Gender differences in sleep behaviors under China's universal two-child policy.

Since 2016, China has progressively relaxed family planning policies to stimulate birth rates. This paper examines the behavioral health repercussions of China's 2016 universal two-child policy (UTCP) by analyzing sleep pattern data from China Family Panel Studies. Napping is a composite indicator that denotes health outcomes, job quality, and personal well-being. It reveals work conditions and environments to some extent. UTCP may lead to heightened social expectations regarding pregnancy likelihood, and changes in social expectations within the workplace may make work environments less equitable and more stressful for females. Leveraging a difference-in-difference model, this paper explores how napping behaviors among the working-age cohort have responded to the policy shifts. Our analysis reveals a gender discrepancy in response to the policy, specifically, females exhibit a discernible reduction in the likelihood of napping, as well as in the duration of both daytime naps and daily sleep. Conversely, such effects are not significant among males. These results suggest policy consequences extend beyond individuals directly impacted by childbirth or contemplating parenthood. Hence, while promoting fertility is still the government's goal, policymakers are encouraged to consider the broader challenges the female population faces from social and workplace environment factors.

Self-performed Rh typing: a cross-sectional study.

OBJECTIVE: To evaluate whether patients are capable and willing to self-administer and interpret an EldonCard test to determine their Rh status. METHODS: This was a cross-sectional study in Honolulu, HI, USA of pregnancy-capable people aged 14-50 years who did not know their blood type and had never used an EldonCard. Participants independently completed EldonCard testing, determined their Rh type and answered a survey on feasibility and acceptability. Separately, a blinded clinician recorded their interpretation of the participant's EldonCard. When available, we obtained blood type from the electronic health record (EHR). We measured Rh type agreement between participant, clinician and EHR, as well as participant comfort and acceptability of testing. RESULTS: Of the 330 total participants, 288 (87.3%) completed testing. Patients and clinicians had 94.0% agreement in their interpretation of the EldonCard for Rh status. Patient interpretation had 83.5% agreement with EHR while clinician and EHR had 92.3% agreement. Sensitivity of EldonCard interpretation by patient and clinician was 100%. Specificity was 83.2% for patients and 92.2% for clinicians. Two patients (of 117) had Rh-negative blood type in the EHR. The vast majority of participants found the EldonCard testing easy (94.4%) and felt comfortable doing the testing (93.7%). Participants with lower education levels felt less confident (p=0.003) and less comfortable with testing (p=0.038); however, their ability to interpret results was similar to others (p=0.051). CONCLUSIONS: Patient-performed Rh typing via the EldonCard is an effective and acceptable option for patients, and could be used as a primary screening test for Rh status.

Changes in family situation and concurrent changes in working life: a 15-year longitudinal analysis.

OBJECTIVE: Currently, little is known regarding changes in family situation with concurrent changes in working life. This study aimed to examine whether changes in family situation (based on living with children and/or marrying/divorcing) were associated with changes in working life and whether the associations were influenced by sex, genetics and early life environment. DESIGN: Prospective cohort study. SETTING AND PARTICIPANTS: Data from Swedish national registers of 16 410 twins were used. Fixed-effects logistic regression models assessing ORs with 95% CIs were applied to examine associations between changes in family situation and working life controlling for time-invariant effects and adjusted for covariates, and conditional models to account for confounding of genetics and early life environment. RESULTS: Changes in individuals life situation from being single and living without children to married and living with children were associated with transitioning from unsustainable (ie, having unemployment or sickness absence/disability pension) to sustainable working life (men: OR 2.40, 95% CI 2.26 to 2.56; women: OR 1.68, 95% CI 1.59 to 1.78). Changes from being married to single, in contrast, attenuated the likelihood of transitioning to a sustainable working life. Moreover, changes in men's working life seem to be more dependent on changes in family situation compared with women. Genetic factors and early life environment play a role in the associations. CONCLUSIONS: Family formation increases the likelihood of a more stable working life whereas divorce is a risk factor for work interruptions. Our study emphasises that family formation improves the work life situation and to a higher degree for men.

