Tài liệu The status, the factors that influence gender imbalance at birth in bac giang province and some effective interventions

1 INTRODUCTION Gender imbalance at birth (GIB) have appeared since the beginning of the 80s of XX century, severely affecting the economic situation, security, politics, society of many countries in Asia. In Vietnam, GIB occured later, from the early years of the twenty-first century, which took place at a faster speed, increasingly widespreaded and has reached a critical level. Bac Giang is one of 10 provinces having the sex ratio at birth (SRB) high. If this situation lasts for, there is no strong interference will cause consequences in many aspects of economic and social development of Bac Giang province in particular and the country in general. Stemming from the above reasons, we performed the theme: "The status, the factors that influence gender imbalance at birth in Bac Giang province and some effective interventions" (2012 - 2013) with the following objectives: 1. Describe the status and a number of factors influence gender imbalance at birth in Bac Giang province (2007-2012); 2. Evaluate initially the effectiveness of some interventions to reduce the increase of gender imbalance at birth in Bac Giang province (2012 -2013). New contributions on practical science of the theme: Described by the status and identified a number of factors affecting GIB: Age, level of education, practice residency and inheritance; knowledge, attitude and practice of fetal sex selection (FSS); the situation of service providers. After 19 months, implemented a number of interventions in the province and in 6 villages studied of 3 districts: Issued directive PPC, Planning and implementing the Directive, the media and interventions applying for service providers. As a result, SRB is 117.4 in the province, down 2.3 percentage points; SRB of 3 studied districts are lower than before the intervention; knowledge, attitude and practice of the FSS subjects obvious changes. 2 The layout of the thesis consists of 145 pages: Introduction: 2 pages; Chapter 1. Overview: 35 pages; Chapter 2. Objects and research methods: 22 pages; Chapter 3. Results: 40 pages; Chapter 4. Discussion: 43 pages; Conclusion: 2 pages; Petition 1 page; 31 tables; 28 charts; 2 pictures; 7 Appendix; 123 references (108 Vietnamese and 15 English documents). Chapter 1 OVERVIEW 1.1. The ststus of gender imbalance at birth 1.1.1. Some related concepts 1.1.1.1. Sex ratio at birth: A statistical index, determined by the number of boys being born in a year on 100 girls being born. 1.1.1.2. GIB: SRB as a rule 104-106 / 100; biological standard 105/100. GIB when SRB exceeds 108/100. 1.1.2. Situations of gender imbalance at birth 1.1.2.1. GIB in some countries in the world 1.1.2.2. GIB in Vietnam 1.1.2.3. GIB in Bac Giang 1.2. Factors affecting GIB 1.2.1. Factors affecting GIB in the world 1.2.2. Factors affecting GIB in Vietnam 1.2.2.1. Generic researches in Vietnam 1.2.2.2. Researches in a number of provinces 1.3. Implications and control solutions GIB 1.3.1. Implications of GIB 1.3.1.1. Social influence 1.3.1.2. Affecting economic growth 1.3.1.3. Affect the security and politic 1.3.2. The solutions control GIB 3 1.3.2.1. The intervention of some countries in the world 1.3.2.2. The interventions in Vietnam. Chapter 2 SUBJECTS AND METHODS 2.1. Object, time, location study 2.1.1. Research subjects: Couples who have children from 1/2007 - 12/2011; elderly, leadership committees, governments, village and district population officer, health officier, statistics, justice, women, youth, the Fatherland Front, culture, information, married women perform abortions from 08 weeks of age or older; all facilities providing reproductive health services; 2.1.2. Research time: Study the status of 5 months (from 01/2012 to 5/2012 end); 19 month intervention study (from 6/2012 until 12/2013). 