a follow-up study of first trimester induced abortions at hospitals and family planning clinics in...

A Follow-up Study of First Trimester Induced Abortions at Hospitals and Family Planning Clinics in Sichuan Province, China Lin Luo,* Shi-Zhong Wu,* Xiao-Qin Chen,* Min-Xiang Li,* and Thomas W. Pulluml-

ELSEVIER

Four-thousand women aged 18-40 underwent an early induced abortion at hospitals and family planning clinics in six counties in Sichuan province, China, between 1 July 1990 and 30 June 1991. The subjects were followed-up three times, on days 15, 90 and 180 after the operation. Information was obtained about their age, parity, contraceptive use, social behaviors, and gynecological and psychological characteristics before and after the abortion. The results indicate that induced abortion is safe when provided by medically trained personnel in health facilities such as hospitals or clinics. Depressive symptomatology was assessed by the CES-D and SCL-90 scales. The depressive symptoms declined over time. A substantial proportion of the abortions were to unmarried women or resulted from non-use of contraception or contraceptive failure, implying that the incidence of unintended pregnancies and induced abortions could be reduced by more effective and accessible contraception. CONTRACEPTION 1996; 53:267--273

KEY WORDS: induced abortion, depression, unintended pregnancy, family planning, contraception

I n t r o d u c t i o n

I nduced abortion is one of the oldest methods of fertility control and one of the most widely used. It is practiced in remote rural societies as well as in

large modem urban centers. Because unintended pregnancy is so prevalent, induced abortion has become one of the most frequently performed surgical procedures throughout the world. Between 40 and 60 million abortions take place around the world every year. 1 No matter how effective family planning ser-

*Sichuan Family Planning Research Institute, Chengdu, China, and 1Popula- tion Research Center, University of Texas, Austin, TX, USA

Name and address for correspondence: Dr. Luo Lin, Sichuan Family Planning Research Institute, Chengdu, China. Fax: 86-28-5583039

Submitted for publication October 17, 1995 Revised January 16, 1996 Accepted for publication February 2, 1996

vices and practices become, there will always be a need for access to safe abortion services. 2

Legal abortion has proved to be a very safe procedure, involving mortal i ty rates much lower than those associated with childbearing. Possible side effects on women's subsequent reproductive capacities have been studied extensively.

China's first population act, in 1953, dealt with contraception and procedures for induced abortions. This 1953 document , drafted by the Ministry of Health and approved by the State Council, specifi- cally loosened conditions for abortion. Induced abortion was legalized in 1956, and shortly thereafter the necessary social conditions to obtain one were liber- alized. It is now used as a therapeutic method and as a backup measure when contraception fails.

Of all the potential complications of abortion, psychological responses are the most difficult to assess. 2 Substantial literature exists, but conclusions have been contradictory. Diverse interpretations result from the limitations of the research methods used, political influences, and value judgments. A recent review of the best scientific studies with the most rigorous research designs shows that in the United States psychological distress is generally greatest before the abortion. However, weaknesses and gaps among studies provide challenges for future research?

The goals of the present study were to investigate short- term complicat ions and psycho-social outcomes of induced abortion in China, and to explore the effect of socio-economic status on these outcomes.

Materials and Methods

Population and Sample Sichuan is China's most populous province, with ap- proximately 9.6 percent of the country's estimated 1.1 billion persons. The study was conducted in six

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268 Luo et al. Contraception 1996;53:267-273

counties in the province. Selection criteria ensured that these counties vary in their geography, income, health facilities, and existing abortion services. The counties are geographically widespread with Changxi and Jiang-go in remote mountainous regions far from Chengdu, the capital of Sichuan province. Guanxian and Pengxian are in hilly and plains areas, and Guang- han and Xingdu are in plains near Chengdu.

