农村育龄妇女孕产期保健需求和可及性研究
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摘要
目的描述安徽省A县和B县农村地区育龄妇女孕产期保健需求及知识、态度、行为(KAP)情况,分析孕产期保健知识、态度、行为之间的关系,剖析影响农村地区育龄妇女孕产期保健需求及KAP的主要因素;了解农村孕产期保健服务现状以及存在的主要问题,探讨提高农村地区孕产期保健服务可及性的有效措施。
方法在安徽省A县和B县,以乡镇为单位采取整群分层随机抽样方法,选取1 789名农村地区育龄妇女(2005年1月1日～2006年12月31日有活产生产史的妇女)为研究对象。根据自愿原则,采取集中和入户的形式对调查对象进行面对面的问卷调查,内容包括农村育龄妇女的社会人口统计学特征、孕产期保健需求情况,孕产期保健知识、态度、行为情况。研究对象的一般情况,孕产期保健需求情况,以及孕产期保健知识、态度、行为基本情况进行描述性统计分析;5次及以上产前检查知识、态度、行为之间的关系采用四象限分析方法(BCG法);对不同人口统计学特征的孕产期保健知识评分等级(低等,中等,高等)采取χ2检验,将单因素卡方检验分析中与知识评分等级相关的因素作为自变量,以孕产期保健知识得分作为因变量,进行多项式Logistic回归分析;以农村育龄妇女对孕产期保健的4种态度作为因变量,人口统计学变量以及孕产期保健知识得分的分级为自变量,进行多因素非条件Logistic回归分析;以产前检查次数、主动询问医生问题、花钱购买孕产期保健资料、改变偏食习惯作为因变量,人口统计学变量以及孕产期保健知识得分的分级、≥5次产前检查的态度作为自变量,进行多因素非条件Logistic回归分析;以对孕产期保健知识和保健服务的需求得分作为因变量,人口统计学变量作为自变量,进行多项式Logistic回归分析。采取定性和定量研究相结合的方法,对农村孕产期保健服务状况进行调查。定量调查采取自制调查问卷,收集1 789名农村育龄妇女接受健康宣教以及对服务提供者服务质量评价的资料,进行描述性统计分析。定性研究对象来自A县和B县的分管妇幼保健及相关领导,共8人,进行个人深入访谈;以及随机抽取2县的乡镇卫生院院长、医护人员,以及村医和计生专干,共60人,进行焦点小组访谈。利用半结构式访谈提纲了解农村孕产期保健工作的现状及进展,及影响农村孕产妇获得保健服务的供方因素。
结果农村育龄妇女对孕产期保健知识需求占前3位的依次为科学育儿知识与技能(92.6%)、产褥期母婴保健与母乳喂养(91.6%)、孕期营养(90.6%)。认为获取保健知识的最佳途径依次为专人指导(91.3%)、健康教育宣传图册(85.7%)、电视媒介(81.3%)。22.0%的农村育龄妇女表示不需要进行产后访视,13.8%的调查对象认为目前产前检查的内容已经足够。正确回答一半以上孕产期保健知识占81.5%。对待孕产期保健的态度:74%认为有必要进行产前检查,71.5%认为即使没有什么异常产前检查次数也要多次,90.3%认为尽管孩子和自己情况很好也会选择住院分娩,81.6%认为生完孩子希望医疗机构能够来家里进行产后访视。产前检查率、早孕检查率、5次产前检查率、住院分娩率分别为96.9、50.3%、56.4%、99.8%;69.4%的调查对象遇到疑问询问医生较少或不问问题;遇到疑问首先咨询医生(65.8%),其次是询问亲戚或朋友(26.1%);57.6%没有花钱买过有关孕产期保健知识的书、杂志、光碟;32.7%不会因为怀孕改变自己的饮食习惯。BCG法结果显示,落入第Ⅲ象限亚群采取正确行为最少,落入第Ⅰ象限亚群采取正确行为最多,符合KAP之间的正常关系。多项式Logistic回归分析显示,不同民族、文化程度的农村育龄妇女,其孕产期保健知识的中、高水平与低水平差异有统计学意义;丈夫外出打工和育龄妇女文化程度越高是孕产期保健需求中等、高等评分高于低等评分的保护因素。多因素非条件Logistic回归分析显示,4种孕产期保健态度均受到孕产期保健知识的影响。调查对象文化程度越高,其对待产前检查、≥5次产前检查、产后访视态度的正确率越高。最后一次活产分娩前的人工和药物流产史,既往不良孕产史(自然流产,死胎死产,婴儿死亡)是产前检查、产后访视正确态度的保护因素。丈夫文化程度越高、有1个孩子,育龄妇女的≥5次产前检查态度的正确率越高。汉族调查对象比少数民族调查对象,其对待住院分娩的正确态度率高。文化程度越低、无既往不良孕产史(自然流产,死胎死产,婴儿死亡)、对待≥5次产前检查态度错误的调查对象,其4种保健行为的形成率越低。丈夫低文化程度、少数民族、有2个及以上孩子是影响育龄妇女采取≥5次产前检查、花钱购买保健资料的危险因素。自评家庭经济状况很差者,其主动询问医生问题的行为形成率明显低于自评家庭条件一般、较好、很好的调查对象,差异具有统计学意义。丈夫外出打工是育龄妇女购买孕产期保健资料的保护因素。
孕产期保健服务的现状:产前检查、住院分娩、产后访视和健康教育在乡镇卫生院都已开展,但是数量和质量达不到要求。孕产期保健服务的供方一致(68/68)认为完成产前检查≥5次的比例不高,有的乡镇甚至不足10%。70%的高危孕妇不能按照要求进行产前检查。访谈的2/3村医有存在愿意负担部分产前保健工作的意愿。大部分村医是男性,工作开展较为不便,多为孕产妇主动求诊。定量调查结果显示,剖宫产率53.6%,由医生决定做剖宫产手术占44.5%,但乡镇卫生院医务工作者反映住院分娩方式80%是由孕产妇自行选择。乡镇卫生院的产后访视开展的层次不好,不平衡,较薄弱,3次及以上产后访视率为2.5%,有1个访谈的乡镇产后访视甚至没开展。产后访视的开展主要受乡镇卫生院人手资金不足、产妇“坐月子”地点不定、交通不便等条件的制约。健康教育状况:农村育龄妇女认为在接受的乡镇卫生院孕产期健康教育中小孩护理(没讲过/不清楚,46.5%)、补充营养预防出生缺陷(没讲过/不清楚,39.5%)、不接触农药(没讲过/不清楚,33.9%)讲的最少。访谈的乡镇卫生院院长及医护人员(36/42)认为用VCD、DVD的宣传方式最适用于农民,其次是发放健康教育的小册子。村计生专干进行健康教育的优势在于孕产期保健知识的宣教贯穿在日常与孕产妇谈心中。孕产期保健服务质量评价:农村育龄妇女对乡镇卫生院产前检查服务医疗水平、服务态度的评价主要是一般(74.5%)、不太满意(53.8%),对乡镇卫生院住院分娩医疗水平、服务态度的评价主要是一般(61.1%)、比较满意(45.5%);对乡村医生提供的保健服务,81.8%的育龄妇女表示满意。近几年,服务提供者加强对妇幼保健工作的重视程度,妇幼保健经费投入逐年增加,通过以会代训、组织参观、相互交流等方式加强妇幼保健工作技术力量的培训,加大宣传力度,改变行政管理,提高了农村乡镇卫生院及村级的妇幼保健服务的可及性。但是服务提供者也存在诸多问题,阻碍农村孕产期保健的普惠性:政府孕产期保健经费投入不足,乡镇卫生院主要以临床的收入补贴妇幼保健工作,同时中心卫生院和一般乡镇卫生院资源分配不均。基层(包括乡镇卫生院、村卫生所)专业的孕产期保健人员匮乏,乡镇卫生院人员素质参差不齐,主要是中专学历,大专学历不足20%,而且保健人员接受正规培训的机会少,临床医生兼职保健,掌握孕产期保健知识有限。普遍存在“重临床轻保健”的思想,妇产科医生不愿做妇幼保健专职人员。农村妇女淡薄自我保健意识,农村健康教育力量薄弱,体系不健全,手段落后,健康教育有待深入。妇幼保健网络建设不完善,县、乡两级的妇幼保健网络相对健全,但在村一级,即“网底”,基本处于空白。
结论文化水平低、经济状况差的农村孕产妇是实施卫生宣教的重点,要研究制定合适的健康促进宣传材料和采取灵活的健康促进方式,有的放矢地进行健康教育。农村孕产期保健服务取得了一定的成绩,同时也存在着制约服务可及性的问题,应该采取因地制宜的措施,探索新的政府投入方式、乡镇和农村结合的孕产期保健模式。
Objectives This study aims to describe the maternal health care needs and knowledge, attitude, practices (KAP) of childbearing-age women in rural area of A and B county of Anhui province and to analyze the association between maternal health care knowledge, attitude and practices. It also will identify the main factors influencing maternal health care needs and KAP among these women of reproductive age in rural area. This study aims to understand the current situation of accessibility of maternal health care service, identify the main problems in provision of maternal health services in rural area of Anhui province, and study the effective measures to improve the accessibility of maternal health care in rural area.
Methods Using a stratified randomized cluster-sampling method, 1 789 childbearing-age women were selected for a questionnaire survey from townships of 2 counties in Anhui province. Only women who had delivered live babies during the period 1 January 2005 to 31 December 2006 were selected. According to their own wills, all participants completed face to face self-adapted questionnaires by centralization and household. The content of the questionnaires included social demography characteristics, perceived needs for maternal health care, and maternal health care knowledge, attitude, practices. Descriptive analysis was to analyze the demographic characteristics, perceived needs for maternal health care and maternal health care knowledge, attitude, practices were analyzed descriptively. BCG method was used to examine the association between knowledge, attitude and practices of 5 or more times prenatal examinations. Theχ2-test determined the maternal health care knowledge score classification of low, middle and high. And the independent variables which were the factors related to the maternal health care knowledge score classification by usingχ2-test model related to the dependent variable which was maternal health care knowledge score classification were analyzed by using multinomial logistic regression model. The dependent variables which were four maternal health care attitude related to the independent variables which were demographic variables and maternal health care knowledge score classification were analyzed by using non-conditional multivariate logistic regression model. The dependent variables which were four maternal health care practices such as doing prenatal checkup, asking doctors questions actively, buying maternal health care data, changing habit about partiality for a particular kind of food related to the independent variables which were demographic variables, maternal health care knowledge score classification and the attitude to 5 or more times prenatal examinations were analyzed by using non-conditional multivariate logistic regression model. The independent variables which were the score classification of maternal health care knowledge and service Needs related to the dependent variables which were demographic variables were analyzed by using multinomial logistic regression model.