Changes in fertility intention among married Chinese couples with two children during COVID-19: a cross-sectional study.

BACKGROUND: A three-child policy was implemented in China to stimulate a rise in fertility levels and coincided with the COVID-19 pandemic. Data suggested that COVID-19 has a negative impact on fertility intention. AIM: To describe married couples' changes in intention to have a third child during the COVID-19 pandemic and determine factors associated with altered intentions. METHODS: An online survey was conducted in October 2021, including sociodemographic characteristics, change of intention to have a third child after the COVID-19 pandemic outbreak, reasons for increased or decreased intention, and the Fertility Intention Scale (FIS). Bivariate and multivariable logistic regression were used to test the potential factors associated with changes in intention. RESULTS: A total of 1308 participants provided responses. Following the COVID-19 outbreak, 35.8% of participants decreased their third-child intention, while 2.8% of participants increased their third-child intention. Males (aOR 1.90, 95% CI 1.42 to 2.54), youngsters (aOR 1.77, 95% CI 1.08 to 2.93) and those living in Estern China (aOR 2.12, 95% CI 1.13 to 3.98) were more likely to decrease their third-child intention. Perceived risk (aOR 1.07, 95% CI 1.03 to 1.10) and policy support (aOR 1.06, 95% CI 1.03 to 1.09) as measured on the FIS decreased couples' intention to have a third child. Social support (aOR 0.94, 95% CI 0.91 to 0.98) as measured on the scale protected participants from decreased intention. CONCLUSIONS: During severe public health emergencies, strong prevention and control policies, together with enhancing support from partners and healthcare professionals for women, are necessary to improve intentions to give birth.

Changes in the characteristics and outcomes of high-risk pregnant women who delivered prior to and after China's universal two-child policy: a real-world retrospective study, 2010-2021.

BACKGROUND: In 2016, the "universal two-child" policy, allowing each couple to have two children, was introduced in China. The characteristic change of the long-term period after the implementation of the universal two-child policy was unclear. We studied trends in the obstetric characteristics and their potential impact on the rates of cesarean section and preterm birth in the era of China's universal two-child policy. METHODS: A tertiary center-based study (2010-2021) retrospectively focused single high-risk pregnancies who delivered from the one-child policy period (OCP, 2010-2015) to the universal two-child policy period (TCP, 2016-2021). A total of 39, 016 pregnancies were enrolled. Maternal demographics, complications, delivery mode and obstetric outcomes were analyzed. Furthermore, logistic regression analysis was used to explore the association between the cesarean section rate, preterm birth and implementation of the universal two-child policy, adjusting maternal age, parity, and fetal distress. RESULTS: Ultimately a total of 39,016 pregnant women met the criteria and were included in this analysis. The proportion of women with advanced maternal age (AMA) increased from 14.6% in the OCP to 31.6% in the TCP. The number of multiparous women increased 2-fold in the TCP. In addition, the overall rate of cesarean section significantly decreased over the policy change, regardless of maternal age, whereas the risk of preterm birth significantly increased in the TCP. Adjusting for maternal age, parity and fetal distress, the universal two-child policy showed a significantly favorable impact on the cesarean section rate (RR 0.745, 95%CI (0.714-0.777), P < 0.001). Compared to the OCP group, a higher increase in fetal distress and premature rupture of membranes (PROM) were observed in the TCP group. In pregnancies with AMA, there was no increase in the risk of postpartum hemorrhage, whereas more women who younger than 35 years old suffered from postpartum hemorrhage in TCP. The logistic regression model showed that the universal two-child policy was positively associated with the risk of postpartum hemorrhage (RR: 1.135, 95%CI: 1.025-1.257, P = 0.015). CONCLUSIONS: After the implementation of the universal two-child policy in China, the rate of the cesarean section significantly decreased, especially for women under 35 years old. However, the overall risk of postpartum hemorrhage increased in women under 35 years old, while there was no change in women with AMA. Under the new population policy, the prevention of postpartum hemorrhage in the young women should not be neglected.

