合干预方案。干预期间选定的对照县开展常规计划生育服务工作。基线期分别在所选干预县和对照县的乡镇中随机各选一个乡镇作为调研现场,最后在抽到的乡镇内常住居民中抽取符合条件的已婚育龄妇女作为基线期研究对象；评估期分别在所选的干预县和对照县的其他(基线期未抽到的)乡镇中随机各选一个乡镇作为调研现场,在抽到的乡镇内常住居民中抽取符合条件的已婚育龄妇女作为评估期研究对象。通过对基线期与评估期的干预县和对照县研究对象两次调查的比较,评价干预对服务对象关于计划生育/生殖健康权利的知识、维权态度和行为的影响。同时评价干预对服务提供方计划生育/性与生殖健康权利的知识、服务态度、贯彻落实服务对象权利的行为及技能的影响。最后进一步综合评价干预活动对计划生育优质服务的总体影响。
[研究结果]
本研究无记名访谈研究对象519人,其中个人深入访谈计划生育管理人员17名；小组访谈计划生育服务人员473人；个人深入访谈已婚育龄妇女29人。结构式问卷调查计划生育服务人员306人,其中基线期干预组153人、对照组153人,并完成306人的评估期随访调查；结构式问卷调查育龄妇女7729人,其中基线期对照组1877人、干预组1879人,评估期对照组2009人、干预组1964人。
1.育龄妇女计划生育/生殖健康权利的实现状况以及存在的问题
通过对计划生育管理人员、计划生育服务人员和育龄妇女的访谈,目前育龄妇女计划生育/生殖健康权利的实现状况以及存在的问题如下：
1)国家政策和法律层面为广大育龄妇女提供了计划生育/生殖健康权利的基本保障,计划生育管理人员普遍对此有所认识；
2)管理人员对人口政策与权利之间关系的认识以及对落实育龄妇女计划生育/生殖健康权利的重大意义的认识有不足之处,缺乏对育龄妇女计划生育/生殖健康权利的关注、日常工作对实现育龄妇女计划生育/生殖健康权利缺乏明确的工作部署以及常规和有效的考核与评价；
3)基层计生服务系统是贴近群众、向群众宣教计划生育/生殖健康权利的重要公共服务组织,“以人为本”的优质服务是计划生育/生殖健康权利促进的基本途径；
4)服务人员对计划生育优质服务注重“技术服务”,对计划生育优质服务的“人文服务”的内涵认识不足；
5)服务人员对维护和促进群众计划生育/生殖健康权利有一定的服务意愿,对计划生育/生殖健康权利知识和实现计划生育/生殖健康权利的认识不足,服务技能欠缺；
6)社会经济发展水平仍然是育龄妇女充分享有计划生育/生殖健康权利的重要制约因素,且来自服务提供者和服务对象双方的传统文化和社会性别意识对实现育龄妇女的计划生育/生殖健康权利有着重要的影响；
7)育龄妇女对自身计划生育/生殖健康权利的认知不足、自我赋权和维权的意识及能力低是影响自身计划生育/生殖健康权利实现的重要障碍；
8)计划生育服务人员认为计生系统开展维护和促进育龄妇女计划生育/生殖健康权利的前三位优势依次是“符合我国计划生育/生殖健康服务工作的发展方向、适宜可行”、“政府支持、有法律保障”、“计划生育服务网络健全”；前三位障碍依次是“政策与现实存在一定矛盾”、“传统社会文化等大环境中不利因素”、“资金投入不足”。
9)计划生育服务人员认为计生系统开展维护和促进计划生育/生殖健康权利前三位策略依次是“强化有利政策的执行”、“加强生殖健康权利宣教、形成社会文化氛围”、“把性与生殖健康权利咨询服务纳入规范的综合咨询”
2.基线期育龄妇女定量研究结果
本研究基线期调查符合条件的已婚育龄妇女3756人,25岁～40岁者居多(78.06%)；研究对象的文化程度以初中为主(42.71%)；研究对象的平均月收入一半以上在1000元以内(56.52%)；户籍性质以农村为多(59.11%)；以现有一个孩子者居多(52.37%)。对已生育孩子的2447名育龄妇女的孩子数量的多因素分析显示,35岁以上的已婚育龄妇女较35岁以下者生育孩子更多；城镇户口者相较农村户口者更倾向于少生育孩子；学历越高,孩子个数越少；与科技人员/教师/医务工作者/公务员相比,从事农业者的孩子个数更多。避孕措施总使用率90.02%；宫内节育器、避孕套和结扎是前三种最为常用的避孕措施,使用比例依次为：宫内节育器62.41%、避孕套20.47%和结扎14.11%；三种合计使用构成达96.99%。多重对应分析结果显示有一个孩子者倾向用宫内节育器,有两个及以上孩子者倾向用输卵管结扎,城镇户籍可能与用避孕套有关联。由夫妻双方共同决定使用避孕措施者占到56.55%；其次为本人决定、占到31.03%。目前使用避孕措施与期望避孕措施之间具有一定的一致性(P<0.01,Kappa=0.49)。对所用避孕方法,使用避孕措施者中77.52%的对象表示了解其优点；有50.84%的对象表示了解其副作用。在2110名使用宫内节育器者,29.86%对具体类型不知晓。在3381名使用避孕措施者中,有16.50%的人对常见避孕药具付费方式不全知晓；有32.89%的对象表示有更换现用方法的愿望。
育龄妇女均听说过法定计划生育权利,主要知晓来源为计生部门及计生服务人员,占到构成的58.97%。育龄妇女对我国法定的计划生育八项基本权利中,了解较好的前三位依次为“依法生育的权利”、“计划生育男女平等的权利”“获得避孕节育技术和生殖保健服务的权利”分别有3255人(86.66%)、3183人(84.74%)、3134人(83.44%),了解较差的为“获得计划生育/生殖健康信息和教育的权利”和“获得法律救济的权利”,分别有2271人(60.46%)和2240人(59.64%)。有2504人(66.67%)表示听说过“计划生育服务对象在计生服务过程中享有权利”的说法；其中,对计生服务过程中享有的十大权利中了解较好的前三位依次为选择权(86.26%)、隐私权及保密权(81.95%)、知情权(80.39%)；了解最差的是安全权(41.29%)。有84.05%的对象认为有必要在计生系统开展计划生育/生殖健康权利促进活动,52.85%的对象表示个人有接受宣教的需求。
有74.36%的人听说过“计划生育优质服务”；有67.17%的人知道当地开展的优质服务。有73.80%的人听说过“避孕节育知情选择”；有67.60%的人知道当地开展的避孕节育知情选择服务。有63.23%的人听说过“生殖健康综合咨询”；有52.93%的人知道当地开展的生殖健康综合咨询服务。2002名育龄妇女对最近一次接受过的避孕节育咨询服务过程总体满意者占72.38%；1442名育龄妇女对最近一次接受过的性与生殖健康综合咨询服务过程总体满意者66.99%；最近一次接受过计划生育门诊服务的2913名育龄妇女表示对服务环境、服务态度、诊疗设备、技术水平、服务项目五个方面满意者分别占到71.88%,83.45%,80.64%,81.67%,74.53%。有73.30%的育龄妇女认为对服务人员应进行专业培训,有71.47%的育龄妇女认为取得专业资格认证的服务人员才可以被允许提供计划生育/生殖健康服务。
3.育龄妇女干预效果评价
综合干预提高了育龄妇女对计划生育/生殖健康权利知识的知晓率、改善了对我国法定计划生育权利、以及国际计生联提出的服务过程中享有的权利的了解情况。干预提高了育龄妇女对“全社会倡导计划生育/生殖健康权利”的积极态度、提高了育龄妇女对计划生育/生殖健康权利进一步宣教服务的个人需求。干预使更多的育龄妇女产生获得全面的知情选择服务、性与生殖健康权利(SRHR)综合服务的要求,以及对服务人员专业素质的要求。干预提高了育龄妇女寻求计划生育/生殖健康权利服务的行为意愿。干预对使用短效可逆避孕方法的育龄妇女的避孕措施决定人尚没有影响、对研究对象安全套避孕使用率没有影响。
4.计划生育服务人员的干预效果
计生服务人员对我国公民法定计划生育权利和服务对象接受计划生育服务过程中的基本权项有较好的了解,综合干预进一步提高了计划生育服务人员对服务对象的法定权利、服务过程中享有权利以及多项性与生殖健康权利的认知。干预使计生服务人员提供SRHR综合咨询服务的技能有提高,但仍处较低水平。干预提高了服务人员提供SRHR宣教服务和咨询服务的意愿。计生服务人员对计生系统开展计划生育/生殖健康权利促进的活动普遍有积极态度,干预后,有更多服务人员认为计划生育/生殖健康权利促进有助于服务对象自主决策、有助于提高服务质量、有利于服务对象与服务人员关系融洽、有助于国家人口发展计划的实现。干预提高了服务人员对SRHR综合咨询服务技能培训的需求。评估期服务人员一致认为计生系统开展生殖健康权利维护和促进具有重要意义,教育和培训是重要策略。
5.计划生育/生殖健康权利促进对优质服务及其服务质量的影响
计生系统开展计划生育/生殖健康权利促进活动后,更多的育龄妇女对计划生育/生殖健康权利促进的有了积极态度；同时育龄妇女对当地开展的避孕节育知情选择服务以及生殖健康综合咨询服务的知晓有所提高、并对服务项目准确和全面的认识有所提高。权利促进活动对服务人员在避孕节育知情选择咨询服务和性与生殖健康综合咨询服务过程中规范操作的实现有了积极影响；为育龄妇女获得更为满意的避孕节育服务结局产生了积极影响；对育龄妇女是否获得更为满意的门诊服务没有影响。权利促进活动使更多育龄妇女对自己现用避孕方法副作用有了了解、对宫内节育器类型和常见避孕药具付费方式有了全面知晓,权利促进活动对育龄妇女更换现用避孕方法的意愿没有影响。
[结论]
计生系统维护和促进育龄妇女计划生育/生殖健康权利有障碍也有优势。育龄妇女计划生育/生殖健康权利的落实不充分。一方面提高育龄妇女计划生育/生殖健康权利的知识和意识十分必要,另一方面加强计划生育管理人员和服务人员对育龄妇女计划生育/生殖健康权利认识、提高对计划生育优质服务“人文服务”内涵的认识十分必要。集“宣教、倡导和咨询服务”为一体的综合干预对育龄妇女计划生育/生殖健康权利的认知水平、维权意识及相关的行为意愿产生了积极作用。集“培训、倡导和提供咨询服务”为一体的参与式综合干预提高了服务人员对计划生育/生殖健康权利的认识水平、改善了服务技能和意愿。从实现育龄妇女计划生育/生殖健康权利的角度深入推进优质服务具有重要性和必要性。权利促进对妇女计划生育/生殖健康及其服务的长期影响还有待进一步研究。
