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Publishable summary of INPAC project

Title: Integrating Post-Abortion Family Planning Services into China’s Existing Abortion Services

in Hospital Settings

Acronym: INPAC

Contract/Grant agreement number: 282490

EC contribution: 2,928,384.00 €

Duration: 48 months

Starting date: 01/08/2012

Reporting period: 01/02/2014 – 31/07/2015

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INPAC project Publishable summary

Project context and objectives

Repeated induced abortion is associated with a high risk of long-term physical and psychological morbidity

and with a heavy social-economic burden. China is one of the countries with high induced abortion rates in

the world. In 2008, about thirteen million induced abortions were estimated, the repeated abortion rate varied

from 19.0% to 57.9% depending on different study populations according to the data from the INPAC

project situation analysis (WP2 & WP3), which has been reported in the first reporting period. The vast

majority of induced abortions in China is performed in hospital settings, though family planning (FP) clinics

also provide abortion services. However, Post-Abortion Family Planning (PAFP) services are often lacking

in hospital settings.

The primary reasons of unintended pregnancies in China were due to contraceptive failure, incorrect or no

use of contraception. PAFP is commonly recognized as an efficient way to reduce the rates of unintended

pregnancies and therefore to protect women’s health. Data from the INPAC situation analysis also show that

there are barriers for providing effective PAFP services including the policy on PAFP is currently absent,

there is a lack of government and management support in hospital settings, a shortage of trained family

planning professionals and lack of access to PAFP guidelines, a lack of standard PAFP information materials

and a lack of PAFP knowledge of clients and service providers.

Overall objective of the research

The overall objectives of this project is to evaluate the effectiveness of introducing integrated post-abortion

family planning services in existing hospital based abortion services in China in order to reduce unintended

pregnancies and repeated abortions. The research findings might be used to develop policy recommendations

on sustainable development and health system organization to enhance equitable access to reproductive

healthcare.

Specific scientific and technical objectives in the1

st & 2

nd reporting period

To assess the needs and feasibility of integrating PAFP into existing abortion services in hospitals

through the review of FP policy and FP current practice in China as well as best practices of strategies

to deliver PAFP in developed and developing countries.

To assess practicability of integrating PAFP into existing abortion services in participating hospitals

through a health system study involving stakeholders: policy makers, health managers, abortion service

providers and women who have undergone abortion.

To develop detailed intervention strategies for improving access to and quality of FP services after

induced abortion.

To implement and monitor intervention processes, their impact on hospitals and problems occurred

during the implementation

To evaluate the effectiveness of integrated PAFP in terms of reduction of unintended pregnancies and

repeat abortions and to identify health system determinants for effectiveness through comparison across

the intervention groups.

To disseminate the research findings and to bridge the gap between research and policy and actions

through involving policy and decision makers at different levels of government.

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Work performed and the main achievements since the beginning of the project

The INPAC project was designed in four phases: PHASE I Situation analysis (WP2, WP3): a detailed situation analysis on the provision and utilization of

abortion services in China.

PHASE II Development of interventions strategies (WP4): the development of project intervention

strategies based on the situation analysis and pre-existing knowledge.

PHASE III Intervention implementation and monitoring (WP5): the implementation and monitoring of

the intervention strategies.

PHASE IV Operational and analytical evaluation (WP6, WP7, WP8): the evaluation of intervention

effectiveness, the project dissemination and policy translation of research findings.

During the first reporting period, INPAC has completed its phase I by the end of January 2014, including

WP2 - Critical review and WP3 - Detailed situation analysis. The main findings were reported in the project

deliverables D2.1 (A report on policy and FP practices based on published and grey literatures) and D3.1 (A

document describe the situation analysis), both reports have been accepted by the EC.

The current 2nd

reporting period mainly covers phase II (WP4) and Phase III (WP5) activities from project

month 19 to month 36 (February 2014 to July 2015). The Phase IV (project dissemination and policy

translation) activities will be done throughout the whole project. A summary of project activities in the 2nd

period is draw in the sections below.

1) The Development of interventions strategies (Phase II - WP4) A three-arm cluster randomized controlled trial was designed based on the results of phase I, which included

two intervention arms and one control arm (Figure 1).

Figure 1: INPAC intervention design

A package of protocol supplementary documents, such as data collection questionnaires and protocol

guidelines for investigators, were developed in both English and Chinese in order to help local investigators

to understand the intervention protocol and the intervention implementation approaches.

This trial has been registered at Current Controlled Trials with a ISRCTN registration number of

ISRCTN01846583 (http://controlled-trials.com/ISRCTN01846583).