Associations between the COVID-19 pandemic and women's fertility intentions: a multi-country, cross-sectional (I-SHARE) study.

INTRODUCTION: The COVID-19 pandemic, together with the subsequent social distancing measures, could lead to shifts in family and fertility planning. This study aimed to explore the associations between the COVID-19 pandemic and changes in fertility intentions among an international sample of reproductive-aged women. METHODS: A multi-country, cross-sectional study based on data from 10 672 women aged 18-49 years who participated in the International Sexual Health And REproductive Health (I-SHARE) study, which organised an international online survey between July 2020 and February 2021. Factors associated with changes in fertility intentions were explored using multinomial probit regression models. Cluster-robust standard errors were used to calculate model parameters. RESULTS: Of 10 672 included reproductive-aged women, 14.4% reported changing their fertility intentions due to the pandemic, with 10.2% postponement and 4.2% acceleration. Women who had ever been isolated/quarantined were more likely to postpone their fertility intentions (adjusted odds ratio (AOR)=1.41; 95% CI 1.18 to 1.69) compared with those who had not; women who lived with a steady partner were more likely to want children sooner (AOR=1.57; 95% CI 1.10 to 2.23) compared with those who did not; and those who reported a higher frequency of getting angry, feeling frustrated, or worrying about their finances were more likely to postpone their fertility intentions. The main findings were robust in the sensitivity analyses. CONCLUSIONS: Most women who changed fertility intentions because of the pandemic have postponed intentions to expand their families. The pandemic-induced exposures were associated with these postponements.

Patterns in the provision of government-subsidised hormonal postpartum contraception in Queensland, Australia between 2012 and 2018: a population-based cohort study.

BACKGROUND: Short birth intervals and unintended pregnancy are associated with poorer maternal and infant outcomes. There is a risk of pregnancy during the immediate postpartum period unless contraception is initiated. This retrospective cohort study aimed to capture the current patterns of hormonal contraceptive provision within 12 months postpartum in a high-income country. METHODS: We used a linked administrative dataset comprising all women who gave birth in Queensland, Australia between 1 July 2012 and 30 June 2018 (n=339 265 pregnancies). We described our cohort by whether they were provided with government-subsidised hormonal contraception within 12 months postpartum. The associations between hormonal postpartum contraceptive provision and demographic and clinical characteristics were examined using univariate and multivariate logistic regression and presented in terms of crude and adjusted odds ratios with 95% confidence intervals. RESULTS: A majority of women (60.2%) were not provided with government-subsidised hormonal postpartum contraception within 12 months postpartum. Women who were younger (<25 years), were overweight or obese, smoked, were born in Australia, were non-Indigenous, gave birth in a public hospital, or were in the lowest socioeconomic status group were more likely to be provided with postpartum contraception after adjusting for other covariates, compared with their counterparts. CONCLUSIONS: Strategies to increase the provision and uptake of contraception in the immediate postpartum period are needed to prevent short birth intervals and unintended pregnancy and ensure women's fertility intentions are enacted. Ongoing research is needed to examine the factors influencing women's access to contraceptive services and, further, the types of contraception provided.

The Provision of Abortion Care via Telehealth in the United States: A Rapid Review.

INTRODUCTION: The recent Supreme Court decision Dobbs v. Jackson Women's Health that has overruled Roe v. Wade has resulted in severe limitations of abortion access throughout the United States. Telehealth has been put forth as one solution for improving access for reproductive health care, including abortion services. Telehealth has demonstrated safety and efficacy in several health care disciplines; however, its use for abortion care and services has not been explored and synthesized. METHODS: As part of a larger review on telehealth and general reproductive health, our team identified a moderate amount of literature on telehealth and abortion care. We conducted a rapid review searching for eligible studies in MEDLINE, Embase, and CINAHL. Information was extracted from each included study to explore 4 key areas of inquiry: (1) clinical effectiveness, (2) patient and provider experiences, (3) barriers and facilitators, and (4) the impact of the coronavirus disease 2019 (COVID-19) pandemic. RESULTS: Twenty-five studies on the use of telehealth for providing abortion services published between 2011 and 2022 were included. Telehealth for medical abortion increased during the COVID-19 pandemic and was found to be safe and clinically effective, with high patient satisfaction. Overall, telehealth improved access and removed barriers for patients including lack of transportation. Legal restrictions in certain states were cited as the primary barriers. Studies contained limited information on the perspectives and experiences of health care providers and diverse patient populations. DISCUSSION: Abortion care via telehealth is safe and effective with high satisfaction and may also remove barriers to care including transportation and fear. Removing restrictions on telehealth for the provision of abortion services may further improve access to care and promote greater health equity.