This was a clinical follow-up study, requiring access to clinic or hospital records or interviews with clinic patients. The study included all first trimester induced abortions to women with a pregnancy test performed in hospitals or family planning clinics in the six counties, from July 1990 through June 1991. After screening, exactly 4000 women aged 18-40 years and having a first trimester abortion volun- teered to participate in the study. They were followed up three times, on days 15, 90 and 180 after the induced abortion.

The 4,000 women in the study ranged in age from 18 to 40 years, with a median age of 25 years. Marital status data revealed 11.4 percent were single and 88.6 percent were married. Only 0.7 percent had a college education; 38.0 percent had graduated from high school; 42.8 percent had a middle school education; 9.0 percent primary school; and 9.5 percent had no formal education. Occupation data revealed 77.4 percent were farmers, 10.4 percent were workers, 6.6 percent were housewives, and 5.6 had some other occupation. Other demographic data revealed 84.7 percent lived in rural areas and 15.5 percent in urban areas. A retrospective question on childhood place of residence indicated that at age 12, 88.5 percent had lived in the countryside and 11.5 percent in towns.

By the t ime they entered the study, the women had a mean of 1.57 births (a standard deviation of 1.04) and a mean of 1.37 pregnancies (s.d. 0.78); 33.6 percent had one prior abortion, 52.1 percent had two or more prior abortions, and 14.3 percent had prior pregnancies but no prior abortions. All of the abortions occurred during the first trimester, but 5.5 percent had less than 40 days of gestation, 69.5 percent had 40-59 days of gestation, and 25.0 percent had 60-90 days of gestation. The procedure used for the abortion consisted of vacuum aspiration in 47.8 percent of the cases, vacuum aspiration and curettage completed in 3.7 percent of the cases, and curettage in 48.3 percent of the cases.

An earlier paper by the same investigators focused on the incidence of medical complications following induced abortions in 457 unmarried women in this sample. 4 Some additional information about the data collection procedures and the social and cultural characteristics of the study area can be found in that paper.

Fieldwork More than 100 gynecologists and psychologists from county or regional hospitals and family planning clinics joined in the study. A pre-service training course was conducted. At the end of the training, an exam was given on the contents of the course and the re- porting forms. The participants who passed the exam were employed as interviewers. The interviews were face-to-face. All subjects gave their consent to participate in the study. The follow-up rate was 99.83 percent on day 15, 99.28 percent on day 90, and 98.70 percent on day 180.

Subjects scheduled to undergo an abortion were first seen by trained gynecologists and psychologists. This initial meeting served the following purposes:

Necessary medical tests were performed to con- firm the pregnancy (laboratory or ul trasound tests).

The decision to terminate the pregnancy was ex- amined.

A physical examination was conducted, with laboratory tests if needed.

It was verified that the subject would voluntarily participate in the study.

Background socio-economic data and a psychological assessment were obtained.

The pre-abortion assessment included a series of questions on the subject's background, reproductive history, contraceptive use, feelings about this pregnancy, reasons for the abortion decision, and stan- dardized tests of psychological distress. The physical examination included temperature, blood pressure, and a pelvic examination to estimate gestational age and configuration of the uterus. Laboratory tests included a urine pregnancy test, a blood test (white blood cells, hemoglobin), bleeding time, clotting time, and a routine urinalysis.

After completing the pre-abortion assessment, the subject went back home (if she lived nearby) or waited in the recovery room. Two days later, she underwent the induced abortion. Post-operative data were collected in the recovery room shortly after the procedure was completed (usually within 15 to 20 min- utes). The post-abortion assessment questionnaire gathered information on the operation regarding the technique used, blood pressure, volume of blood, trauma, duration of operation, and the patient's reac- tion during and after the operation. It also asked about the operative doctor's training and experience with induced abortions.

The follow-up questionnaire obtained information on post-abortion care (job, nutrition, rest, and health care), medical complications following the abortion (bleeding, retained tissue, cervical or uterine trauma,

Contraception Follow-up of Induced Abortions in Sichuan 269 1996;53:267-273

or uterine perforation), and psycho-social outcomes, us ing the Cen te r for Epidemiologic Studies- Depression Scale (CES-D) and the Symptoms Check- list (SCL-90) self-rating questionnaire.