[Background]
Family planning is an inevitable and historical choice as a basic policy of China under the specific status of population and social development, and family planning service is the core of the reproductive health services in China. Since the international conference on population and development held in Cairo In1994, the concepts of sexual and reproductive health&rights (SRHR) which the international society emphasized have been accepted by Chinese government. Both service fields and contents of family planning has shifted from the simple population control to the combination of population control, population and health. The work mechanism has changed from simple administrative management into the combination of high quality service and scientific management. The shift from family planning service to reproductive health service both in knowledge and in practice was made gradually by the family planning system. The women-central reproductive health had played a prominent role in the whole reproductive health field. As the rapid and comprehensive progress of human society, especially since the Fourth World Women Conference in1995, protecting and respecting women's reproductive health rights had been highly concerned gradually in reproductive health fields, even in national overall routine. In recent years, a lot of research and practice were conducted in reproductive health field worldwide. However, striving for and maintaining human reproductive health rights are still in the process, and more research and rethink are still needed.
The support environment of promoting women's family planning&reproductive health rights was formed based on a series of rules and regulations with the law of the People's Republic of Population and Family Planning as a representative. Client-centered has been the core concept of strengthening population and family planning service, as well as formatting and perfecting the humanized management and service mechanism. Nationwide high-quality service has been generally carried out. Informed choice helped family planning clients to express their own goals with safety and dignity in the care of quality and improved the reproductive family planning service quality and furthered women's empowerment in these efforts to in China. However, fully realizing the women's family planning and reproductive health right still faces severe challenges:On the one hand, there are some contradictions between individual rights and national policies, as well as between the current interests and long-term interests, which should be coordinated. With the constant development of society and the deepening of the economy reform, the desires and requirements of impartial, empowerment and harmony come from the mass are more urgent than before. On the other hand, the service level of family planning service team is rather low, and service concept is still not perfect. Meanwhile, comprehensive and scientific understanding of people-oriented family planning service is not obtained by service personnel, and then the people-oriented family planning service is not conducted by service personnel. Family planning service providers pay no attention to clients' rights and cannot understand clients' rights fully with the lack of awareness and skill in realizing of clients' rights in family planning. At the same time, the women at reproductive age can't actively participate in service and maintenance of their rights because of the short of knowledge of basic rights in family planning. Therefore, to solve these problems above, it is urgent to re-examine the family planning and reproductive health services in perspective of realizing clients' rights in family planning. To advocate policy and to implement the administration according to law, the consciousness of service providers should also be enhanced. The urgent needs are to improve the family planning service providers' knowledge, service awareness and skills related SRHR, but also to provide further publicity, education, advocacy, and comprehensive consulting services related SRHR in public, especially among women at reproductive age.