Policy Changes in China's Family Planning: Perspectives of Advocacy Coalitions.

Studies on policy change focus on governmental decision-making from a technical rationality perspective, ignoring the fact that policy change is a complicated social construction process involving multiple actors. This study used the modified advocacy coalition framework to explain changes in China's family planning policy and discourse network analysis to show the debate on the birth control policy among multiple actors (central government, local governments, experts, media, and the public). It found that the dominant coalition and the minority coalition can learn and adjust deep core beliefs from each other; the sharing and flow of actors' policy beliefs drive change in the network structure; and actors' obvious preferential attachment when the promulgation of the central document, are all helpful in policy change. This study can explain macro-policy changes from a micro-perspective to reveal the process and mechanism of policy changes in China's authoritarian regime.

Accessing abortion in a highly restrictive legal regime: characteristics of women and pregnant people in Malta self-managing their abortion through online telemedicine.

OBJECTIVE: To examine the numbers and characteristics of women and pregnant people in Malta seeking at-home medical abortion using online telemedicine from 2017 to 2021. DESIGN: Population-based study. SETTING: Republic of Malta PARTICIPANTS: Between 1 January 2017 and 31 December 2021, 1090 women and pregnant people requested at-home medical abortion through one online telemedicine provider (Women on Web). Mifepristone and misoprostol were shipped to 658 women (60.4% of requests). MAIN OUTCOME MEASURES: The numbers and demographics of persons to which abortion pills were shipped, their reasons for accessing abortion, and reasons for requesting medical abortion via telemedicine between January 2017 and December 2021 were analysed. Selected data were compared across different groups. RESULTS: The number of people in Malta to whom medical abortion pills were shipped increased significantly in the 5 years analysed. Women and pregnant people requesting medical abortion were diverse with respect to age, pregnancy circumstances and reasons for seeking an abortion. More than half had existing children and over 90% reached out to Women on Web at <7 weeks. Among those completing a medical abortion, 63% did not use contraception, and in 30% there was contraception failure. The most common reasons for ordering medical abortion pills online were difficulty accessing abortion because of legal restrictions (73%) and abortion pills not being available (45%) in the country. CONCLUSIONS: Despite a complete ban on abortion, the number of women and pregnant people residing in Malta completing at-home medical abortions is considerable and has been steadily increasing.

Physician perspectives of abortion advocacy: findings from a mixed-methods study.

OBJECTIVE: Our aim was to assess physicians' perspectives of what constitutes abortion advocacy and the skills needed to be effective in their efforts to safeguard legal abortion. METHODS: Alumni from a physician training programme for sexual and reproductive health advocacy completed a cross-sectional survey including questions on perceived skills needed for effective advocacy. The research team conducted in-depth interviews (IDIs) with alumni, based on their level of engagement in advocacy. We present descriptive statistics for survey data and themes identified in the interview data using techniques informed by grounded theory. RESULTS: Of the survey respondents (n=231), almost a third (28.6%; n=66) felt the most important media skill they learnt was the ability to stay on message. The most important policy skill was communicating effectively with policymakers (47.0%; n=108), followed by distilling evidence for policymakers and laypeople (13.0%; n=30). In the IDIs (n=36), participants reported activities such as media interviews as clear examples of advocacy, but also considered implementing institutional policies and abortion provision to be advocacy. They discussed how individual comfort and capacity for advocacy activities may change over time, given personal and professional considerations. Regardless of the type of activity, physicians valued strategic communication and relationship-building skills. CONCLUSIONS: Based on our findings, training programmes that seek to mobilise physician advocates to advance sexual and reproductive health and rights should work with trainees to create a tailored advocacy plan that fits their personal and professional lives and goals. Regardless of the types of advocacy activities physicians focus on, strategic communication may be central in skills-based training.