The CES-D was developed by the National Institute of Mental Health in the United States in 1977. It has been widely used for epidemiological investigation and for assessing the degrees of seriousness of depression of patients in clinical examinations. The CES-D has a demonstrated capacity to identify clinically ab- normal populations, but is designed for use in general population surveys. It was "designed to measure current level of depressive symptomatology, with em- phasis on the affective component , depressed mood. ''s Respondents use a four-point scale ranging from "rarely, never" (less than one day a week) to "often" (at least five days a week) to indicate the frequency with which they experienced each of 20 symptoms of depression during the past week. The CES-D total score is divided into three intervals (grade I: total score (TS) 15; grade II: 16 TS 19; grade III: TS 20). A score of 16 or greater on the CES-D is an indicator of depressive symptomatology.

The SCL-90 is a multi-dimensional symptom self- report inventory comprised of 90 items, each rated on a five-point scale of distress (0 to 4) from "not at all" to "extremely." It is well suited for use in research protocols where the major interest is assessment of an outpatient symptomatic configuration. 6 The questionnaire was usually completed by the patient but was administered by a trained doctor when the patient could not complete it.

The SCL-90 and CES-D have been used as psychiatric instruments in China since the 1980s. 7 If the screening measure is intended to detect cases of major depression rather than overall psychiatric impair- ment, then the cut points for defining major depression may be different in China from what they are in America. 8 Moreover, our research investigated women who sought an induced abortion, and they may differ systematically from other women in the same cultural context. Therefore, our description of depressive symptomatology using cut points developed in the United States should be interpreted with caution.

We know of no other studies of the CES-D and SCL- 90 scores of Chinese pregnant women.

Results Medical Sequelae As shown in Table 1, 75.9 percent of the respondents were aged less than 30, and only 11.1 percent were older than 34; the women tended to be young. In China, all contraceptive methods (the pill, IUDs, ster-

Table 1. Age distribution of the 4,000 participants in this- study

Age Group Number of Cases Percent

<20 148 3.7 20-24 1567 39.2 25-29 1319 33.0 30-34 524 13.1 35-39 427 10.7 40-44 15 .4

Total 4000 100.0

ilization, diaphragms, condoms, etc.) have been legal and available since the 1950s. Use of these methods increased rapidly after 1970, and about 86 percent of China's 150 million women of reproductive age (or their husbands) were estimated to be practicing birth control in 1985. 9 In Sichuan province, the main methods are IUDs, vasectomy and tubal ligation. The IUD is more popular among younger women and tubal sterilization is more popular among older women. Pills, condoms, and other methods are also used, although their use requires an efficient and timely sup- ply of contraceptives. Some use is relatively ineffec- tive and some supplies are not very good, with consequent risks of pregnancy.

Table 2 shows that 1471 (36.8 percent) of the 4,000 pregnancies were due to contraceptive failure. Among these 1471 patients, 964 (65.5 percent) were using the IUD, 90 (6.1 percent) were using pills, 100 (6.8 percent) were using condoms, and 317 (21.6 percent) were using other methods. Among the 1995 women who had an unintended pregnancy, 1739 were not using contraception, 128 were using an IUD, 9 were using condoms, 19 were using pills, and 7 were using withdrawal.

Table 2 shows that 424 of the women sought an abortion because they were unmarried. Among these 424 women, 94.8 percent were aged less than 24, 80.0 percent were farmers, 85.1 percent lived in rural areas, and 94.1 percent were not using contraception. The results show that the Chinese custom of early

Table 2. Reasons for induced abortion obtained before the abortion

Reasons Number of Cases Percent

Unintended 1995 49.9 Contraceptive failure 1471 36.8 Unmarried 424 10.6 Mother's health problem 34 0.9 Economic problem 38 1.0 Family problem 13 0.3 Fetus' health problem 25 0.6

Total 4000 100.0


Table 3. Blood loss during operation

Volume (ml) Number of Cases Percent

<50 2,744 68.6 50-100 1,044 26.1

101-200 166 4.2 201-300 28 0.7

>300 14 0.3 Unknown 4 0.1

Total 4,000 100.0

marriage still exists, especially in rural areas and among farmers.