By using both qualitative and quantitative methods, the situation of maternal health care service was investigated. In the quantitative study, 1 789 childbearing-age women in rural areas completed a questionnaire about the maternal health education and services they had received. This data were analyzed by descriptive analysis. In the qualitative study, individual interviews were conducted with 8 leaders from maternal health care and other departments. Focus group discussions were held with administrators of township hospitals, township doctors and nurses, village doctors and family planning workers. A total of 60 people were included in the focus group discussions. Topic guides were used to explore providers and policy makers’perceptions of the current situation and development of maternal health care services and factors influencing these services by semi-structured interviews outline.
Results This study found that women identified the most important areas for maternal health care knowledge as:knowledge and skills of caring for the baby (92.6%), maternal health care in postnatal period and breast-feeding (91.6%) and nutrition (90.6%). The best approaches for pregnant women to obtain knowledge were in turn: advice from health professionals (91.3%), leaflets (85.7%) and television programmes and other media (81.3%). 22.0% of rural women expressed that they did not need postpartum visits, and 13.8% of women thought that the current content of prenatal check-up was adequate. 81.5% of women gave correct answers to more than half of the maternal health care questions. The study findings on attitude towards the maternal health care included: 74% of women thought that it was necessary to have prenatal examinations; 71.5% of women thought that they should have at least 5 prenatal examinations even if they had no problems; 90.3% of women would choose hospital delivery though themselves and their children were healthy; and 81.6% of women wanted health professionals to visit their homes to do postpartum care. The survey found that the prenatal examination rate, rate of prenatal examination in the first three months of pregnancy, 5 or more prenatal examinations rate, and percentage of hospitalized delivery were 96.9, 50.3%, 56.4%, 99.8% respectively. 65.8% of women said they would first consult the doctor for advice whilst 26.1% of women would ask their relatives and friends. 57.6% of women did not buy any books, magazines or discs on maternal health care. 32.7% of women did not change their dietary habits. The result of the BCG analysis showed that the number of people inⅢquadrant who adopted the correct practices was least, and the people inⅠquadrant who adopted the correct practices were greatest. This is in keeping with the natural relationship between knowledge, attitude and practices. Analysis using the multinomial logistic regression model showed that the middle and high levels of maternal health care knowledge were with significant difference compared to the low level among childbearing-age women with different nationality and culture degree. Husbands who went out of their home area for work and higher education level of the women were protective factors of the score of middle and high level of maternal health care needs which were higher than the low level. The non-conditional multivariate logistic regression model showed that the four maternal health care attitude measures were all affected by maternal health care knowledge. Women with higher education level were more likely to have a positive attitude to prenatal examination, 5 or more prenatal examinations, and more postpartum visits. Histories of induced abortion, abortion drug before the last childbirth, and poor outcome in previous pregnancies (including spontaneous abortion, fetal death, stillbirth and infant death) were protective factors for prenatal examination and postpartum visit. Positive attitude to having 5 or more prenatal examinations was higher amongst women who had one child and whose husbands had higher education level. Positive attitude to hospital delivery was higher amongst women with Han nationality than women of minority nationalities. The four health care practices were lower among women with lower education level women with no history of poor outcome in previous pregnancies (including spontaneous abortion, fetal death, stillbirth and infant death), and women with negative attitudes to 5 or more prenatal examinations. Lower education level, minority nationality, and having more than one child were risk factors for the two practices: having 5 or more prenatal examinations and buying materials about maternal health care. Women who assessed their economic status as low, were less likely to actively consult the doctor for advice than women who assessed their economic status as average, good and high economic. Husbands who went out of their home area for work was a protective factor for women buying material on maternal health care.