2.1.3. Research location: In 03 districts: Luc Nam, Lang Giang, Viet Yen; each district, town and village with high SRB to investigate and intervene. 2.2. Research Methods 2.2.1. Study design: Descriptive cross-sectional study combine quantitative and qualitative research, retrospective statistics and community intervention studies (with before – after comparison), there is no control group. 2.2.2. Descriptive study 2.2.2.1. SRB status of Bac Giang province: SRB (1999-2011), by birth order; characteristics of the study subjects ...by retrospective statistics methods. 2.2.2.2. A number of factors affect GIB: knowledge, attitudes, practice of SSB; status of SSB service providers and abortion situation. - Study design: Descriptive cross-sectional study combine quantitative and qualitative research. - Research subjects, sample sizes and sampling + Sampling object: couples have children from 1/2007- 12/2011, follows the formula, calculate the number of samples in each village and town to 4 investigate is 194 x 6 = 1.164 (couple), reality has collected 1.164 satisfactory questionaires (Luc Nam 387; Lang Giang 387; Viet Yen 390). + Select the entire sample of 319 married women performing abortion from 8 weeks of age or older, the actual interview was 300 (per district 100); 108 owners provide reproductive health services, interviewed 100 (Luc Nam 33, Lang Giang 34; Viet Yen 33); each village have 10 in-depth interviews = 60; 3 seminars in three districts, 6 in 6 social seminars. 2.2.3. Intervention studies 2.2.3.1. The content and the interventions - Intervention on the scale of the province: perform the state management measures (issues a directive of the PPC; plans, seminars); media; interventions for service providers (interdisciplinary inspection, testing and disseminating regulations and organizations signed not SSB). - Intervention in the research area: Seminar, group communication, direct communication consulting at home, praising represented women, building team; training; common provisions; flyers, pictures, posters ...; Posting propaganda; provide information; signed commitments, extracurricular activities, reported newspapers. 2.2.3.2. Evaluated the effectiveness of interventions - Study design: community intervention studies. - Sample sizes and sampling + Subject: couples have children after the intervention period, calculated according to the formula to assess the effectiveness of intervention, be n = 244. However, by the time of the investigation, there are over 413 subject in areas with a baby should fully investigate, real interviewed 400 subjects (Luc Nam 133, Lang Giang 134; Viet Yen 133). + Select the entire sample of 104 married women performing abortion from 08 week or older at the time of the survey after the intervention, the actual interview is 99 (per district 33); 107 owners provide reproductive health services, actual collect 101 questionaires (Luc Nam 34; Lang Giang 33; Viet Yen 34). 5 2.2.3.3. The index evaluated the effectiveness of interventions The effectiveness for the SRB of studied province and 3 district; effectiveness change knowledge, attitudes, practices of SSB; the provision of services; choice service providers; change the SRB at areas; reduce the pressure to have an abortion to a son, reduce the rate of known fetal sex before abortion and abortion to FSS. 2.2.4. Methods and tools for data collection 2.2.4.1. Methods of data collection: Quantitative methods, Qualitative methods 2.2.4.2.Tools for data collection Includes 6 form, investigating the couple, owners of ultrasound, owners of abortion service provider, married women perform abortions from 08 weeks of age or older, in-depth questionnaires, group discussion guide. 2.3. Organizing research 2.3.1. Survey, investigate to collect data 2.3.2. Implement interventions 2.4. Measures to control errors: Design toolkit, select investigators, supervisors have experience, pre-testing, clean check. 2.5. Data processing: Data processing by software EpiInfo 6.04 and SPSS 16.0; use some biomedical statistical algorithms; general qualitative results. 