The primary reason why unmarried women get an induced abortion is that premarital fertility is cultur- ally unacceptable. In China, young unmarried women are too shy to seek contraceptives and they have few sources of information about contraceptive use. Abor- tion is primarily a substitute for contraception rather than a backup for contraceptive failure, although about two percent of the unmarried women used contraceptives and their pregnancies can be described as contraceptive failures. There is an urgent need to popularize knowledge of sexuality and contraception among unmarried Chinese women.

In our study, most cases of induced abortion (96.3%) were due to unintended pregnancies while the woman was unmarried or when she had a contraceptive failure. A few women (1.5 %) sought an abortion because they or their fetus had health problems. The remainder (1.2%) had an abortion because of economic or family problems. All the abortions were vol- untary or were recommended as a way to avoid an unwanted pregnancy.

The Sichuan Province Family Planning Law, approved in 1987, provides that induced abortions must be performed by doctors with certification from the Medical and Family Planning Department and in a health facility such as a hospital or clinic. Among the 4000 operations in the study, 13.5 percent, 26.4 percent, and 56.9 percent were performed by doctors who graduated from medical college, medical vocational school, or a family planning technique training program, respectively (3.2 percent were non-response); 90.4 percent, 5.9 percent, 2.8 percent, 0.9 percent

Table 4. State of bleeding 15 days post-operation

Amount of Bleeding Number of Cases Percent

No bleeding 1,951 48.9 Spotting 1,740 43.6 Same as menses 274 6.9 More than menses 28 0.7

Total 3,993 100.1

were performed by doctors who had more than 3 years, 1-2 years, 6-12 months, or less than six months' experience of practicing induced abortion, respectively.

Of the 4000 operations, 47.8 percent used aspiration, 48.3 percent curettage, and 3.7 percent a combi- nation of aspiration and curettage. There were no complications of retained tissue, cervical or uterine trauma, or uterine perforation among the 4000 patients. As shown in Tables 3-5, the levels of bleeding and fever were normal for most patients. The results indicate that induced abortions provided by medically trained personnel and performed in health facilities are safer than childbirth. In the United States, abortion-related death rates have been estimated at 50 to 100 per 100,000 illegal procedures compared to 1 per 100,000 legal abortionsJ °

Psychological Sequelae: Assessment by CES-D The CES-D scale includes information about 20 symptoms of depression during the past week:

1. I was bothered by things that usually don't bother me.

2. I did not feel like eating; my appetite was poor. 3. I felt that I could not shake off the blues even

with help from my family or friends. 4. I felt that I was just as good as other people. 5. I had trouble keeping my mind on what I was

doing. 6. I felt depressed. 7. I felt that everything I did was an effort. 8. I felt hopeful about the future. 9. I thought my life had been a failure.

10. I felt fearful. 11. My sleep was restless. 12. I was happy. 13. I talked less than usual. 14. I felt lonely. 15. People were unfriendly. 16. I enjoyed life. 17. I had crying spells. 18. I felt sad. 19. I felt that people dislike me. 20. I could not get "going."

The term "depression" refers to the syndrome of behaviors that have been identified in descriptive studies of depressed individuals. 11 It includes verbal state- ments of dysphoria, self-depreciation, guilt, material burdens, social isolation, somatic complaints, and a reduced rate of many behaviors. Severely depressed patients may be characterized by both the absence of positive affect and the presence of negative affect. 12

A simple total score is recommended as an estimate


T a b l e 5. Short-term fever 15 days post-operation

Fever Number of Cases Percent

No 3,830 95.92 Yes 139 3.48 Unknown 24 0.60

Total 3,993 100.00

of the degree of depressive symptomatology. 6 The as- sessments before and after abortion showed a significant dec l ine in the to ta l score, f rom M=6.83 (s.d.=6.37) before the abortion to M=2.77 (s.d.=3.68) afterwards (Table 6). The percentages of depressive cases also showed a significant decrease, from 4.73 percent before the abortion to 0.89 percent afterwards (see Table 7).