With regard to maternal health care services, prenatal examination, hospital delivery, postpartum visit and health education were all carried out in the township hospitals. However the quantity and quality of these services did not reach the national requirements. All maternal health care service providers (68/68) thought that the proportion of prenatal examinations of at least 5 was low, and in some townships the proportion was as low as 10%. 70% high risk pregnant women did not have prenatal examinations according to the national requirements. Although two thirds of the village doctors interviewed wanted to do prenatal health care, as most village doctors were male it was difficult for them to provide this service. At present, pregnant women went to village doctors for examination. The survey showed that 53.6% of women had caesarean sections, of which, 44.5% were decided by the doctors. However interviews with doctors and nurses of township hospitals interviewed revealed that 80% pregnant women chose the type of delivery themselves. In the township hospitals, the postpartum visits were seldom carried out. Only 2.5 % of women received more than 2 postpartum visits. In some hospitals, no postpartum visits were done. Carrying out postpartum visits was hampered by a number of factors including: lack of personnel and limited funds in the township hospitals, not knowing where women stayed following delivery and transport problems.
The study revealed the following findings about health education: 46.5% of women did not know about breastfeeding; 39.5% of women did not know about eating certain foods to prevent birth defects; and 33.9% of women did not know about avoiding contact with pesticides during pregnancy. Most administrators, doctors and nurses in township hospitals who were interviewed (36/42) thought that the maternal health care VCDs and DVDs were the most effective mode of health education for farmers. The second most effect way was giving leaflets. One advantage for village family planning workers to provide health education was that they could do during their talks with pregnant women.
This study showed the following key findings on the quality of maternal health care services. Women evaluated their satisfaction with medical treatment and attitudes of staff during prenatal examination as average (74.5%) and not bad (53.8%). Satisfaction with medical treatment and attitudes of staff during hospital delivery was graded as average (61.1%) and good (45.5%). 81.8% women were satisfied with the health care services provided by village doctors. In recent years, the accessibility of maternal health care services in township hospitals and village clinics has improved through measures such as greater government awareness, increased allocation of funds, more training of staff, increased education and changes in management. However there are still many obstacles in providing maternal health care services. Funds allocated to maternal health are inadequate. In township hospitals the funding for maternal health care services is mainly income generated from clinical work. Central and common township hospitals do not receive equal funding. In township hospitals and village clinics skilled maternal health care personnel are lacking. The education level of most doctors was technical secondary school, and less than 20% had qualification from junior college. Opportunities for further training were few. The doctors mastered limited maternal health care knowledge because they were pluralists of maternal health care work. Obstetric doctors did not want to become maternal health care workers as they“valued clinical work but looked down on health care”. In rural areas, women were not aware of the importance of health care, existing health education was ineffective, and the means of health education was not popular. So the health education in rural areas should be strengthened. The maternal health care network was not complete. At the county and township levels the maternal health care services existed, but at the village level, these services did not exist.