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2) The Intervention implementation and monitoring (Phase III – WP5) The INPAC intervention study received its ethical approval from the Ethical Committees at Ghent University

(Belgium), Liverpool School (UK) and National Research Institute for Family Planning (NRIFP) (China).

The implementation was officially kicked off on July 05, 2014. By the date of this report, the follow-up data

collection is still on going. To ensure the success of intervention implementation, the following strategies

and activities were carried out.

Hospital randomization and enrolment: we first developed a hospital sampling frame from 30

provinces. Each province provided 12 eligible hospitals except Ningxia, Qinghai and Inner Mongolia

provinces. Since the number of eligible hospitals is limited, they provided 6 hospitals. Three

hospitals were randomly selected from each province, and then randomly assigned to the two

intervention arms or the control arm. A total of 41 selected hospitals have withdrawn after

randomization due to varies practical reasons.

Development of survey questionnaires and informed consent forms for institutions, service providers

and clients: data collection questionnaires were developed for institutions, service providers and

service users (the abortion women) at different pre- and post-intervention time-points. Instructions

on how to fill in the questionnaires were developed in Chinese for the investigators.

Pre-intervention trainings for investigators: two national training workshops were conducted in July

and August 2014 for provincial coordinators from the 30 provinces and hospital investigators from

the 90 participating hospitals (including the hospital replacements). Training material were

developed by Chinese partners. These cover the following topics:

o General information about PAFP services

o Responsibility and capacity of consultants

o PAFP counselling services (principles, procedures, and skills)

o Group education (principles, procedures, and skills)

o Core information to provide after an abortion (health risks of induced abortion and repeated

abortion, reasons of contraception failure, the modern contraceptive methods,

recommendations of contraceptive methods after abortion)

Development of Intervention materials: intervention information posters and leaflets in Chinese were

developed by WP5 leader (CSFP) in close collaboration with UG-ICRH and with support from other

partners.

Intervention implementation and current status: On July 10, 2014, the first hospital enrolled and

started the recruitment of women underwent abortion. The last hospital enrolled on Dec.11, 2014. By

July 31, 2015, all 90 hospitals have completed the facility pre-intervention questionnaires. 58

hospitals completed the facility post-intervention questionnaires. A total of 771 pre-intervention

questionnaires for service providers were completed. 60 hospitals completed the post-intervention

questionnaires for service providers. A total of 18,106 women had been recruited. Among these,

16,359 (90%) completed the one-month follow-up survey, 14,082 (78%) and 10,861 (60%)

completed the three-month and the six-month follow-up survey respectively. Almost all hospitals in

the two intervention groups have received free contraceptives and the IEC materials. Almost all

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hospitals in Intervention Group II have established incentive mechanisms to encourage providing

PAFP services.

Development and implementation of electronic data capture (EDC) system: INPAC has developed

its own EDC system, which has been used for WP5 data collection.

A pilot study was conducted by WCSUH team to test the questionnaires and the EDC system in June

2014.

Monitoring of intervention implementation: to ensure the smooth implementation of the intervention

plan and to get correct, objective and reliable intervention results, the INPAC project intervention

study was monitored at four levels with a set of monitoring check lists (Monitoring Plan) to ensure

the intervention progress, the protocol compliance and the data quality control (Figure 2):

The provincial/municipal supervisors were mainly responsible for supervising the three participating

hospitals in his/her own province. The national supervision are organised in 7 groups, each of them

supervising several provinces/municipalities. They reported to the WP5 leader (CSFP) or directly

report to the project coordinator (UG-ICRH). Monitoring is done either by phone contact or by field

visits. Monthly TC meetings are being held since the beginning of WP5 .

During the implementation period, a consortium TC was conducted each month, in order to review

the monitoring data, to solve eventual problems and to discuss possible solutions. Each three months,

the WP5 lead – CSFP reported in writing about the progress of intervention study.

3) Evaluation of intervention effectiveness (WP6) Both quantitative and qualitative methods have been developed to evaluate the effect of intervention

implementation.

Quantitative evaluation: A set of primary and secondary indicators was defined in the evaluation plan (MS3

– Methodology for evaluation of the intervention) which has been developed by the AU-DESC team and

combined with the qualitative evaluation strategies led by LSTM team. A report of pre-intervention study

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was developed by the AU-DESC with the collaboration from CSFP (MS4 – Pre-intervention study

completed).

Qualitative evaluation: To perform the qualitative evaluation, LSTM team provided several training

workshops for the Chinese researchers. The pre-intervention and post-intervention data were collected,

transcribed and coded by the 4 Chinese partners who carried out the field work, according to the guidelines

developed by LSTM. Analysis will be done by LSTM during the next reporting period.