Tables 8 and 9 list the six indicators of depression that appeared most frequently. Two days before the induced abortion, there were 1457 mentions of the absence of positive affect for 3-4 days during the past week; there were 787 mentions of the absence of positive affect for 5-7 days. By 180 days after the induced abortion, these mentions declined to 1135 and 252, respectively. Tables 8 and 9 show that the distribu- tions are very skewed toward the absence of positive affect.

What kinds of subjects were particularly likely to indicate that they were depressed or not depressed at the t ime of their abortion? In multiple regressions, the initial CES-D score was regressed on the indepen- dent variables collected in the study. Occupation, education, age, number of previous abortions, number of previous pregnancies, the subject's feeling when learning of this pregnancy, reasons for obtaining the abortion, and the operator's training level and education were significantly associated with the total CES- D. Women with higher depression scores tended to be non-farmers, had more education, were unhappy when learning of this pregnancy, had no child, had a health problem, or were unmarried. Symptoms of depression were also more common if the operator had a lower training level or a higher level of education. We found no clear relation between post-operative complications and income, residence, or operation procedure.

T a b l e 6. Total CES-D score at admission and after the induced abortion

Time N Mean s.d.

At admission 4,000 6.83 6.37 Day 15 3,993 4.93 4.95 Day 90 3,971 3.13 4.05 Day 180 3,948 2.77 3.68 F = 4 . 0 7 , p < 0 . 0 0 0 0 1 .

Two other regressions showed that psychological effects which remain 180 days after the abortion are related to the educational level and occupation of the women and to the operator's experience in perform- ing induced abortions. Better educated women, with more intellectual occupations, appear to be more troubled by the experience and are more likely to show some psychological distress even 180 days later. A more experienced operator performs an abortion with less pain and blood loss, which in turn affects the women's emotions during the abortion and afterwards.

Psychological Sequelae: Assessment by SCL-90 The SCL-90, developed by Derogatis on the basis of Hopkins' Checklist, 5 is used clinically to measure the seriousness of psychological distress. The 90 items cover a wide scope of problems or symptoms, and each i tem is graded with a 5-score system, ranging from "0" to represent "No, I do not have such a problem or symptom," to "4" for "Yes, I have the problem or symptom and it is very serious."

The 90 items of SCL-90 are usually divided into 9 groups or factors, as follows:

1. Somatization (12 items); 2. Obsessive-compulsive (10 items); 3. Interpersonal sensitivity (9 items); 4. Depression (13 items); 5. Anxiety (10 items); 6. Hostility (6 items); 7. Phobic anxiety (7 items); 8. Paranoic ideation (6 items); 9. Psychoticism (10 items).

The score for each factor is calculated as the mean of the items within the factor.

The self-report measurements before and after the induced abortion revealed a heightened level of distress at the t ime of the abortion for all nine factors. The highest levels were found for the symptoms cap- tured by the somatization factor, which reflects distress arising from perceptions of bodily dysfunction. Complaints focused on cardiovascular, gastrointesti- nal, respiratory, and other systems with strong auto- nomic mediat ion are included. Headaches, back- aches, and pain and discomfort localized in the gross musculature are also represented, as are other somatic equivalents of anxiety.

The relatively higher CES-D and SCL-90 total scores before the induced abortion probably reflects the stress of both the unexpected pregnancy and the impending abortion, and the lower scores after 15, 30,


T a b l e 7. Depression before and after the induced abortion

Time N N

Depressive Symptoms Depression

Percent N Percent

At admission 4,000 189 4.73 192 4.80 Day 15 3,993 71 1.78" 69 1.73" Day 90 3,971 51 1.28" 24 0.61" Day 180 3,948 35 0.89* 18 0.45*

*p < 0.000001, compared with the baseline.

and 180 days show the subsequent relief of distress after the abortion.