2.6. Ethics in research: Compliance of medical ethics in research, ensure privacy; objectively interview; truthful information; data security. 2.7. Limitations of the study: Research area is narrow, small sample size, the representation is not high; intervention studies comparing before - after no control group, did not perform on the same subject; short intervention period (19 months). Chapter 3 RESEARCH RESULTS 3.1. Status, the factors affecting GIB in Bac Giang 3.1.1. SRB of Bac Giang province, period: 2007 - 2011 6 - From the year 1999-2002, the SRB has not increased (from 101.0 to 106.0); By 2004, SRB began to increase (108.4), especially since 2006 (115.8). - SRB, during 2009-2011: increased since first birth: 112.0; second: 113.4 and spike at third: 217.3; fourth and above: 293.7. 3.1.2. Several factors affecting GIB 3.1.2.1. Some characteristics of the study subjects - Birth mother's age Table 3.3. SRB under the birth mother's age (n = 1,164) Age group Sex <25 n Male SRB 241 25 - 34 n 508 Female 218 110,5 442 35 - 44 SRB 114,9 Total n SRB 287 >44 n 62 238 120,5 25 SRB 248,0 n SRB 1.098 119,0 923 Total 459 950 525 87 2.021 SRB under the birth mother's age <35 was 113.5; groups of 35 or more is 132.7. Table 3.4. SRB under the mother's education level (n = 1,164) Sex Secondary school or lower n Male 561 Female 482 SRB 116,4 High school or higher Total n SRB n 537 121,8 1098 441 923 SRB 119,0 Total 1043 978 2021 SRB of the mother's education level is secondary school or lower: 116.4; high school or higher: 121.8. overall SRB is 119.0. - Ethnicity: Most studied couples are Kinh (98.6% wife, 99.8% husband); - Children’s name: 100% of the study subjects take father’s name; - Economic conditions: 67.9% of couples rated themselves average economic; 27.0% of couples are prosperous; 4.5% of couples are poor. - Life situation: 50.4% of studied subjects whose husband was the eldest son. 7 - The number of son, daughter and sex birth order. Table 3.5.The number of son, daughter under sex birth order (n=1,164) Luc Nam Lang Giang Sex birth order/sex n % n % The first child Son 211 54,7 203 53,2 Daughter 176 45,3 184 46.8 The second child Son 104 55,9 121 53,1 Daughter 82 44,1 107 46,9 The third child Son 42 71,2 54 71,0 Daughter 18 28,9 22 29,0 The first birth: SRB is 110.9; Second: Viet Yen n % n Total % 198 192 51,3 48,7 612 552 52,5 47,5 119 116 50,6 49,4 344 305 53,0 47,0 46 64,0 142 68,3 26 36,0 66 31,7 112.8; Third+: 215.1; Overall: 119.0; third+ birth rate is 10.3%. 3.1.2.2. Knowledge, attitudes and practices of FSS - Knowledge of the subject of FSS Graph 3.6. Percentage the object known measures of FSS is used in the community (n = 1,164) 28.0% objects know FSS measures is used in the community. Table 3.6. Measures of FSS that subjects know (n = 1,164) 8 Luc Nam Lang Giang Viet Yen Total n % n % n % n % Ultrasound, abortion 83 21,4 27 7,0 27 6,9 137 11,8 As of date 48 12,4 32 8,3 18 4,6 98 8,4 Empirical 53 13,7 9 2,3 16 4,1 78 6,7 Horoscope, immolate 7 1,8 9 2,3 5 1,3 21 1,8 Diet 43 11,1 46 1,9 15 3,8 104 8,9 Other 44 11,4 24 6,2 12 3,1 80 6,9 The objects know many ways to FSS, in which most are ultrasound for Measures sex selection abortions (11.8%). Table 3.7. Understanding the affect of FSS and the prohibited behaviors (n = 1,164) Affect /Behavior Luc Nam n % Lang Giang Viet Yen n % n % Total n % Affects of FSS No affect 62 16,0 62 16,0 23 5,9 Male excess, Female 88, deficiences 315 81,4 313 80,9 345 5 Men difficult to get 77, married 217 56,1 159 41,1 302 4 Others 1 0,3 1 0,3 4 1,0 The behaviors of fetal sex selection are prohibited by law FSS propaganda 174 45,0 168 43,4 231 59,2 Notice FSS 232 59,9 221 57,1 284 72,8 Sex selection abortions 257 66,4 189 48,8 299 76,7 Do not know 51 13,2 67 17,3 22 5,6 12.6% of subjects said FSS does not affect society; 12.0% 147 12,6 973 83,6 678 6 58,2 0,5 573 737 745 140 do not 49,2 63,3 64,0 12,0 know FSS behaviors