Conclusions Health education should focus on rural pregnant women with low education level and poor economic status. It is necessary to study and establish effective health education programmes and materials. In rural areas there have been some achievements made by the maternal health care services. However there are some problems which hinder the use and effectiveness of the services. We should develop new approaches to maternal care which take into consideration local conditions, and explore new ways so that township hospitals work with village clinics to provide maternal care services.
方法在安徽省A县和B县,以乡镇为单位采取整群分层随机抽样方法,选取1 789名农村地区育龄妇女(2005年1月1日～2006年12月31日有活产生产史的妇女)为研究对象。根据自愿原则,采取集中和入户的形式对调查对象进行面对面的问卷调查,内容包括农村育龄妇女的社会人口统计学特征、孕产期保健需求情况,孕产期保健知识、态度、行为情况。研究对象的一般情况,孕产期保健需求情况,以及孕产期保健知识、态度、行为基本情况进行描述性统计分析;5次及以上产前检查知识、态度、行为之间的关系采用四象限分析方法(BCG法);对不同人口统计学特征的孕产期保健知识评分等级(低等,中等,高等)采取χ2检验,将单因素卡方检验分析中与知识评分等级相关的因素作为自变量,以孕产期保健知识得分作为因变量,进行多项式Logistic回归分析;以农村育龄妇女对孕产期保健的4种态度作为因变量,人口统计学变量以及孕产期保健知识得分的分级为自变量,进行多因素非条件Logistic回归分析;以产前检查次数、主动询问医生问题、花钱购买孕产期保健资料、改变偏食习惯作为因变量,人口统计学变量以及孕产期保健知识得分的分级、≥5次产前检查的态度作为自变量,进行多因素非条件Logistic回归分析;以对孕产期保健知识和保健服务的需求得分作为因变量,人口统计学变量作为自变量,进行多项式Logistic回归分析。采取定性和定量研究相结合的方法,对农村孕产期保健服务状况进行调查。定量调查采取自制调查问卷,收集1 789名农村育龄妇女接受健康宣教以及对服务提供者服务质量评价的资料,进行描述性统计分析。定性研究对象来自A县和B县的分管妇幼保健及相关领导,共8人,进行个人深入访谈;以及随机抽取2县的乡镇卫生院院长、医护人员,以及村医和计生专干,共60人,进行焦点小组访谈。利用半结构式访谈提纲了解农村孕产期保健工作的现状及进展,及影响农村孕产妇获得保健服务的供方因素。
结果农村育龄妇女对孕产期保健知识需求占前3位的依次为科学育儿知识与技能(92.6%)、产褥期母婴保健与母乳喂养(91.6%)、孕期营养(90.6%)。认为获取保健知识的最佳途径依次为专人指导(91.3%)、健康教育宣传图册(85.7%)、电视媒介(81.3%)。22.0%的农村育龄妇女表示不需要进行产后访视,13.8%的调查对象认为目前产前检查的内容已经足够。正确回答一半以上孕产期保健知识占81.5%。对待孕产期保健的态度:74%认为有必要进行产前检查,71.5%认为即使没有什么异常产前检查次数也要多次,90.3%认为尽管孩子和自己情况很好也会选择住院分娩,81.6%认为生完孩子希望医疗机构能够来家里进行产后访视。产前检查率、早孕检查率、5次产前检查率、住院分娩率分别为96.9、50.3%、56.4%、99.8%;69.4%的调查对象遇到疑问询问医生较少或不问问题;遇到疑问首先咨询医生(65.8%),其次是询问亲戚或朋友(26.1%);57.6%没有花钱买过有关孕产期保健知识的书、杂志、光碟;32.7%不会因为怀孕改变自己的饮食习惯。BCG法结果显示,落入第Ⅲ象限亚群采取正确行为最少,落入第Ⅰ象限亚群采取正确行为最多,符合KAP之间的正常关系。多项式Logistic回归分析显示,不同民族、文化程度的农村育龄妇女,其孕产期保健知识的中、高水平与低水平差异有统计学意义;丈夫外出打工和育龄妇女文化程度越高是孕产期保健需求中等、高等评分高于低等评分的保护因素。多因素非条件Logistic回归分析显示,4种孕产期保健态度均受到孕产期保健知识的影响。调查对象文化程度越高,其对待产前检查、≥5次产前检查、产后访视态度的正确率越高。最后一次活产分娩前的人工和药物流产史,既往不良孕产史(自然流产,死胎死产,婴儿死亡)是产前检查、产后访视正确态度的保护因素。丈夫文化程度越高、有1个孩子,育龄妇女的≥5次产前检查态度的正确率越高。汉族调查对象比少数民族调查对象,其对待住院分娩的正确态度率高。文化程度越低、无既往不良孕产史(自然流产,死胎死产,婴儿死亡)、对待≥5次产前检查态度错误的调查对象,其4种保健行为的形成率越低。丈夫低文化程度、少数民族、有2个及以上孩子是影响育龄妇女采取≥5次产前检查、花钱购买保健资料的危险因素。自评家庭经济状况很差者,其主动询问医生问题的行为形成率明显低于自评家庭条件一般、较好、很好的调查对象,差异具有统计学意义。丈夫外出打工是育龄妇女购买孕产期保健资料的保护因素。
孕产期保健服务的现状:产前检查、住院分娩、产后访视和健康教育在乡镇卫生院都已开展,但是数量和质量达不到要求。孕产期保健服务的供方一致(68/68)认为完成产前检查≥5次的比例不高,有的乡镇甚至不足10%。70%的高危孕妇不能按照要求进行产前检查。访谈的2/3村医有存在愿意负担部分产前保健工作的意愿。大部分村医是男性,工作开展较为不便,多为孕产妇主动求诊。定量调查结果显示,剖宫产率53.6%,由医生决定做剖宫产手术占44.5%,但乡镇卫生院医务工作者反映住院分娩方式80%是由孕产妇自行选择。乡镇卫生院的产后访视开展的层次不好,不平衡,较薄弱,3次及以上产后访视率为2.5%,有1个访谈的乡镇产后访视甚至没开展。产后访视的开展主要受乡镇卫生院人手资金不足、产妇“坐月子”地点不定、交通不便等条件的制约。健康教育状况:农村育龄妇女认为在接受的乡镇卫生院孕产期健康教育中小孩护理(没讲过/不清楚,46.5%)、补充营养预防出生缺陷(没讲过/不清楚,39.5%)、不接触农药(没讲过/不清楚,33.9%)讲的最少。访谈的乡镇卫生院院长及医护人员(36/42)认为用VCD、DVD的宣传方式最适用于农民,其次是发放健康教育的小册子。村计生专干进行健康教育的优势在于孕产期保健知识的宣教贯穿在日常与孕产妇谈心中。孕产期保健服务质量评价:农村育龄妇女对乡镇卫生院产前检查服务医疗水平、服务态度的评价主要是一般(74.5%)、不太满意(53.8%),对乡镇卫生院住院分娩医疗水平、服务态度的评价主要是一般(61.1%)、比较满意(45.5%);对乡村医生提供的保健服务,81.8%的育龄妇女表示满意。近几年,服务提供者加强对妇幼保健工作的重视程度,妇幼保健经费投入逐年增加,通过以会代训、组织参观、相互交流等方式加强妇幼保健工作技术力量的培训,加大宣传力度,改变行政管理,提高了农村乡镇卫生院及村级的妇幼保健服务的可及性。但是服务提供者也存在诸多问题,阻碍农村孕产期保健的普惠性:政府孕产期保健经费投入不足,乡镇卫生院主要以临床的收入补贴妇幼保健工作,同时中心卫生院和一般乡镇卫生院资源分配不均。基层(包括乡镇卫生院、村卫生所)专业的孕产期保健人员匮乏,乡镇卫生院人员素质参差不齐,主要是中专学历,大专学历不足20%,而且保健人员接受正规培训的机会少,临床医生兼职保健,掌握孕产期保健知识有限。普遍存在“重临床轻保健”的思想,妇产科医生不愿做妇幼保健专职人员。农村妇女淡薄自我保健意识,农村健康教育力量薄弱,体系不健全,手段落后,健康教育有待深入。妇幼保健网络建设不完善,县、乡两级的妇幼保健网络相对健全,但在村一级,即“网底”,基本处于空白。
结论文化水平低、经济状况差的农村孕产妇是实施卫生宣教的重点,要研究制定合适的健康促进宣传材料和采取灵活的健康促进方式,有的放矢地进行健康教育。农村孕产期保健服务取得了一定的成绩,同时也存在着制约服务可及性的问题,应该采取因地制宜的措施,探索新的政府投入方式、乡镇和农村结合的孕产期保健模式。
Objectives This study aims to describe the maternal health care needs and knowledge, attitude, practices (KAP) of childbearing-age women in rural area of A and B county of Anhui province and to analyze the association between maternal health care knowledge, attitude and practices. It also will identify the main factors influencing maternal health care needs and KAP among these women of reproductive age in rural area. This study aims to understand the current situation of accessibility of maternal health care service, identify the main problems in provision of maternal health services in rural area of Anhui province, and study the effective measures to improve the accessibility of maternal health care in rural area.