4) Translating research into policy and actions (WP7) During the first reporting period, we developed “a list of potential barriers to research translation into action”

(D7.1). After that, we made great efforts on policy translation to strengthen the impact of the INPAC project

on PAFP services. As the WP7 lead partner, WCSUH team in collaboration with NRIFP and FU team,

communicated and interviewed national and provincial level policy makers and kept them informed about

the progress of the INPAC project. A list of policy translation strategies was developed during this reporting

period (D7.2) and has been accepted by the EC. The 3rd PAB meeting is scheduled in September 2015 in

China, several policy makers at different levels will be invited to participate in the meeting where INPAC

progress and the strategies used for policy translation will be discussed. .

5) Dissemination of project progress and preliminary findings (WP8) The dissemination of project progress and preliminary findings was done largely at national and

international levels. 10 abstracts were presented at different international and national scientific conferences

during this reporting period.

Other dissemination approaches were also used, such as the distribution of the project’s leaflets in both

English’ and Chinese languages at national and international conferences, the project’s newsletters, website

updates, and regional or provincial scientific workshops.

6) Project management and coordination activities in the 2nd

reporting period (WP1 and

WP9) The project coordination team UG-ICRH takes the responsibilities of day-to-day project management and

coordination, as well as the scientific supervision. All project activities were carried out under the guidance

of the project management team (PMT), the Scientific Advisory Board (SAB), the Ethical Advisory Board

(EAB) and the Policy Advisory Board (PAB). Various communication approaches were used.

From the beginning of the 2nd reporting period (Feb. 2014) to the end of this period (July 2015), the

following activities have taken place:

Face-to-face meetings, project workshops and advisory board meetings:

o The 1st EAB face-to face meeting was held in July 2014 in China. It was hosted by the NRIFP

team and led by UG-ICRH with four EAB members attended.

o The WP5 kick-off meeting was held in July 2014 in Beijing.

o Two WP5 training workshops were conducted in July and August 2014 in China, all

collaborators from 90 hospitals in 30 provinces participated in the training programs on the

topics mentioned above.

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o The intervention evaluation training workshop on qualitative study was conducted in July 2014

in Beijing, China.

o The 1st SAB meeting was held in December 2014 at ICRH in Belgium.

Consortium TCs on the project progress: since September 2012, each month, a consortium TC was

conducted on WP5 progress and monitoring. Several small group TCs were held on WP5 specific topics.

In total, 17 TCs were conducted during the 2nd reporting period.

Monitoring of the budget use: to ensure the budget use in the consortium, the project coordinator (UG-

ICRH) organized an interim financial report between March and April 2015.

The expected final results and their potential impacts

INPAC has achieved most of its objectives for the 2nd

reporting period with deviation on the timeline.

The main conclusions and findings of PHASE I (WP2 and WP3) on the provision and utilization of abortion

services in China have been reported during the first periodic report, and have been reported in detail in D2.1

and D3.1, which provided information on the feasibility and practicability of integrating PAFP services into

existing abortion services in hospitals in China, and has guided the intervention design.

Intervention packages, its implementation and monitoring

A three-arm cluster randomized controlled trial has been designed based on the results of the critical review

and the situation analysis. We also developed intervention guidelines to describe the details of the

intervention packages, together with the tools for the data collection.

We developed a project EDC system to ensure the electronic data entry and management, and conducted a

pilot study before the intervention implementation. The three level trial monitoring ensured the protocol

compliance and the data quality control.

Translational research into policy

Research translation is the final aim of this project. To achieve this objective, we developed a list of potential

barriers to research translation into action. This list has been developed during the first reporting period.

During the second reporting period, we communicated and conducted interviews with national, provincial

and local health authorities and policy makers, to get advice from them on the translation strategies. These

interviews resulted in a list of recommendations on policy translation strategies (D7.2), it has been accepted

by the EC.

Project management activities

A series of project management activates were carried out by all consortium partners. Face-to-face meetings,

regular TCs, phone and email contacts were used to ensure a smooth and efficient communication among all

partners. This ensured the project to achieve its main objectives.

Timeline deviation: The INPAC study is progressing well. However, we are facing important challenges in

the process of intervention implementation as described above. Currently the whole project timeline is

delayed with about 12 month, mainly due to delays on WP3 and WP5. The delays are mainly caused by the

merger between the Chinese Ministry of Health and the Ministry of Family Planning in 2012, which highly

influenced the hospital participation. Since this merger took place after the launch of the project, the

enrolment of hospitals and recruitment of participants took much more time than originally estimated, since

we did not want to make any compromise in science and wanted to follow the study protocol as originally

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planned. The delay in WP3 and WP5 has been communicated to the EC in the first period report and in the

deliverables of WP3 and WP5.