prohibited by law. + Opinions of objects on reasons of FSS. Table 3.9. Reasons for choosing FSS (n = 1,164) Luc Nam Lang Giang Viet Yen n % n % n % Pressure to be born son There was pressure 205 53,0 50 12,9 106 27,2 No pressure 182 47,0 336 86,8 283 72,6 No answer 0 0 1 0,3 1 0,3 The reason for the behavior of fetal sex selection has been made No penalty 306 79,1 250 64,6 317 81,3 Reasons Total n % 361 801 2 31,0 68,8 0,2 873 75,0 9 Nobody reminder 99 25,6 92 23,8 60 15,4 Many support services 314 81,1 199 51,4 302 77,4 Others 0 0,0 6 1,6 23 5,9 There are 31.0% answered there was pressure to be born 251 21,6 815 70,0 29 2,5 son; there are many reasons for the behaviors of FSS still performed. + Opinions of objects on restrictive measures of FSS status: Table 3.12. Opinions on the type of effective media (n = 1,164) Luc Nam Lang Giang Viet Yen Total n % n % n % n % Broadcasting 210 54,3 194 50,1 242 62,1 646 55,5 Newspapers, magazines 10 2,6 6 1,6 8 2,1 24 2,1 Posters, leaflets 23 5,9 12 3,1 32 8,2 67 5,8 Internet 4 1,0 0 0,0 0 0,0 4 0,3 Media group 77 19,9 147 38,0 56 14,4 280 24,1 Consult at home 59 15,2 28 7,2 42 10,8 129 11,1 Others 0 0,0 0 0,0 7 1,8 7 0,6 Type of effective media is not applied at local level: media group Type of media (24.1%); Consult at home (11.1%). - The attitude of the object of fetal sex selection Table 3.13. Intend to have more children and the desired sex of the child in the next birth (n = 1,164) Luc Nam Lang Giang Viet Yen n % n % n % There are intended 218 56,3 130 33,6 168 43,1 Expect son 109 50,0 85 65,4 88 3,4 Expect daughter 60 27,5 23 17,7 35 20,8 Not important 49 22,5 22 16,9 42 25,0 Not intended 160 41,3 254 65,6 221 56,7 No answer 9 2,3 3 0,8 1 0,3 There are 516 people (44.3%) intend to have more child; Intended/ desired Total n % 516 44,3 282 54,6 118 22,9 113 21,9 635 54,6 13 1,1 54.6% expect son; 22.9% expect daughters (22.9%); 21.9% does not matter male or female. - FSS practice of objects: + Rate object has FSS in the last birth: 10 Graph 3:8. Rate object has FSS in last birth (n = 1,164) 18.0% has FSS in last birth; + The reason for performing the abortion of the objects Graph 3.10. Reason for abortion of the subjects (n = 183) Of the 183 subjects abortions, there are 8.7% the fetus is a girl. 3.1.3.3. The situation of FSS service provision - Condition know fetal sex before birth: 11 Chart 3:12. Rate know fetal sex before birth (n = 1,164) There are 74.7% of subjects know fetal sex before birth. - Status diagnostic fetal sex by ultrasound: Graph 3:15. Rate of subjects known fetal sex by ultrasound (n = 1,155) There are 70.3% of subjects known fetal sex by ultrasound. 3.1.3.4. Status of abortion in Bac Giang province through the survey of married women have an abortion from 8 weeks of age and older, in three districts studied, 2012 12 - The ultrasound before abortion and abortion reason of object Table 3:20: Rate of subjects knows fetal sex before abortion and how to know fetal sex (n = 300) Lang Giang Viet Yen Total Sex/ Reconigned Luc Nam measure n % n % n % n % Rate of object knows fetal sex before abortion Not know 70 70,0 75 75,0 68 68,0 213 71,0 Know 29 29,0 25 25,0 28 28,0 82 27,4 No answer 1 1,0 0 0,0 5 4,0 5 1,6 Reconigned measure of fetal sex Ultrasound 29 100,0 24 96,0 27 96,0 36 97,7 Prediction 0 0,0 1 4,0 1 4,0 2 2,3 There are 27.4% know fetal sex before abortion; in which 97.7% said by ultrasound. Graph 3:16. The reason of subjects perform abortions (n = 300) 10.7% of subjects performing abortions fetus is a girl. - Pressure to be born son 13 Table 3:21. The pressure have an abortion to be born son (n = 300) Lang Giang Viet Yen Pressure have Luc Nam an abortion n % n % n % Yes 65 65,0 62 62,0 58 58,0 No 35 35,0 37 37,0 32 32,0 No answer 0 0,0 1 1,0 0 0,0 There are 61.7% of subjects have the pressure to have Total n % 185 61,7 114 38,0 1 0,3 an abortion in order to be born son. 3.2. Effectivens Evaluation of Some Intervention 3.2.1. Effective interventions on the scale of the province Table 3.24. Births, SRB of province and 3 studied districts, 2013 Sex Male Lang Giang 2.016 Female 1.745 Total 3.761 Luc Nam 2.209 115,5 1.814 4.023 Viet Yen 1.854 121,8 1.598 3.452 Scale of province 16.774 116,0 14.292 117,4 31.066 Graph 3:17. SRB before and after intervention Post-intervention SRB of province and the studied districts were reduced. 