Methods Using a stratified randomized cluster-sampling method, 1 789 childbearing-age women were selected for a questionnaire survey from townships of 2 counties in Anhui province. Only women who had delivered live babies during the period 1 January 2005 to 31 December 2006 were selected. According to their own wills, all participants completed face to face self-adapted questionnaires by centralization and household. The content of the questionnaires included social demography characteristics, perceived needs for maternal health care, and maternal health care knowledge, attitude, practices. Descriptive analysis was to analyze the demographic characteristics, perceived needs for maternal health care and maternal health care knowledge, attitude, practices were analyzed descriptively. BCG method was used to examine the association between knowledge, attitude and practices of 5 or more times prenatal examinations. Theχ2-test determined the maternal health care knowledge score classification of low, middle and high. And the independent variables which were the factors related to the maternal health care knowledge score classification by usingχ2-test model related to the dependent variable which was maternal health care knowledge score classification were analyzed by using multinomial logistic regression model. The dependent variables which were four maternal health care attitude related to the independent variables which were demographic variables and maternal health care knowledge score classification were analyzed by using non-conditional multivariate logistic regression model. The dependent variables which were four maternal health care practices such as doing prenatal checkup, asking doctors questions actively, buying maternal health care data, changing habit about partiality for a particular kind of food related to the independent variables which were demographic variables, maternal health care knowledge score classification and the attitude to 5 or more times prenatal examinations were analyzed by using non-conditional multivariate logistic regression model. The independent variables which were the score classification of maternal health care knowledge and service Needs related to the dependent variables which were demographic variables were analyzed by using multinomial logistic regression model.
By using both qualitative and quantitative methods, the situation of maternal health care service was investigated. In the quantitative study, 1 789 childbearing-age women in rural areas completed a questionnaire about the maternal health education and services they had received. This data were analyzed by descriptive analysis. In the qualitative study, individual interviews were conducted with 8 leaders from maternal health care and other departments. Focus group discussions were held with administrators of township hospitals, township doctors and nurses, village doctors and family planning workers. A total of 60 people were included in the focus group discussions. Topic guides were used to explore providers and policy makers’perceptions of the current situation and development of maternal health care services and factors influencing these services by semi-structured interviews outline.
Results This study found that women identified the most important areas for maternal health care knowledge as:knowledge and skills of caring for the baby (92.6%), maternal health care in postnatal period and breast-feeding (91.6%) and nutrition (90.6%). The best approaches for pregnant women to obtain knowledge were in turn: advice from health professionals (91.3%), leaflets (85.7%) and television programmes and other media (81.3%). 22.0% of rural women expressed that they did not need postpartum visits, and 13.8% of women thought that the current content of prenatal check-up was adequate. 81.5% of women gave correct answers to more than half of the maternal health care questions. The study findings on attitude towards the maternal health care included: 74% of women thought that it was necessary to have prenatal examinations; 71.5% of women thought that they should have at least 5 prenatal examinations even if they had no problems; 90.3% of women would choose hospital delivery though themselves and their children were healthy; and 81.6% of women wanted health professionals to visit their homes to do postpartum care. The survey found that the prenatal examination rate, rate of prenatal examination in the first three months of pregnancy, 5 or more prenatal examinations rate, and percentage of hospitalized delivery were 96.9, 50.3%, 56.4%, 99.8% respectively. 65.8% of women said they would first consult the doctor for advice whilst 26.1% of women would ask their relatives and friends. 57.6% of women did not buy any books, magazines or discs on maternal health care. 32.7% of women did not change their dietary habits. The result of the BCG analysis showed that the number of people inⅢquadrant who adopted the correct practices was least, and the people inⅠquadrant who adopted the correct practices were greatest. This is in keeping with the natural relationship between knowledge, attitude and practices. Analysis using the multinomial logistic regression model showed that the middle and high levels of maternal health care knowledge were with significant difference compared to the low level among childbearing-age women with different nationality and culture degree. Husbands who went out of their home area for work and higher education level of the women were protective factors of the score of middle and high level of maternal health care needs which were higher than the low level. The non-conditional multivariate logistic regression model showed that the four maternal health care attitude measures were all affected by maternal health care knowledge. Women with higher education level were more likely to have a positive attitude to prenatal examination, 5 or more prenatal examinations, and more postpartum visits. Histories of induced abortion, abortion drug before the last childbirth, and poor outcome in previous pregnancies (including spontaneous abortion, fetal death, stillbirth and infant death) were protective factors for prenatal examination and postpartum visit. Positive attitude to having 5 or more prenatal examinations was higher amongst women who had one child and whose husbands had higher education level. Positive attitude to hospital delivery was higher amongst women with Han nationality than women of minority nationalities. The four health care practices were lower among women with lower education level women with no history of poor outcome in previous pregnancies (including spontaneous abortion, fetal death, stillbirth and infant death), and women with negative attitudes to 5 or more prenatal examinations. Lower education level, minority nationality, and having more than one child were risk factors for the two practices: having 5 or more prenatal examinations and buying materials about maternal health care. Women who assessed their economic status as low, were less likely to actively consult the doctor for advice than women who assessed their economic status as average, good and high economic. Husbands who went out of their home area for work was a protective factor for women buying material on maternal health care.
With regard to maternal health care services, prenatal examination, hospital delivery, postpartum visit and health education were all carried out in the township hospitals. However the quantity and quality of these services did not reach the national requirements. All maternal health care service providers (68/68) thought that the proportion of prenatal examinations of at least 5 was low, and in some townships the proportion was as low as 10%. 70% high risk pregnant women did not have prenatal examinations according to the national requirements. Although two thirds of the village doctors interviewed wanted to do prenatal health care, as most village doctors were male it was difficult for them to provide this service. At present, pregnant women went to village doctors for examination. The survey showed that 53.6% of women had caesarean sections, of which, 44.5% were decided by the doctors. However interviews with doctors and nurses of township hospitals interviewed revealed that 80% pregnant women chose the type of delivery themselves. In the township hospitals, the postpartum visits were seldom carried out. Only 2.5 % of women received more than 2 postpartum visits. In some hospitals, no postpartum visits were done. Carrying out postpartum visits was hampered by a number of factors including: lack of personnel and limited funds in the township hospitals, not knowing where women stayed following delivery and transport problems.
The study revealed the following findings about health education: 46.5% of women did not know about breastfeeding; 39.5% of women did not know about eating certain foods to prevent birth defects; and 33.9% of women did not know about avoiding contact with pesticides during pregnancy. Most administrators, doctors and nurses in township hospitals who were interviewed (36/42) thought that the maternal health care VCDs and DVDs were the most effective mode of health education for farmers. The second most effect way was giving leaflets. One advantage for village family planning workers to provide health education was that they could do during their talks with pregnant women.