Experiences using a progestin-only pill in an over-the-counter environment in the United States: a cross-sectional survey.

BACKGROUND: Efforts are underway to make a progestin-only pill (POP) over the counter (OTC) in the United States (US); however, little is known about POP user experiences, which could impact uptake and continuation. METHODS: From January 2020-September 2021, we conducted a cross-sectional online survey with individuals who used OTC POPs in a US trial. We calculated descriptive statistics and Pearson chi-square and Fisher's exact tests to assess menstrual bleeding acceptability, how OTC POP experiences compared with prior contraceptive methods, and preferred ways to get answers to questions during OTC POP use. RESULTS: Among 550 adult and 115 adolescent participants, 80% (n=531) felt their menstrual bleeding was acceptable. Participants reported a range of menstrual bleeding experiences compared with prior long-acting or hormonal methods used; 58% (n=84) said the POP bleeding was similar or better and 36% (n=53) said it was worse. Among participants who used contraception in the month prior to the trial, 77% (n=201) said their overall OTC POP experience was similar or better. Top benefits compared with prior methods included less worry about pregnancy, ease of access, fewer side effects, and greater decision-making power. Adults preferred to get answers about OTC POPs via webpage or app, whereas teens preferred asking pharmacists or other healthcare providers. CONCLUSIONS: Overall, OTC POP users in a trial setting found the menstrual bleeding acceptable and the method similar to or better than previous methods. POP labelling should provide clear messaging about bleeding changes users may experience.

Principal Factors Affecting Couples' Childbearing Policies: A Roadmap for Policymaking.

Background: The concept of negative population growth, population aging, and the need to implement child-encouraging policies is an important concern in many countries. As this issue is completely cultural and country-based, this study is designed to assess and prioritize the perception of newly married couples to the policies that may have a crucial role in the childbearing intention around the world. Materials and Methods: Through a descriptive cross-sectional study, 300 couples were selected by a simple random sampling method. Multilevel binary logistic regression was used for investigating the relationships among dimensions of family policies, socio-demographic variables, and childbearing intention. Results: Childbearing perception positively correlated with education and permanent job in both genders, maternal age range of 25-35, the higher length of marriage, having more children, and living in a government settlement. The most important family policies that couples preferred were contextual requirements (mean rank of 4.50%). Positive childbearing perception negatively correlated with higher age categories in women, the number of children, rental housing status, no insurance access, higher educational attainment, and low employment ranks in both men and women. Conclusions: This study cleared that family policies affect the childbearing intention of young couples. Polices involved contextual requirements, supporting couples to integrate work and home, health promotion plans, child-centered social support, and promoting the level of social and cultural relations.

Epidemiological characteristics and risk factors of obstetric infection after the Universal Two-Child Policy in North China: a 5-year retrospective study based on 268,311 cases.