Discussion Three major findings emerge from this study of short- term complications and psycho-social outcomes of induced abortion in Sichuan province, China.

First, there were no instances of retained tissue, cervical or uterine trauma, uterine perforations or serious bleeding. Unwanted pregnancies put women in many parts of the developing world at risk of morbid- i ty and mor ta l i ty associated wi th pregnancy and childbearing. Our results show that when abortions are performed under safe medical conditions, the risks are much lower.

Second, in this study, the psychological responses demonstrate that distress was commonly greatest before the abortion and significantly associated with occupation, number of previous abortions and births, and the operator's training level and education. Thus, the patient's pre-abortion counseling and the operator's training level should be continually improved.

Third, most of the 4,000 women were aged less than 30 years and their main reason for obtaining an abortion was that their pregnancy was unintended, resulting either from contraceptive failure or from non-use of contraception because they were unmarried. Over the last several decades, the Chinese gov- ernment, through a highly organized and intensive family planning program effort, has successfully re-

T a b l e 8. Reports of main indicators of depression obtained at admission (two days before the induced abortion)

Characteristic

Felt This Way During the Past Week

on 3-4 Days on 5-7 Days

N % N %

Absence of good 301 7.5 291 7.3 Absence of hopeful 387 9.7 185 4.6 Absence of happy 429 10.7 178 4.5 Absence of enjoy 340 8.5 133 3.3 Poor appetite 510 12.8 103 2.6 Effort 181 4.5 34 0.9

duced the birth rate of its large population. By 1988, 71 percent of the 206 mi l l ion marr ied Chinese w o m e n of reproductive age were using a modern method of contraception. Among users, the primary methods were the IUD (41 percent) and tubal ligation (38 percent), the main methods promoted by the national family planning program. From this study, it is apparent that contraceptive failures among married w o m e n and non-use of contracept ion among the unmarried are still risk factors for unwanted pregnancies and induced abortions.The official Chinese posi- tion is that abortion should not be relied on as an alternative to contraception. Birth control should be based on contraceptive use, with induced abortion used only as a backup in case of contraceptive failure.13 When modern contraception is widely available and used effectively, reliance on abortion will be reduced. To this end, the program could reduce the in- c idence of u n i n t e n d e d pregnancies and induced abortions by further promoting more effective contraceptives and making contraception more easily available to unmarried couples. The current policy encour- ages the insertion of an IUD after the birth of the first child. There have been some studies of the comparative failure rates and expulsion rates of various IUDs made in China. 14'1s The present study does not allow for a direct measurement of the incidence of contraceptive failure. However, of the 1,471 patients in this study who had their induced abortion because of contraceptive failure, 65.5 percent were current users of IUDs, and the contribution of IUD failures to the use

T a b l e 9. Reports of main indicators of depression obtained 180 days after the induced abortion

Characteristic

Felt This Way During the Past Week

on 3-4 Days on 5-7 Days

N % N %

Absence of good 202 5.1 106 2.7 Absence of hopeful 334 8.5 10 0.3 Absence of happy 331 8.4 18 0.5 Absence of enjoy 229 5.8 18 0.5 Poor appetite 26 0.7 1 0.0 Effort 13 0.3 2 0.1


of abortion is substantial. It should be possible to in- troduce better IUDs with lower failure rates, especially in poorer communities.

Acknowledgments This investigation received financial support from the Special Program of Research, Development and Re- search Training in H u m a n Reproduct ion , World Health Organization (WHO). The authors are grateful for expert consultation from Axel Mundigo and Iqbal Shah. We also acknowledge technical assistance from Fu Jingshan and helpful comments from Toni Falbo on an earlier draft.

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a follow-up study of first trimester induced abortions at hospitals and family planning clinics in...

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