The planned 4 deliverables and 3 milestones were fully achieved for the 2nd

reporting period:

D5.1 An implementation plan for the implementation of interventions

D5.2 Mid-term report on the implementation & monitoring process

D7.2 A list of recommendations on the way of knowledge translation from PAB

D8.2 Dissemination strategy available

MS2 A document describing the interventions protocol

MS3 Methodology for evaluation of the intervention

MS4 Pre-intervention study completed

The address of the project public website English version: http://www.inpacproject.eu

Chinese version: www.pac-china.org

Contact details of INPAC consortium

The INPAC project is a four-year collaboration between four Chinese and three European partners,. The

consortium is composed of:

Lead partner: International Centre for Reproductive Health of the Ghent University (UG-

ICRH), Sint-Pietersnieuwstraat 25, 9000 Gent, Belgium. Contact person: Prof. Dr. Marleen

Temmerman & Prof. Dr. Wei-Hong Zhang, e-mail: marleen.temmerman@ugent.be &

weihong.zhang@ugent.be

Partner 2: Chinese Society of Family Planning - Chinese Medical Association (CSFP). West

street Dongsi Xidajie 42, Beijing 100710, China. Contact person: Prof. Dr. Jian Li, e-mail:

lijian5710@gmail.com

Partner 3: Fudan University (FU), School of Public Health. Handan Road 220, Shanghai 200433,

China. Contact person: Prof. Xu Qian, e-mail: xqian@fudan.edu.cn

Partner 4: National Research Institute for Family Planning (NRIFP). Haidian District, Da Hui

Si 12, Beijing 100081, China. Contact person: Prof. Shangchun Wu, e-mail:

wu.shang.chun@yeah.net

Partner 5: Sichuan University (WCSUH). People’s South Road 17, Wuhou District, Chengdu

610041, China. Contact person: Prof. Dr. Lina Hu, e-mail: cqhulina@126.com

Partner 6: Aarhus University - Danish Epidemiology Science Centre (AU-DESC), Nordre

Ringgade 1, AARHUS C, 8000 Denmark. Contact person: Prof. Dr. Jørn Olsen, e-mail:

jo@soci.au.dk

Partner 7: Liverpool School of Tropical Medicine (LSTM), United Kingdom, Pembroke Place,

Liverpool, L135QA, UK. Contact person: Dr. Rachel Tolhurst, e-mail: R.J.Tolhurst@liverpool.ac.uk

More information can be found on www.inpacproject.eu

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Pictures : 1. Project meetings

1.1. WP6 Qualitative evaluation training workshop in Shanghai, June 2015

1.2. The 1st SAB meeting in Ghent, Beglium, Dec. 2014

1.3. The WP5 kick-off meeting and training workshops in Beijing and Wuhan, July-August 2014

1.4. The 1st EAB meeting in Beijing, China, July 2014

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1.5. The EC review visit at CSFP, Beijing, China, May 2014

2. WP5 monitoring field visits

2.1. INPAC project leader prof. Wei-Hong Zhang visited Gansu, Qinghai and Ningxia provinces, July 2015

2.2. CMA prof. Li Jian visited INPAC participating hospitals in Gansu and Qinghai provinces, April 2015

2.3. CSFP prof. Che Yan visited participating hospitals in Ningxia province for WP5 monitoring in March

2015.

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2.4. The FU team (Prof.Qian Xu, Dr. Liang Ji) member is checking the intervention materials and the data

collection in Jiangsu and Jiangxi provinces, Sep. 2014

2.5. Group education and intervention posters in the intervention hospitals, 2014

3. Project dissemination activities

3.1. Project dissemination (WCSUH team prof. Hu Lina) at the Western China Forum for Gynecology and

Obstetrics, and at the Chongqing Medical and Family Planning Commission experts symposium, July 16,

2015.

3.2. SCU team Prof. Hu Lina presented the Policy Translation Obstacles and Approaches of INPAC project

in the 8th Asia-Pacific Evidence-Based Medicine Conference in March 2015.

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3.3. WP5 intervention posters and information flyer in local languge

3.4. The third global symposium on health systems research (Poster) (Cape Town, South Africa, 30

September – 03 October, 2014)

3.5. Dr. Hong JIANG (FU), Jieshuang XU (FU) and Shuchen WANG (UG-ICRH) attended the 12th ESC

conference in Lisbon, May 2014.

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3.6. INPAC newsletters