[Objective]
The aims include to explore current achievement of reproductive health rights among women of child-bearing age in China and to design the intervention plans and to implement a series of intervention activities of promoting SRHR among providers and women of child-bearing age in the pilot areas, and then to evaluate the intervention effect, and to explore further approach to deepen family planning service from visual angle of child-bearing aged women's of family planning and reproductive health right.
[Methods]
This study was designed as a community-based intervention program with the qualitative and quantitative methods to collect data. The multistage systematic sampling was used. In Stage one, four pilot areas including Chongqing City, Guangdong Province, Inner Mongolia Autonomous Region and Henan Province were selected. In Stage two, two counties with similar condition of development were chosen in each pilot area and were randomly assigned to intervention group and control group. The intervention activities mainly including education, propaganda, integrated sexuality and reproductive health rights counselling were implemented among women of child-bearing age in intervention group and the intervention mainly including advocacy, propaganda, SRHR integrated training were implemented among FP staff in intervention group, while routine FP work was conducted in the control group. One town was randomly chosen from intervention group and control group respectively in each pilot area as the site of survey in baseline. And another town was randomly chosen from intervention group and control group respectively in each pilot area as the site of survey in end line. Eligible married women of child-bearing age and FP centre personnel were recruited in these towns selected for survey. Information was gathered by quantitative questionnaires, focus group discussion and in-depth interviews. The intervention effects were evaluated by comparing the results of base line survey and end line survey. The overall impact of the protection and promotion of SRHR on high quality service was evaluated.
[Results]
Anonymous interviews were implemented among519subjects including individual in-depth interviews with17family planning management personnel, focus group discussion with473family planning service staff and individual in-depth interviews with29married women of child-bearing age. A quantitative questionnaire was used to gather the information of306family planning service providers from intervention group(153subjects) and control group(153subjects) respectively. Another quantitative questionnaire was used to gather the information of married women of child-bearing age including1879subjects from intervention group and1877subjects from control group. After1year's intervention,153family planning service providers were followed from intervention group and control group. At the same time, married women of child-bearing age including1964subjects from intervention group and2009subjects from control group were investigated by corresponding questionnaire.
1. Current fulfillment and achievement of reproductive women's family planning and reproductive health rights and the problems existed
Through interviews with FP managers, FP service providers and reproductive women, current status and suggestions of protection and promotion of family planning and reproductive health rights were listed below:
1) It is generally known by family planning managers that national policy and laws is the basic guarantee of women's family planning and reproductive health rights.
2) The lack of correct understanding of the relationship between national population policy and women's family planning and reproductive health rights, as well as the lack of the concern on fulfillment of reproductive women's family planning and reproductive health rights exist. Specific plans, routine and effective assessment are insufficient to realize women's family planning and reproductive health rights.
3) The front line family planning service system is an important public service organization due to its public accessibility."People oriented" quality service is the basic way of improving women's family planning and reproductive health rights.
4) FP service personnel pay more attention to "technical service" of family planning while pay less attention to "humanistic service" of family planning.
5) FP service personnel have the wiliness to protect and to promote reproductive women's family planning and reproductive health rights. But lack of the knowledge, skills and understanding related to fulfillment of reproductive women's family planning and reproductive health rights among the front line family planning service providers exists.
6) The level of social economic development is still an important restricting factor towards full enjoyment of family planning and reproductive health rights of women. And traditional culture and social gender consciousness from both sides of service providers and service subjects has important effect on the realization of women's family planning and reproductive health rights.
7) The lack of the knowledge, self-empowerment and awareness of women's family planning and reproductive health rights among women is an serious obstacle for obtaining women's family planning and reproductive health rights.
8) The three advantages to improve women's family planning and reproductive health rights that family planning service providers considered are " the coherence to development direction of FP in China, and the feasibility"," the support and legal protection from government"," perfect network of PF service " successively. Meanwhile, the three barriers are" the contradiction between national policy and reality"," adverse factors such as traditional social culture, support environment and so on"," insufficient investment" in turn.
9) PF service personnel put forward three strategies for promoting women's family planning and reproductive health rights which include" to strengthen the implementation of policy","to strengthen the propaganda and education of reproductive health rights to develop social culture","to integrate consulting service of SRHR into formal comprehensive consulting service'
2. The results from questionnaire investigation among married women of child-bearing age in baseline survey
Total3756married women of child-bearing age were recruited in baseline survey. Most respondents (78.06%) were aged25to40years old. Nearly43%of them had the education level of junior high school. About56.52%of respondents had an average income of below1000(RMB) monthly. The majority of these women (59.11%) were rural registered residents, and the majority of these women (52.37%) had one child. Multivariate Logistic regression analysis showed that age, register of residence, educational attainment and occupation are the main influencing factors of the number of children. Contraceptive prevalence was90.02%. The main contraceptive methods were the intrauterine device (62.41%), condoms (20.47%) and female sterilization (14.11%). And total use rate of the three methods account for96.99%. Multiple corresponding analysis results showed that women with one child tend to use IUDs while women with two or more children tend to use female sterilization. Most contraceptive decisions made by both husband and wife, the proportion were56.55%. And contraceptive decisions made by oneself accounted for31.03%. There was a certain consistency between the contraceptive measures used in current and the contraceptive measures expected. Among the contraceptive user,77.52%understood the advantages of the contraceptive method they used while50.84%understood the side effects of the contraceptive they used. Nearly30%of the IUDs users did not know the type of their IUDs. And16.50%of the subjects did not know all the payment types of the common contraceptives. And32.89%of the subjects wanted to change the current contraceptive they used.