3.2.2. Efficiency at studied areas through surveys among women giving birth - Make changes FSS in knowledge, attitude and practice (Unit: Percentage %) 14 Table 3:25. Change knowledge about the influence of FSS Before (n=1.164) Content After (n=400) Compare (increase, decrease) 12,6 8,3 - 4,3 83,6 91,8 + 8,2 58,2 66,3 + 8,1 The number said FSS does not effect on society is reduced,EI 34.1%. No affect Male excess, Female deficiences Men difficult to get married EI 34,1 9,8 13,9 Table 3:26. Effective changes the intention to have more children Intention Before (n=1.164) After Compare (n=400) (increase, decrease) Yes EI 44,3 48,8 - Have 1 children alive 83,5 88,7 - Having 2-3 children alive 16,5 11,3 - 5,2 31,5 No 54,6 51,3 The number of subjects with 2-3 children alive intend more children decreased. Table 3:27. Effective changes the desired sex of the child in the next birth Desired sex Before (n=1.164) After (n=400) Compare (increase, decrease) - 14,6 EI Male 54,6 40,0 26,7 - Had son 9,3 3,6 - No son 45,4 36,4 9,0 19,8 Female 22,9 32,3 + 9,4 41,0 - Had daughter 0,6 0,5 - No daughter 22,3 31,8 + 9,5 42,6 Not important 21,9 27,7 + 5,8 26,5 The number of the desired sex of the child in the next birth is son decrease. 15 Graph 3:18. The rate of FSS in last birth The rate of FSS in last birth reduces, EI=51.1%. - Effective for service delivery situation after the intervention Graph 3:19. Rate knows fetal sex by ultrasound Rate of the subjects knows fetal sex after intervention by ultrasound 63.9%, is down by 6.4% compared to pre-intervention, EI = 9.1%. 16 Graph 3:20. Rate of the subjects knows fetal sex before birth Rate of the subjects knows fetal sex before birth after intervention is 64.8%, down 9.2% compared to pre-intervention, EI=12.4%. - Efficiency for SRB in the areas of research: Table 3:29. SRB by birth order before and after ntervention Unit: Percentage (%) Before (n=1.164) After (n=400) Compare (increase, decrease) EI The first 110,9 109,6 -1,3 1,2 The second 112,8 108,4 -4,4 3,9 The third+ 221,9 166,7 -55,2 24,9 The births 119,0 112,8 - 6,2 5,2 Births 3+ birth rate 10,2% 8,0% -2,2% 21,6 The third+ birth rate, the number of boys / girls of all children born by birth order and of all births after intervention are lower than before intervention, EI from 1.2 to 24.9 %; especially the third+ birth, the sex ratio decreased 55.2%, EI=24.9%; the third birth rate falls by 2.2% and EI=21.6% . 3.2.3. Efficiency at research areas across objects having abortion 17 - Efficiency for service providers: Graph 3:21. Effective for know fetal sex before abortions Rate of objects know before abortions after the intervention (13.1%), lower than before the intervention (27.4%); EI=52.2%. - Efficiency reduces the pressure of family and community on abortion Graph 3:23. Efficiency reduces the pressure to have an abortion to a son Rate of subjects have pressure to have an abortion to a son after intervention was 41.4%, down by 20.3% compared to the pre-intervention, EI=32.9%. - Efficiency for the performance of abortions to FSS: 18 Graph 3:24. Efficiency for sex selection abortion Rate of subjects have abortion because fetus is a girl after intervention by 4.0%, down by 6.7% compared to pre-intervention, EI=62.6%. Chapter 4 DISCUSS 4.1. The status of GIB in Bac Giang province and affecting factors 4.1.1. The sex ratio at birth of Bac Giang province, from 1999-2011 SRB of Bac Giang provinve appears later (2004), most markedly since 2006, rapid increases; SRB increases at all births by birth order. 