This study showed the following key findings on the quality of maternal health care services. Women evaluated their satisfaction with medical treatment and attitudes of staff during prenatal examination as average (74.5%) and not bad (53.8%). Satisfaction with medical treatment and attitudes of staff during hospital delivery was graded as average (61.1%) and good (45.5%). 81.8% women were satisfied with the health care services provided by village doctors. In recent years, the accessibility of maternal health care services in township hospitals and village clinics has improved through measures such as greater government awareness, increased allocation of funds, more training of staff, increased education and changes in management. However there are still many obstacles in providing maternal health care services. Funds allocated to maternal health are inadequate. In township hospitals the funding for maternal health care services is mainly income generated from clinical work. Central and common township hospitals do not receive equal funding. In township hospitals and village clinics skilled maternal health care personnel are lacking. The education level of most doctors was technical secondary school, and less than 20% had qualification from junior college. Opportunities for further training were few. The doctors mastered limited maternal health care knowledge because they were pluralists of maternal health care work. Obstetric doctors did not want to become maternal health care workers as they“valued clinical work but looked down on health care”. In rural areas, women were not aware of the importance of health care, existing health education was ineffective, and the means of health education was not popular. So the health education in rural areas should be strengthened. The maternal health care network was not complete. At the county and township levels the maternal health care services existed, but at the village level, these services did not exist.
Conclusions Health education should focus on rural pregnant women with low education level and poor economic status. It is necessary to study and establish effective health education programmes and materials. In rural areas there have been some achievements made by the maternal health care services. However there are some problems which hinder the use and effectiveness of the services. We should develop new approaches to maternal care which take into consideration local conditions, and explore new ways so that township hospitals work with village clinics to provide maternal care services.
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6.鲁玉虹,陈桂芬,张云飞,等.澄江县1158例农村育龄妇女妇幼保健心理需求评估.玉溪师范学院学报, 2003, 19(1): 88-90.
7.欧水招,叶惠敏.城市妇女孕产期健康教育需求调查分析.中国健康教育, 2002, 18(6): 369-371.
8.于海莲,封锦平,牛新力.北京市西城区新街口社区妇幼保健服务现状和服务需求调查.中国妇幼保健, 2000, 15(4):227-228.
9.王海俊,路国涛,郭福新,等.农村已婚育龄妇女健康知识及获取途径调查.中国健康教育, 2007, 23 (6): 441-443.
10.薛玲,贾延军,庞淑兰,等. 300例孕妇孕产期保健知识现状调查与分析.中国妇幼保健, 2007, 22(15): 2115-2117.
11.李向云,张惠兰,王爱燕.产褥期妇女卫生服务需求调查.中国生育健康杂志, 2005, 16(4): 199-201.
12.赵凤敏,郭素芳,张彤,等.不同时期育龄妇女产前保健及影响因素分析.中国公共卫生, 2006, 22 (1): 9-11.
13.中华人民共和国统计局, www.stats.gov.cn/tjsj/ndsj/2006/indexch.htm.
14.黄敬亭主编.健康教育学,第4版.上海:复旦大学出版社, 2006, 35-38.
15.郭素芳,赵凤敏,吴久玲,等.已婚妇女社会性别意识和家庭地位状况调查.中国妇幼保健, 2007, 22(29): 4139-4141.
16.陶红兵,方鹤骞,张文斌,等.农村贫困地区育龄妇女健康知识知晓程度的影响因素及其对策.中国妇幼保健, 2007, (23): 3194-3196.
17.赵媛媛,陶芳标,许韶君.同伴教育在农村孕产妇健康促进中的应用.中国妇幼健康研究, 2006, 17 (5): 440-443.
1. Fujita N, Matsui M, Srey S, et al. Antenatal care in the capital city of Cambodia: Current situation and impact on obstetric outcome. J Obstet Gynaecol Res, 2005, 31(2): 133-139.
2.王燕,石玲,周虹.中国部分贫困地区孕产妇保健服务提供质量状况分析.中国初级卫生保健, 2003, 17(3): 1-3.
3. Houweling TA, Ronsmans C, Campbell OM. Huge poor-rich inequalities in maternity care: an international comparative study of maternity and child care in developing countries. Bull World Health Organ. 2007, 85(10): 745-54.
4. De Lange TE, Budde MP, Heard AR, et al. Avoidable risk factors in perinatal deaths: A perinatal audit in South Australia. Aust N Z J Obstet Gynaecol. 2008, 48(1): 50-7.
5. WHO, ICM, FIGO. Making pregnancy safer: the critical role of the skilled attendant. Geneva: WHO, 2004.
6. Hudelsm P. Qualitative research for health programmes. Geneva: WHO, 1994.
7.陈向明.质的研究方法与社会科学研究,第1版.北京:教育科学出版社, 2000, 269-288.
8.赵凤敏,郭素芳,张形.不同时期育龄妇女产前保健及影响因素分析.中国公共卫生, 2006, 22(1): 9-11.
9.吴擢春,李晓燕,高军,等. 1993-2003年中国妇女孕产期保健服务利用状况研究.中国初级卫生保健, 2005, 19(9): 45-57.
10.薛玉凤,王新立,卢安,等.河北省孕产妇卫生保健现状调查.中国妇幼保健, 2005, 20(15): 1971-1972.
11. Almeida C, Braveman P, Gold MR, et al. Methodological concerns and recommendations on policy consequences of the World Health Report 2000. Lancet, 2001, 357(9269): 1692-1697.
12.卫生部统计信息中心. 2005年中国卫生事业发展情况统计公报.北京:中华人民共和国卫生部, 2006.
13.杨宏斌,黄利民.制约农村卫生院预防保健功能发挥的主要因素与对策探讨.中国农村卫生事业管理, 1997, 17(2): 92.
14. Kotzee TJ, Couper ID. What interventions do South African qualified doctors think will retain them in rural hospitals of the Limpopo province of South Africa? Rural and Remote Health, 2006, 6(3):581.
15. Bundred P, Levitt C. Medical Migration: Who are the real losers? Lancet, 2000, 356(9225): 245-246.
16.高惠琦,关伟.参与性健康教育在生育健康促进中应用的展望.中国初级卫生保健, 2002, 16(4): 26-27.
17. G.Turner, J. Shepherd. A method in search of a theory peer education and health promotion. Health Educ Res, 1999, 14(2): 235-247.
18. WHO Dept. of Reproductive Health and Research. WHO antenatal care randomized trial: manual for the implementation of the new model. Geneva: WHO, 2002.
1.孟丽萍,李凤兰,贾其贤.济南市孕产妇妇幼卫生知识调查.预防医学文献信息, 2002, 8 (2): 184.
2.鲁玉虹,陈桂芬,张云飞,等.澄江县1158例农村育龄妇女妇幼保健心理需求评估.玉溪师范学院学报, 2003, 19(1): 88-90.
3.李向云,张惠兰,王爱燕.产褥期妇女卫生服务需求调查.中国生育健康杂志, 2005, 16(4): 199-201.
4.张翔,张亮,冯占春.贫困农村妇女对基本生育卫生服务需要与需求的社会学评估.中国妇幼保健, 2004, 19(11): 7-9.