All respondents heard the legal rights of family planning in China, and family planning service personnel were the main source accounting for58.97%. Three of the eight legal rights were understood better by respondents which were "the right to bear according to law","the right to equality between men and women in family planning,"'the right to get the contraception, birth control technology and reproductive health services ", and the proportions of the subjects were86.66%,84.74%and83.44%successively. The last two legal rights understood poorly by respondents were respectively "the right to get information and education about family planning and reproductive health"(60.46%) and "the right to obtain legal relief"(59.64%). There were2504respondents (66.67%) who heard of the view of "family planning service subjects possess their rights in the service process". Three of the ten rights were understood better by these women which were respectively "the right to choose"(86.26%),"the right to privacy and confidentiality"(86.26%) and the right to know (80.39%), and only41.29%of them understood the right to security. There were84.05%of the respondents who thought it was necessary to carry out promotion activities of family planning&reproductive health rights in PF system and there were52.85%of the respondents who required propaganda and education about family planning&reproductive health rights.
There were74.36%of the respondents who had heard of "quality of care" and67.17%of the respondents knew local quality of care. There were73.80%of the respondents who heard of "informed choice" and67.60%of them knew local informed choice. There were63.23%of the respondents who heard of "integrated reproductive health counseling" and52.93%of the respondents knew local integrated reproductive health counseling. Among2002respondents who received contraceptive counseling,72.38%were satisfied with the latest service process. Among1442respondents who received integrated SRHR counseling,66.99%were satisfied with the latest service process. Among2913respondents who received latest outpatient service, the proportion of the women who were satisfied with service environment, service attitude, medical equipment, technical level and service project were respectively71.88%,83.45%,80.64%,81.67%, and74.53%.There were73.30%of the respondents who thought FP providers should be trained professionally and there were71.47%of the respondents who thought those FP providers who attained professional qualification authentication should be allowed to provide services.
3. Intervention effect on married women of child-bearing age
The knowledge and awareness of family planning and reproductive health rights including the legal rights in China and women's rights in service process proposed by international family planning association were improved among married women of child-bearing age through comprehensive intervention. Interventions also enhanced positive attitude towards advocacy of family planning and reproductive health rights widely and boosted the individual needs of education services about family planning and reproductive health rights, and the demands of comprehensive informed choice, integrated sexual and reproductive health service, as well as the service personnel professional quality requirements. Intervention contributed to women's behavior tendency to seeking for services related to family planning and reproductive health rights. Interventions have no effect on proportion of decision-makers of short-acting reversible contraceptive, as well as the proportion of condom user.
4. Intervention effect on FP service providers
The legal rights in China and women's rights in service process proposed by international family planning association were known generally among FP service providers. After comprehensive intervention, the knowledge and understanding of family planning and reproductive health rights among FP service providers were further increased. FP service providers'skills and abilities of SRHR counseling were improved, but still at a low level. Intervention improved service providers'will to perform SRHR education and integrated counseling service. Family plan service personnel have positive attitudes towards carrying out the activities of family planning and reproductive health rights promotion generally. After intervention, there were more service providers'who considered that the promotion of family planning and reproductive health rights was helpful to the clients'independent decision, harmonious relationship between service providers and clients and the realization of the national population development plan. The needs of skills training among service personnel were increased. Service providers'consensus was that the protection and promotion of SRHR played an important role, and then, education and training were major strategies.
5. The results of promotion activities of family planning and reproductive health rights in advance of quality of care
After intervention, there were more married women of child-bearing age who hold positive attitudes towards the promotion of family planning and reproductive health rights. At the same time, the proportion of the women who knew the quality of care, contraceptive informed choice services and integrated reproductive health counseling were increased. And their accurate and comprehensive understanding of the three services was also increased. The promotion activities of family planning and reproductive health rights have a positive effect on standard operation of contraceptive informed choice services and integrated reproductive health counseling. And these promotion activities promote the positive influence to clients'satisfaction for contraception services while these promotion activities had no effect on clients' satisfaction for outpatient services. As a result, the proportion of the women who knew the side effects, types and payment types of common contraceptives were all increased. But promotion activities had no effect on the proportion of the women who want to change current contraceptive they used.
[Conclusion]
Not only did advantages but also obstacles towards protecting and improving women'family planning and reproductive health rights through family planning service system exist. The realization of women' family planning and reproductive health rights was not enough. On one hand, to improve knowledge and awareness of women' family planning and reproductive health rights among married women of child-bearing age were extremely necessary. On the other hand, to improve awareness of women' family planning and reproductive health rights and to improve awareness of humanistic meaning of quality of care among FP managers and providers were also extremely necessary. The collection "education and training, advocacy, and counseling service" as one of the participatory intervention integrated with training, advocacy, and counseling service deliver improve the service providers' understanding of family planning and reproductive health rights and improve the skills and will of service. The intervention integrated with education, advocacy, and counseling service improve the service subjects'understanding of family planning and reproductive health rights had a positive effect on self empowerment consciousness and corresponding behavior tendency. It was significant and necessary way to propel quality of care deeply through realizing women's family planning and reproductive health rights. The long-term effects of protection and promotion of women's family planning and reproductive health rights on women's family planning&reproductive health should be further evaluated.