4.1.2. Several factors influence GIB in Bac Giang province 4.1.2.1. Characteristics of the studied subjects - Birth mother’s age: Higher maternal age is higher sex ratio of child. - Education of subjects: Sex ratio of child have high school or higher group (121.8) is higher than secondary school or lower group(116.4); - The number of sons and daughters of the object and the sex ratio at birth belong to birth order 19 Overall sex ratio for all births of the studied subjects (119.0) is high and equivalent results the scale of the province, in accord with general SRB result, SRB by birth order of Bac Giang province 2009-2011 and affirm that FSS relates with son, daughter by birth order. 4.1.2.2. Knowledge, attitudes and practices of fetal sex selection - FSS knowledge of the subject: + There are 29.0% of subjects said FSS measures; these subjects will look to the support services are available locally to FSS, increases the rate of abortion, knowing the fetal sex before birth and SRB. + FSS measures has best known as ultrasound, abortion (11.8%), less others; This result shows that in order to restrict FSS, should focus more closely control the service provider of ultrasound, abortion. + Remaining 12.6% of subjects said FSS not affect to society, 12.0% do not know FSS behaviors are prohibited by law; these subjects will directly or advocacy others to join FSS; This result shows that the task of propaganda is very hard. + In the opinion of the subjects on FSS reasons: 31.0% of the subjects have pressured to be born son, expressed preference for sons has been very heavy, while in rural areas 21.4 %, urban 9.6%; this is a major obstacle to the propaganda by Bac Giang, over 90% of the population live in rural areas. In the opinion of the subjects, the monitoring of implementation of the law of the authorities is limited, besides the FSS support services are available, so the FSS behavior still real performed. + To restrict FSS: In addition to the common forms of media that the subjects had access (64.3%), to enhance the media group, club activities (24.1%), direct consult in households (111.1%). - The FSS attitude of the subjects: Among 44.3% of subjects had intended to have more babies, 13.5% had 2 children but still want more 20 children, results matter alert recommended increasing birth rate 3 times or more, the risk births would cause SRB LCGTTN rising; Results 54.6% of subjects desired sex of the next child is a boy, showed preference for sons is very strong in the community. - FSS practice of subjects: In the last birth, there are 18.0% of subjects said have FSS, these showed that there is a high percentage of subjects for FSS of their children. 8.7% of subjects said an abortion because the fetus is a girl; based on the ratio of abortion of the whole province, every year more than 7,000 women abortion, there are more than 600 girls demolished, leading to differences in the number of boys and girls are born, makes SRB of Bac Giang province increases. 4.1.2.3. The situation of FSS service provision The study results showed that 74.7% said prenatal fetal sex, 70.3% know fetal sex via ultrasound, so the use of ultrasound to diagnose fetal sex is very popular; 4.1.2.4. Status of Abortion in Bac Giang province through the survey of married women have an abortion from 8 weeks of age and older, 2012 - The ultrasound before abortion and abortion reason: Rate knows fetal sex before abortions: 27.4%, 97.7% said that through ultrasound, this shows abortion rates to quite high, because most of the ultrasound facility only know fetal sex on third months of pregnancy; this also shows the subjects know fetal sex from ultrasound services are very popular. Among subjects had an abortion, 10.7% of subjects said the reason abortion when the fetus is a girl, only 1.7% of subjects said abortion when the fetus is a boy. This rate has contributed to rising SRB in geographical research and confirmed the support of the service providers for the purpose of abortion for gender reasons.