5.刘凯波,何芳,聂妍,等.北京市流动孕产妇保健质量及需求状况.中国妇幼保健, 2004, 19(2): 14-15.
6.欧水招,叶惠敏.城市妇女孕产期健康教育需求调查分析.中国健康教育, 2002, 18(6): 369-371.
7.于海莲,封锦平,牛新力.北京市西城区新街口社区妇幼保健服务现状和服务需求调查.中国妇幼保健, 2000, 15(4): 227-228.
8.候泽荣,冯占春,贾红英.农村贫困地区育龄妇女生育相关知识、态度、行为研究.医学与社会, 2007, 20(11): 5-17.
9.潘淑琴.甘肃农村社区与家庭妇幼保健知识水平卫生行为及健康需求的调查.中国妇幼保健, 2001, 16(31): 89-191.
10.王德斌,管建粉,洪倩,等.农村育龄妇女生殖健康知识与其个性的关系.中国妇幼保健, 2007, 22(26): 3636-3638.
11.熊巨洋,张翔,陈汉平.非必须剖宫产与产妇的分娩知识、态度和行为(KAP)的关系—1:2病例对照研究.中国妇幼保健, 2005, 20(4): 502-504.
12.宋慎苓,周霞.健康教育在围产期保健的作用.中国妇幼保健, 2005, 20(21): 2761-2763.
13.钱跃升,于文平,武较农,等.健康教育对农村妇女孕期保健行为的影响.中国妇幼保健, 2000, 15(3): 164-165.
14.郝波,赵更力,张文坤,等.健康教育对贫困农村母亲养育行为影响的效果评价.中国妇幼保健, 2006, 21(3): 310-313.
15.李雨,宿鲁,张麓曾,等.农村健康教育面临的挑战与对策.中国公共卫生, 2004, 20(4): 508.
16.王海燕,刘文忠,商雯,等.农村孕产妇健康教育效果评价.河南预防医学杂志, 2001, 12(5): 281.
17.杨功焕,王若涛,汪洋,等.健康促进—理论与实践,第1版.成都:四川科学技术出版社, 1999, 32-33.
18.陈洁,王战云,于丽航,等.产褥期妇女休养观念的调查分析.中国初级卫生保健, 2001, 15(5): 43-44.
19.薛鹏德,张玉昌,浦波,等.加强孕产期健康教育降低少数民族贫困地区孕产妇死亡率.中国妇幼保健, 2004, 19(1): 23.
20.晏家胜,刘家智,蔚志新.参与式方法在改善生殖健康服务中的应用.中国妇幼保健, 2002, 17(6): 347-348.
21.李健,刘苹.农村贫困地区健康教育的实践与思考.中国初级卫生保健, 2000, 14(4): 58-59.
22.宋沈超,晏家胜,杨黔立,等.参与性方法在农村贫困地区卫生项目中的应用效果评价.贵阳医学院学报, 2004, 29(4): 293-295.
23.王作振,闫宝华,王克利,等.同伴教育及其研究状况.中国健康教育, 2004, 20(5): 429-430.
24.陶芳标主编.妇幼保健学,第1版.合肥:安徽人学出版社, 2003, 248.
25. Koula Merakou, Jenny Kourea-Kremastinou. Peer education in HIV prevention: an evaluation in schools. Eur J Public Health, 2006, 16(2): 128-132.
26. Woods DW, Koch M, Miltenberger RG. The impact of Tic Severity on the effects of peer education about Tourette’s Syndrome. J Dev Phys Disabil, 2003, 15(1): 63-78.
27. G.Turner,J. Shepherd. A method in search of a theory peer education and health promotion. Health Educ Res, 1999, 14(2): 235-247.
2. Fujita N, Matsui M, Srey S, et al. Antenatal care in the capital city of Cambodia: Current situation and impact on obstetric outcome. J Obstet Gynaecol Res, 2005, 31(2): 133-139.
3.卫生部统计信息中心. 2005年中国卫生统计年鉴.北京:中华人民共和国卫生部, 2006.
4.吴擢春,李晓燕,高军,等. 1993-2003年中国妇女孕产期保健服务利用状况研究.中国初级卫生保健, 2005, 19(9): 45-57.
5.王晓莉,王燕,周穗赞.中国农村地区产褥期禁忌行为及相关因素研究.中国妇幼保健,2005,20(16): 2041-2044.
6.黄妍绫,赵梅晶.产褥期的传统习俗及其健康教育.福建医药杂志, 2007, 29(5): 176.
7.李雨,宿鲁,张麓曾,等.农村健康教育面临的挑战与对策.中国公共卫生, 2004, 20(4): 508.
8.孟丽萍,李凤兰,贾其贤.济南市孕产妇妇幼卫生知识调查.预防医学文献信息, 2002, 8(2): 184.
9.李玲,张惠兰,龚继敏.产褥期妇女对育儿保健服务需求调查.中国妇幼保健, 2007, 22(27): 3892-3894.
10.欧水招,叶惠敏.城市妇女孕产期健康教育需求调查分析.中国健康教育, 2002, 18(6): 369-371.
11.于海莲,封锦平,牛新力.北京市西城区新街口社区妇幼保健服务现状和服务需求调查.中国妇幼保健, 2000, 15(4): 227-228.
12.贾延军,薛玲,庞淑兰.孕妇孕产期保健需求调查分析.中国妇幼保健, 2007, 22(16): 2268-2269.
13.杨惠娟,沈汝栩,李禾.北京市孕产妇保健需求调查.中国妇幼保健, 2007, 22(28): 3938-3940.
14.潘淑琴.甘肃农村社区与家庭妇幼保健知识水平卫生行为及健康需求的调查.中国妇幼保健, 2001, 16(31): 89-191.
15.候泽荣,冯占春,贾红英.农村贫困地区育龄妇女生育相关知识、态度、行为研究.医学与社会, 2007, 20(11): 15-17.
16.陈辉,方为民.高校更年期妇女性健康的KAP研究.中国妇幼保健, 2002, 17(2): 117-119.
17.曾桂群.知信行理论对334名农村妇女健康教育的影响.中国卫生统计, 2007, 24(3): 285-286.
18. Ross JA, Begala JE. Measures of strength for maternal health programs in 55 developing countries: the MNPI study. Matern Child Health J, 2005, 9(1): 59-70.
19.王燕,石玲,周虹.中国部分贫困地区孕产妇保健服务提供质量状况分析.中国初级卫生保健, 2003, 17(3): 1-3.
20.郑英.孕产妇死亡率、儿童死亡率水平及影响因素分析.大连:大连医科大学, 2007.
1.钟军,吕姿之.雅加达宣言—21世纪健康促进.中国健康教育, 1998, 14(2): 32-34.
2.曹慧,赵洪艳.妇女在家庭健康促进中的地位和作用.中国初级卫生保健, 2003, 17(2): 91-92.