计划生育作为我国的基本国策,是我国社会发展过程中特定人口及国情下必然的和历史的选择,计划生育服务是我国生殖健康服务领域的核心问题。1994年开罗国际人口与发展大会之后,我国政府接受了国际社会关于生殖健康及其权利的概念。计划生育工作在服务领域和内容方面从单纯的控制人口转变为计划生育、人口与健康相结合,从简单的行政管理转向优质服务与科学管理相结合,系统地逐步认识并贯彻着从计划生育到生殖健康的服务实践。以妇女为中心的生殖健康在整个生殖健康领域占有突出地位。随着人类社会全面、快速的进步以及人们的认识和实践的不断深入,尤其是1995年世界妇女大会以来、保护和尊重妇女的生殖健康权利逐渐成为各国政府在生殖健康工作领域、以至整个国家全面工作中高度关注的问题。近年来,国内、外在生殖健康领域做了大量的研究和实践,争取、维护人类生殖健康权利的努力还在进程中,还需要更多的调查研究和反思。
我国生殖健康服务实践以计划生育为核心,以《中华人民共和国人口与计划生育法》为代表的一系列法律、法规已形成促进妇女计划生育/生殖健康权利实现的良好的支持环境。“以人为本”成为加强人口和计划生育工作、形成和完善人性化管理和服务机制的核心理念,全国范围内已普遍开展计划生育优质服务。在优质服务中推行的知情选择帮助了服务对象安全和有尊严地表达了他们自己的生殖目标、改善了计划生育服务质量,并在这些努力中进一步赋权于中国妇女。然而,充分实现妇女计划生育/生殖健康权利仍然面临着严峻的挑战：一方面,在个人权利、当前利益与国家的政策、长远利益之间,仍然存在需要进一步协调的矛盾,而且随着我国社会持续发展和经济改革的不断深化,群众“求公平、求维权、求和谐”的愿望和需求更为迫切。另一方面,计划生育服务队伍的服务水平还比较低,服务理念还不够完善,尚不能全面、科学地理解和实践“以人为本”的计划生育优质服务。服务人员对“服务对象在计划生育方面享有的基本权利”存在漠视或理解不够,贯彻落实“服务对象的权利”的意识和技能缺乏；同时,广大育龄妇女缺乏在计划生育方面享有的基本权利的认知、不能主动参与服务和维护自身权利。因此,要解决以上问题,迫切需要从服务对象的计划生育/生殖健康权利的视角重新审视计划生育/生殖健康服务,需要政策层面的大力倡导和强化服务提供方依法行政的意识；提高计划生育服务人员的相关认识、服务意识和技能；需要进一步对广大群众、尤其是育龄妇女开展计划生育/生殖健康权利相关的宣传、教育、倡导和综合咨询服务。
[研究目的]
探讨目前我国育龄妇女计划生育/生殖健康权利的实现状况、制定针对性的干预方案,在试点地区对计划生育服务方和育龄妇女开展性与生殖健康及权利的维护与促进的干预活动,评价干预效果,从维护和促进育龄妇女计划生育/生殖健康权利的角度探索进一步深化计划生育优质服务的进路。
[研究方法]
本研究为流行病学社区干预研究,采用定性和定量相结合的方法收集资料。在中国的内蒙、重庆、广东、河南4个项目试点地区,各选择条件相似的两个县,随机分为干预县和对照县。选定的干预县在常规计划生育服务工作基础上,对育龄妇女实施基于社区的以计划生育/生殖健康权利知识宣教和相应的综合咨询服务为主的综合干预方案；同时,对选定的干预县计划生育服务提供方(管理人员和服务人员)实施贯彻服务对象计划生育/生殖健康权利的政策倡导和性与生殖健康权利知识宣教和对服务人员进行相关咨询服务技能培训为主的综合干预方案。干预期间选定的对照县开展常规计划生育服务工作。基线期分别在所选干预县和对照县的乡镇中随机各选一个乡镇作为调研现场,最后在抽到的乡镇内常住居民中抽取符合条件的已婚育龄妇女作为基线期研究对象；评估期分别在所选的干预县和对照县的其他(基线期未抽到的)乡镇中随机各选一个乡镇作为调研现场,在抽到的乡镇内常住居民中抽取符合条件的已婚育龄妇女作为评估期研究对象。通过对基线期与评估期的干预县和对照县研究对象两次调查的比较,评价干预对服务对象关于计划生育/生殖健康权利的知识、维权态度和行为的影响。同时评价干预对服务提供方计划生育/性与生殖健康权利的知识、服务态度、贯彻落实服务对象权利的行为及技能的影响。最后进一步综合评价干预活动对计划生育优质服务的总体影响。
[研究结果]
本研究无记名访谈研究对象519人,其中个人深入访谈计划生育管理人员17名；小组访谈计划生育服务人员473人；个人深入访谈已婚育龄妇女29人。结构式问卷调查计划生育服务人员306人,其中基线期干预组153人、对照组153人,并完成306人的评估期随访调查；结构式问卷调查育龄妇女7729人,其中基线期对照组1877人、干预组1879人,评估期对照组2009人、干预组1964人。
1.育龄妇女计划生育/生殖健康权利的实现状况以及存在的问题
通过对计划生育管理人员、计划生育服务人员和育龄妇女的访谈,目前育龄妇女计划生育/生殖健康权利的实现状况以及存在的问题如下：
1)国家政策和法律层面为广大育龄妇女提供了计划生育/生殖健康权利的基本保障,计划生育管理人员普遍对此有所认识；
2)管理人员对人口政策与权利之间关系的认识以及对落实育龄妇女计划生育/生殖健康权利的重大意义的认识有不足之处,缺乏对育龄妇女计划生育/生殖健康权利的关注、日常工作对实现育龄妇女计划生育/生殖健康权利缺乏明确的工作部署以及常规和有效的考核与评价；
3)基层计生服务系统是贴近群众、向群众宣教计划生育/生殖健康权利的重要公共服务组织,“以人为本”的优质服务是计划生育/生殖健康权利促进的基本途径；
4)服务人员对计划生育优质服务注重“技术服务”,对计划生育优质服务的“人文服务”的内涵认识不足；
5)服务人员对维护和促进群众计划生育/生殖健康权利有一定的服务意愿,对计划生育/生殖健康权利知识和实现计划生育/生殖健康权利的认识不足,服务技能欠缺；
6)社会经济发展水平仍然是育龄妇女充分享有计划生育/生殖健康权利的重要制约因素,且来自服务提供者和服务对象双方的传统文化和社会性别意识对实现育龄妇女的计划生育/生殖健康权利有着重要的影响；
7)育龄妇女对自身计划生育/生殖健康权利的认知不足、自我赋权和维权的意识及能力低是影响自身计划生育/生殖健康权利实现的重要障碍；
8)计划生育服务人员认为计生系统开展维护和促进育龄妇女计划生育/生殖健康权利的前三位优势依次是“符合我国计划生育/生殖健康服务工作的发展方向、适宜可行”、“政府支持、有法律保障”、“计划生育服务网络健全”；前三位障碍依次是“政策与现实存在一定矛盾”、“传统社会文化等大环境中不利因素”、“资金投入不足”。
9)计划生育服务人员认为计生系统开展维护和促进计划生育/生殖健康权利前三位策略依次是“强化有利政策的执行”、“加强生殖健康权利宣教、形成社会文化氛围”、“把性与生殖健康权利咨询服务纳入规范的综合咨询”
2.基线期育龄妇女定量研究结果
本研究基线期调查符合条件的已婚育龄妇女3756人,25岁～40岁者居多(78.06%)；研究对象的文化程度以初中为主(42.71%)；研究对象的平均月收入一半以上在1000元以内(56.52%)；户籍性质以农村为多(59.11%)；以现有一个孩子者居多(52.37%)。对已生育孩子的2447名育龄妇女的孩子数量的多因素分析显示,35岁以上的已婚育龄妇女较35岁以下者生育孩子更多；城镇户口者相较农村户口者更倾向于少生育孩子；学历越高,孩子个数越少；与科技人员/教师/医务工作者/公务员相比,从事农业者的孩子个数更多。避孕措施总使用率90.02%；宫内节育器、避孕套和结扎是前三种最为常用的避孕措施,使用比例依次为：宫内节育器62.41%、避孕套20.47%和结扎14.11%；三种合计使用构成达96.99%。多重对应分析结果显示有一个孩子者倾向用宫内节育器,有两个及以上孩子者倾向用输卵管结扎,城镇户籍可能与用避孕套有关联。由夫妻双方共同决定使用避孕措施者占到56.55%；其次为本人决定、占到31.03%。目前使用避孕措施与期望避孕措施之间具有一定的一致性(P<0.01,Kappa=0.49)。对所用避孕方法,使用避孕措施者中77.52%的对象表示了解其优点；有50.84%的对象表示了解其副作用。在2110名使用宫内节育器者,29.86%对具体类型不知晓。在3381名使用避孕措施者中,有16.50%的人对常见避孕药具付费方式不全知晓；有32.89%的对象表示有更换现用方法的愿望。
育龄妇女均听说过法定计划生育权利,主要知晓来源为计生部门及计生服务人员,占到构成的58.97%。育龄妇女对我国法定的计划生育八项基本权利中,了解较好的前三位依次为“依法生育的权利”、“计划生育男女平等的权利”“获得避孕节育技术和生殖保健服务的权利”分别有3255人(86.66%)、3183人(84.74%)、3134人(83.44%),了解较差的为“获得计划生育/生殖健康信息和教育的权利”和“获得法律救济的权利”,分别有2271人(60.46%)和2240人(59.64%)。有2504人(66.67%)表示听说过“计划生育服务对象在计生服务过程中享有权利”的说法；其中,对计生服务过程中享有的十大权利中了解较好的前三位依次为选择权(86.26%)、隐私权及保密权(81.95%)、知情权(80.39%)；了解最差的是安全权(41.29%)。有84.05%的对象认为有必要在计生系统开展计划生育/生殖健康权利促进活动,52.85%的对象表示个人有接受宣教的需求。
有74.36%的人听说过“计划生育优质服务”；有67.17%的人知道当地开展的优质服务。有73.80%的人听说过“避孕节育知情选择”；有67.60%的人知道当地开展的避孕节育知情选择服务。有63.23%的人听说过“生殖健康综合咨询”；有52.93%的人知道当地开展的生殖健康综合咨询服务。2002名育龄妇女对最近一次接受过的避孕节育咨询服务过程总体满意者占72.38%；1442名育龄妇女对最近一次接受过的性与生殖健康综合咨询服务过程总体满意者66.99%；最近一次接受过计划生育门诊服务的2913名育龄妇女表示对服务环境、服务态度、诊疗设备、技术水平、服务项目五个方面满意者分别占到71.88%,83.45%,80.64%,81.67%,74.53%。有73.30%的育龄妇女认为对服务人员应进行专业培训,有71.47%的育龄妇女认为取得专业资格认证的服务人员才可以被允许提供计划生育/生殖健康服务。
3.育龄妇女干预效果评价
综合干预提高了育龄妇女对计划生育/生殖健康权利知识的知晓率、改善了对我国法定计划生育权利、以及国际计生联提出的服务过程中享有的权利的了解情况。干预提高了育龄妇女对“全社会倡导计划生育/生殖健康权利”的积极态度、提高了育龄妇女对计划生育/生殖健康权利进一步宣教服务的个人需求。干预使更多的育龄妇女产生获得全面的知情选择服务、性与生殖健康权利(SRHR)综合服务的要求,以及对服务人员专业素质的要求。干预提高了育龄妇女寻求计划生育/生殖健康权利服务的行为意愿。干预对使用短效可逆避孕方法的育龄妇女的避孕措施决定人尚没有影响、对研究对象安全套避孕使用率没有影响。
4.计划生育服务人员的干预效果
计生服务人员对我国公民法定计划生育权利和服务对象接受计划生育服务过程中的基本权项有较好的了解,综合干预进一步提高了计划生育服务人员对服务对象的法定权利、服务过程中享有权利以及多项性与生殖健康权利的认知。干预使计生服务人员提供SRHR综合咨询服务的技能有提高,但仍处较低水平。干预提高了服务人员提供SRHR宣教服务和咨询服务的意愿。计生服务人员对计生系统开展计划生育/生殖健康权利促进的活动普遍有积极态度,干预后,有更多服务人员认为计划生育/生殖健康权利促进有助于服务对象自主决策、有助于提高服务质量、有利于服务对象与服务人员关系融洽、有助于国家人口发展计划的实现。干预提高了服务人员对SRHR综合咨询服务技能培训的需求。评估期服务人员一致认为计生系统开展生殖健康权利维护和促进具有重要意义,教育和培训是重要策略。
5.计划生育/生殖健康权利促进对优质服务及其服务质量的影响
计生系统开展计划生育/生殖健康权利促进活动后,更多的育龄妇女对计划生育/生殖健康权利促进的有了积极态度；同时育龄妇女对当地开展的避孕节育知情选择服务以及生殖健康综合咨询服务的知晓有所提高、并对服务项目准确和全面的认识有所提高。权利促进活动对服务人员在避孕节育知情选择咨询服务和性与生殖健康综合咨询服务过程中规范操作的实现有了积极影响；为育龄妇女获得更为满意的避孕节育服务结局产生了积极影响；对育龄妇女是否获得更为满意的门诊服务没有影响。权利促进活动使更多育龄妇女对自己现用避孕方法副作用有了了解、对宫内节育器类型和常见避孕药具付费方式有了全面知晓,权利促进活动对育龄妇女更换现用避孕方法的意愿没有影响。
[结论]
计生系统维护和促进育龄妇女计划生育/生殖健康权利有障碍也有优势。育龄妇女计划生育/生殖健康权利的落实不充分。一方面提高育龄妇女计划生育/生殖健康权利的知识和意识十分必要,另一方面加强计划生育管理人员和服务人员对育龄妇女计划生育/生殖健康权利认识、提高对计划生育优质服务“人文服务”内涵的认识十分必要。集“宣教、倡导和咨询服务”为一体的综合干预对育龄妇女计划生育/生殖健康权利的认知水平、维权意识及相关的行为意愿产生了积极作用。集“培训、倡导和提供咨询服务”为一体的参与式综合干预提高了服务人员对计划生育/生殖健康权利的认识水平、改善了服务技能和意愿。从实现育龄妇女计划生育/生殖健康权利的角度深入推进优质服务具有重要性和必要性。权利促进对妇女计划生育/生殖健康及其服务的长期影响还有待进一步研究。
[Background]
Family planning is an inevitable and historical choice as a basic policy of China under the specific status of population and social development, and family planning service is the core of the reproductive health services in China. Since the international conference on population and development held in Cairo In1994, the concepts of sexual and reproductive health&rights (SRHR) which the international society emphasized have been accepted by Chinese government. Both service fields and contents of family planning has shifted from the simple population control to the combination of population control, population and health. The work mechanism has changed from simple administrative management into the combination of high quality service and scientific management. The shift from family planning service to reproductive health service both in knowledge and in practice was made gradually by the family planning system. The women-central reproductive health had played a prominent role in the whole reproductive health field. As the rapid and comprehensive progress of human society, especially since the Fourth World Women Conference in1995, protecting and respecting women's reproductive health rights had been highly concerned gradually in reproductive health fields, even in national overall routine. In recent years, a lot of research and practice were conducted in reproductive health field worldwide. However, striving for and maintaining human reproductive health rights are still in the process, and more research and rethink are still needed.