3.陈敏章.贯彻全国卫生工作会议精神,加快健康教育事业发展步伐.中国健康教育, 1997, 13(11): 4-8.
4. Oral M. A Methodology for competitiveness analysis and strategy formulation in glass industry. European Journal of Operational Research, 1993, 68(1): 9-12.
5.林健燕,罗红,王凤婕,等.四象限分析法在KAP调查中的应用.中国健康教育, 2005, 21(8): 596-598.
6.鲁玉虹,陈桂芬,张云飞,等.澄江县1158例农村育龄妇女妇幼保健心理需求评估.玉溪师范学院学报, 2003, 19(1): 88-90.
7.欧水招,叶惠敏.城市妇女孕产期健康教育需求调查分析.中国健康教育, 2002, 18(6): 369-371.
8.于海莲,封锦平,牛新力.北京市西城区新街口社区妇幼保健服务现状和服务需求调查.中国妇幼保健, 2000, 15(4):227-228.
9.王海俊,路国涛,郭福新,等.农村已婚育龄妇女健康知识及获取途径调查.中国健康教育, 2007, 23 (6): 441-443.
10.薛玲,贾延军,庞淑兰,等. 300例孕妇孕产期保健知识现状调查与分析.中国妇幼保健, 2007, 22(15): 2115-2117.
11.李向云,张惠兰,王爱燕.产褥期妇女卫生服务需求调查.中国生育健康杂志, 2005, 16(4): 199-201.
12.赵凤敏,郭素芳,张彤,等.不同时期育龄妇女产前保健及影响因素分析.中国公共卫生, 2006, 22 (1): 9-11.
13.中华人民共和国统计局, www.stats.gov.cn/tjsj/ndsj/2006/indexch.htm.
14.黄敬亭主编.健康教育学,第4版.上海:复旦大学出版社, 2006, 35-38.
15.郭素芳,赵凤敏,吴久玲,等.已婚妇女社会性别意识和家庭地位状况调查.中国妇幼保健, 2007, 22(29): 4139-4141.
16.陶红兵,方鹤骞,张文斌,等.农村贫困地区育龄妇女健康知识知晓程度的影响因素及其对策.中国妇幼保健, 2007, (23): 3194-3196.
17.赵媛媛,陶芳标,许韶君.同伴教育在农村孕产妇健康促进中的应用.中国妇幼健康研究, 2006, 17 (5): 440-443.
1. Fujita N, Matsui M, Srey S, et al. Antenatal care in the capital city of Cambodia: Current situation and impact on obstetric outcome. J Obstet Gynaecol Res, 2005, 31(2): 133-139.
2.王燕,石玲,周虹.中国部分贫困地区孕产妇保健服务提供质量状况分析.中国初级卫生保健, 2003, 17(3): 1-3.
3. Houweling TA, Ronsmans C, Campbell OM. Huge poor-rich inequalities in maternity care: an international comparative study of maternity and child care in developing countries. Bull World Health Organ. 2007, 85(10): 745-54.
4. De Lange TE, Budde MP, Heard AR, et al. Avoidable risk factors in perinatal deaths: A perinatal audit in South Australia. Aust N Z J Obstet Gynaecol. 2008, 48(1): 50-7.
5. WHO, ICM, FIGO. Making pregnancy safer: the critical role of the skilled attendant. Geneva: WHO, 2004.
6. Hudelsm P. Qualitative research for health programmes. Geneva: WHO, 1994.
7.陈向明.质的研究方法与社会科学研究,第1版.北京:教育科学出版社, 2000, 269-288.
8.赵凤敏,郭素芳,张形.不同时期育龄妇女产前保健及影响因素分析.中国公共卫生, 2006, 22(1): 9-11.
9.吴擢春,李晓燕,高军,等. 1993-2003年中国妇女孕产期保健服务利用状况研究.中国初级卫生保健, 2005, 19(9): 45-57.
10.薛玉凤,王新立,卢安,等.河北省孕产妇卫生保健现状调查.中国妇幼保健, 2005, 20(15): 1971-1972.
11. Almeida C, Braveman P, Gold MR, et al. Methodological concerns and recommendations on policy consequences of the World Health Report 2000. Lancet, 2001, 357(9269): 1692-1697.
12.卫生部统计信息中心. 2005年中国卫生事业发展情况统计公报.北京:中华人民共和国卫生部, 2006.
13.杨宏斌,黄利民.制约农村卫生院预防保健功能发挥的主要因素与对策探讨.中国农村卫生事业管理, 1997, 17(2): 92.
14. Kotzee TJ, Couper ID. What interventions do South African qualified doctors think will retain them in rural hospitals of the Limpopo province of South Africa? Rural and Remote Health, 2006, 6(3):581.
15. Bundred P, Levitt C. Medical Migration: Who are the real losers? Lancet, 2000, 356(9225): 245-246.
16.高惠琦,关伟.参与性健康教育在生育健康促进中应用的展望.中国初级卫生保健, 2002, 16(4): 26-27.
17. G.Turner, J. Shepherd. A method in search of a theory peer education and health promotion. Health Educ Res, 1999, 14(2): 235-247.
18. WHO Dept. of Reproductive Health and Research. WHO antenatal care randomized trial: manual for the implementation of the new model. Geneva: WHO, 2002.
1.孟丽萍,李凤兰,贾其贤.济南市孕产妇妇幼卫生知识调查.预防医学文献信息, 2002, 8 (2): 184.
2.鲁玉虹,陈桂芬,张云飞,等.澄江县1158例农村育龄妇女妇幼保健心理需求评估.玉溪师范学院学报, 2003, 19(1): 88-90.
3.李向云,张惠兰,王爱燕.产褥期妇女卫生服务需求调查.中国生育健康杂志, 2005, 16(4): 199-201.
4.张翔,张亮,冯占春.贫困农村妇女对基本生育卫生服务需要与需求的社会学评估.中国妇幼保健, 2004, 19(11): 7-9.
5.刘凯波,何芳,聂妍,等.北京市流动孕产妇保健质量及需求状况.中国妇幼保健, 2004, 19(2): 14-15.
6.欧水招,叶惠敏.城市妇女孕产期健康教育需求调查分析.中国健康教育, 2002, 18(6): 369-371.
7.于海莲,封锦平,牛新力.北京市西城区新街口社区妇幼保健服务现状和服务需求调查.中国妇幼保健, 2000, 15(4): 227-228.
8.候泽荣,冯占春,贾红英.农村贫困地区育龄妇女生育相关知识、态度、行为研究.医学与社会, 2007, 20(11): 5-17.
9.潘淑琴.甘肃农村社区与家庭妇幼保健知识水平卫生行为及健康需求的调查.中国妇幼保健, 2001, 16(31): 89-191.
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