The support environment of promoting women's family planning&reproductive health rights was formed based on a series of rules and regulations with the law of the People's Republic of Population and Family Planning as a representative. Client-centered has been the core concept of strengthening population and family planning service, as well as formatting and perfecting the humanized management and service mechanism. Nationwide high-quality service has been generally carried out. Informed choice helped family planning clients to express their own goals with safety and dignity in the care of quality and improved the reproductive family planning service quality and furthered women's empowerment in these efforts to in China. However, fully realizing the women's family planning and reproductive health right still faces severe challenges:On the one hand, there are some contradictions between individual rights and national policies, as well as between the current interests and long-term interests, which should be coordinated. With the constant development of society and the deepening of the economy reform, the desires and requirements of impartial, empowerment and harmony come from the mass are more urgent than before. On the other hand, the service level of family planning service team is rather low, and service concept is still not perfect. Meanwhile, comprehensive and scientific understanding of people-oriented family planning service is not obtained by service personnel, and then the people-oriented family planning service is not conducted by service personnel. Family planning service providers pay no attention to clients' rights and cannot understand clients' rights fully with the lack of awareness and skill in realizing of clients' rights in family planning. At the same time, the women at reproductive age can't actively participate in service and maintenance of their rights because of the short of knowledge of basic rights in family planning. Therefore, to solve these problems above, it is urgent to re-examine the family planning and reproductive health services in perspective of realizing clients' rights in family planning. To advocate policy and to implement the administration according to law, the consciousness of service providers should also be enhanced. The urgent needs are to improve the family planning service providers' knowledge, service awareness and skills related SRHR, but also to provide further publicity, education, advocacy, and comprehensive consulting services related SRHR in public, especially among women at reproductive age.
[Objective]
The aims include to explore current achievement of reproductive health rights among women of child-bearing age in China and to design the intervention plans and to implement a series of intervention activities of promoting SRHR among providers and women of child-bearing age in the pilot areas, and then to evaluate the intervention effect, and to explore further approach to deepen family planning service from visual angle of child-bearing aged women's of family planning and reproductive health right.
[Methods]
This study was designed as a community-based intervention program with the qualitative and quantitative methods to collect data. The multistage systematic sampling was used. In Stage one, four pilot areas including Chongqing City, Guangdong Province, Inner Mongolia Autonomous Region and Henan Province were selected. In Stage two, two counties with similar condition of development were chosen in each pilot area and were randomly assigned to intervention group and control group. The intervention activities mainly including education, propaganda, integrated sexuality and reproductive health rights counselling were implemented among women of child-bearing age in intervention group and the intervention mainly including advocacy, propaganda, SRHR integrated training were implemented among FP staff in intervention group, while routine FP work was conducted in the control group. One town was randomly chosen from intervention group and control group respectively in each pilot area as the site of survey in baseline. And another town was randomly chosen from intervention group and control group respectively in each pilot area as the site of survey in end line. Eligible married women of child-bearing age and FP centre personnel were recruited in these towns selected for survey. Information was gathered by quantitative questionnaires, focus group discussion and in-depth interviews. The intervention effects were evaluated by comparing the results of base line survey and end line survey. The overall impact of the protection and promotion of SRHR on high quality service was evaluated.
[Results]
Anonymous interviews were implemented among519subjects including individual in-depth interviews with17family planning management personnel, focus group discussion with473family planning service staff and individual in-depth interviews with29married women of child-bearing age. A quantitative questionnaire was used to gather the information of306family planning service providers from intervention group(153subjects) and control group(153subjects) respectively. Another quantitative questionnaire was used to gather the information of married women of child-bearing age including1879subjects from intervention group and1877subjects from control group. After1year's intervention,153family planning service providers were followed from intervention group and control group. At the same time, married women of child-bearing age including1964subjects from intervention group and2009subjects from control group were investigated by corresponding questionnaire.
1. Current fulfillment and achievement of reproductive women's family planning and reproductive health rights and the problems existed
Through interviews with FP managers, FP service providers and reproductive women, current status and suggestions of protection and promotion of family planning and reproductive health rights were listed below:
1) It is generally known by family planning managers that national policy and laws is the basic guarantee of women's family planning and reproductive health rights.
2) The lack of correct understanding of the relationship between national population policy and women's family planning and reproductive health rights, as well as the lack of the concern on fulfillment of reproductive women's family planning and reproductive health rights exist. Specific plans, routine and effective assessment are insufficient to realize women's family planning and reproductive health rights.
3) The front line family planning service system is an important public service organization due to its public accessibility."People oriented" quality service is the basic way of improving women's family planning and reproductive health rights.
4) FP service personnel pay more attention to "technical service" of family planning while pay less attention to "humanistic service" of family planning.
5) FP service personnel have the wiliness to protect and to promote reproductive women's family planning and reproductive health rights. But lack of the knowledge, skills and understanding related to fulfillment of reproductive women's family planning and reproductive health rights among the front line family planning service providers exists.
6) The level of social economic development is still an important restricting factor towards full enjoyment of family planning and reproductive health rights of women. And traditional culture and social gender consciousness from both sides of service providers and service subjects has important effect on the realization of women's family planning and reproductive health rights.
7) The lack of the knowledge, self-empowerment and awareness of women's family planning and reproductive health rights among women is an serious obstacle for obtaining women's family planning and reproductive health rights.
8) The three advantages to improve women's family planning and reproductive health rights that family planning service providers considered are " the coherence to development direction of FP in China, and the feasibility"," the support and legal protection from government"," perfect network of PF service " successively. Meanwhile, the three barriers are" the contradiction between national policy and reality"," adverse factors such as traditional social culture, support environment and so on"," insufficient investment" in turn.
9) PF service personnel put forward three strategies for promoting women's family planning and reproductive health rights which include" to strengthen the implementation of policy","to strengthen the propaganda and education of reproductive health rights to develop social culture","to integrate consulting service of SRHR into formal comprehensive consulting service'
2. The results from questionnaire investigation among married women of child-bearing age in baseline survey
Total3756married women of child-bearing age were recruited in baseline survey. Most respondents (78.06%) were aged25to40years old. Nearly43%of them had the education level of junior high school. About56.52%of respondents had an average income of below1000(RMB) monthly. The majority of these women (59.11%) were rural registered residents, and the majority of these women (52.37%) had one child. Multivariate Logistic regression analysis showed that age, register of residence, educational attainment and occupation are the main influencing factors of the number of children. Contraceptive prevalence was90.02%. The main contraceptive methods were the intrauterine device (62.41%), condoms (20.47%) and female sterilization (14.11%). And total use rate of the three methods account for96.99%. Multiple corresponding analysis results showed that women with one child tend to use IUDs while women with two or more children tend to use female sterilization. Most contraceptive decisions made by both husband and wife, the proportion were56.55%. And contraceptive decisions made by oneself accounted for31.03%. There was a certain consistency between the contraceptive measures used in current and the contraceptive measures expected. Among the contraceptive user,77.52%understood the advantages of the contraceptive method they used while50.84%understood the side effects of the contraceptive they used. Nearly30%of the IUDs users did not know the type of their IUDs. And16.50%of the subjects did not know all the payment types of the common contraceptives. And32.89%of the subjects wanted to change the current contraceptive they used.
All respondents heard the legal rights of family planning in China, and family planning service personnel were the main source accounting for58.97%. Three of the eight legal rights were understood better by respondents which were "the right to bear according to law","the right to equality between men and women in family planning,"'the right to get the contraception, birth control technology and reproductive health services ", and the proportions of the subjects were86.66%,84.74%and83.44%successively. The last two legal rights understood poorly by respondents were respectively "the right to get information and education about family planning and reproductive health"(60.46%) and "the right to obtain legal relief"(59.64%). There were2504respondents (66.67%) who heard of the view of "family planning service subjects possess their rights in the service process". Three of the ten rights were understood better by these women which were respectively "the right to choose"(86.26%),"the right to privacy and confidentiality"(86.26%) and the right to know (80.39%), and only41.29%of them understood the right to security. There were84.05%of the respondents who thought it was necessary to carry out promotion activities of family planning&reproductive health rights in PF system and there were52.85%of the respondents who required propaganda and education about family planning&reproductive health rights.
There were74.36%of the respondents who had heard of "quality of care" and67.17%of the respondents knew local quality of care. There were73.80%of the respondents who heard of "informed choice" and67.60%of them knew local informed choice. There were63.23%of the respondents who heard of "integrated reproductive health counseling" and52.93%of the respondents knew local integrated reproductive health counseling. Among2002respondents who received contraceptive counseling,72.38%were satisfied with the latest service process. Among1442respondents who received integrated SRHR counseling,66.99%were satisfied with the latest service process. Among2913respondents who received latest outpatient service, the proportion of the women who were satisfied with service environment, service attitude, medical equipment, technical level and service project were respectively71.88%,83.45%,80.64%,81.67%, and74.53%.There were73.30%of the respondents who thought FP providers should be trained professionally and there were71.47%of the respondents who thought those FP providers who attained professional qualification authentication should be allowed to provide services.
3. Intervention effect on married women of child-bearing age
The knowledge and awareness of family planning and reproductive health rights including the legal rights in China and women's rights in service process proposed by international family planning association were improved among married women of child-bearing age through comprehensive intervention. Interventions also enhanced positive attitude towards advocacy of family planning and reproductive health rights widely and boosted the individual needs of education services about family planning and reproductive health rights, and the demands of comprehensive informed choice, integrated sexual and reproductive health service, as well as the service personnel professional quality requirements. Intervention contributed to women's behavior tendency to seeking for services related to family planning and reproductive health rights. Interventions have no effect on proportion of decision-makers of short-acting reversible contraceptive, as well as the proportion of condom user.
4. Intervention effect on FP service providers
The legal rights in China and women's rights in service process proposed by international family planning association were known generally among FP service providers. After comprehensive intervention, the knowledge and understanding of family planning and reproductive health rights among FP service providers were further increased. FP service providers'skills and abilities of SRHR counseling were improved, but still at a low level. Intervention improved service providers'will to perform SRHR education and integrated counseling service. Family plan service personnel have positive attitudes towards carrying out the activities of family planning and reproductive health rights promotion generally. After intervention, there were more service providers'who considered that the promotion of family planning and reproductive health rights was helpful to the clients'independent decision, harmonious relationship between service providers and clients and the realization of the national population development plan. The needs of skills training among service personnel were increased. Service providers'consensus was that the protection and promotion of SRHR played an important role, and then, education and training were major strategies.
5. The results of promotion activities of family planning and reproductive health rights in advance of quality of care
After intervention, there were more married women of child-bearing age who hold positive attitudes towards the promotion of family planning and reproductive health rights. At the same time, the proportion of the women who knew the quality of care, contraceptive informed choice services and integrated reproductive health counseling were increased. And their accurate and comprehensive understanding of the three services was also increased. The promotion activities of family planning and reproductive health rights have a positive effect on standard operation of contraceptive informed choice services and integrated reproductive health counseling. And these promotion activities promote the positive influence to clients'satisfaction for contraception services while these promotion activities had no effect on clients' satisfaction for outpatient services. As a result, the proportion of the women who knew the side effects, types and payment types of common contraceptives were all increased. But promotion activities had no effect on the proportion of the women who want to change current contraceptive they used.
[Conclusion]
Not only did advantages but also obstacles towards protecting and improving women'family planning and reproductive health rights through family planning service system exist. The realization of women' family planning and reproductive health rights was not enough. On one hand, to improve knowledge and awareness of women' family planning and reproductive health rights among married women of child-bearing age were extremely necessary. On the other hand, to improve awareness of women' family planning and reproductive health rights and to improve awareness of humanistic meaning of quality of care among FP managers and providers were also extremely necessary. The collection "education and training, advocacy, and counseling service" as one of the participatory intervention integrated with training, advocacy, and counseling service deliver improve the service providers' understanding of family planning and reproductive health rights and improve the skills and will of service. The intervention integrated with education, advocacy, and counseling service improve the service subjects'understanding of family planning and reproductive health rights had a positive effect on self empowerment consciousness and corresponding behavior tendency. It was significant and necessary way to propel quality of care deeply through realizing women's family planning and reproductive health rights. The long-term effects of protection and promotion of women's family planning and reproductive health rights on women's family planning&reproductive health should be further evaluated.
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