BACKGROUND: Obstetrical infection is one of the causes of maternal death and a difficult problem for many clinicians. Changes in the demographic and obstetric background of pregnant women following the Universal Two-Child Policy may have an impact on some fertility phenomena. And with the increase in the number of deliveries, the limited medical resources become more scarce. How will China's health system quickly adapt to the growing needs and expectations for maternal health and ensure the provision of qualified and accessible medical services? In addition, what social support measures should be provided to reduce preventable obstetric complications? Given the relatively low per capita share of medical resources in China, how should China deal with the impact of the Universal Two-Child Policy? Therefore, more studies based on the change of fertility policy are needed. We try to analyze the epidemiological characteristics and risk factors of obstetric infection before and after the Universal Two-Child Policy, with a view to providing reference for the prevention and control of obstetric infection in regions after the change of fertility policy, and also hope to make corresponding contributions to the solution of the above problems through relevant studies. METHODS: The subjects of the survey were 268,311 pregnant women from Hebei Province Maternal Near Miss Surveillance System (HBMNMSS) of Hebei Women and Children's Health Center from January 1, 2013 to December 31, 2017. We analyzed the region, time and population distribution characteristics of obstetric infection, compared the epidemiological factors of obstetric infection before and after the Universal Two-Child Policy, and analyzed the relevant risk factors of obstetric infection. RESULTS: The incidence of obstetric infection increased nearly twice after the Universal Two-Child Policy. The incidence of obstetric infection was highest in Chengde (1.9%), a city with a northward geographical distribution, Baoding (1.6%), Cangzhou (1.5%) followed; The higher the hospital grade, the higher the incidence; The incidence of obstetric infections in hospitals at all levels has increased; The age of onset before the Universal Two-Child Policy was (27.82 ± 5.047) years old, and the age after the Universal Two-Child Policy was (28.97 ± 4.880) years old; The incidence of obstetric infections is higher in winter. The rate of abortion-related infection (increased from 0.61 to 1.65%) and the rate of pregnant women with high school education (increased from 0.35 to 0.74%) increased significantly. The results of multivariate Logistic regression analysis after the Universal Two-Child Policy showed that anemia (OR = 1.249, 95%CI: 1.071-1.458), chronic hypertension (OR = 1.934, 95%CI: 1.375-2.722), mild preeclampsia (OR = 2.103, 95%CI: 1.323-3.344) and severe preeclampsia (OR = 2.228, 95%CI: 1.703-2.916) were independent risk factors for obstetric infection. Gestational age ≥ 37 weeks was a protective factor. CONCLUSION: After the Universal Two-Child Policy, the prevention and control of obstetric infections should be strengthened, especially for abortion-related infections and elderly maternal with obstetric complications and complication in high-grade hospitals in winter. Educational background is also one of the factors that should be considered in the prevention of obstetric sensation. Prolonging gestational age is helpful to reduce the incidence of obstetric infection.

Factors associated with the depression status of Chinese parents who have lost their only child.

Aim: This study aimed to assess the risk factors for depression among parents who have lost their only child (PLOCs). Methods: We used a cross-sectional survey to reveal the risk factors of depression among PLOCs. Multi-stage, stratified, cluster sampling was used to recruit the participants. The cluster sampling method was used to select PLOCs in Hangzhou, Zhejiang Province, and Wuhu, Anhui Province, while the stratified cluster sampling method was used in Anshun, Guizhou Province. A total of 651 PLOCs were recruited in this study. Participants completed the Social Support Rating Scale (SSRS) and the Geriatric Depression Scale-15 (GDS-15). Socio-demographics were also collected, including age, sex, monthly income, education level, marital status, self-reported health, and a number of diseases were collected as well. Chi-square tests and binary logistic regression were conducted to analyze the influence of these factors on PLOCs' mental status. Results: Two hundred and fifty-eight PLOCs (39.56%) reported depression. Compared to PLOCs living in Wuhu, those living in Hangzhou (OR = 3.374, CI = 2.337-4.870) had a higher risk of depression. Being single (OR = 1.449, CI = 1.019-2.061) and the presence/absence of grandchildren (OR = 0.430, CI = 0.274-0.676)were significantly associated with the depression status of PLOCs. Conclusion: The sampled Chinese PLOCs reported a high prevalence of depression that was influenced by their place of residence, marital status, and presence/absence of grandchildren. This may highlight the need for routine assessment and help of this group by the relevant stakeholders (including government, non-profit social organizations, and professional psychologists) with more attention paid to single and low-income PLOCs that have no grandchildren. It is imperative to build a comprehensive care system of "extended family-community-society-government" for this vulnerable group.

Potential candidate for oral pericoital contraception: evaluating ulipristal acetate plus cyclo-oxygenase-2 inhibitor for ovulation disruption.

BACKGROUND: There remains considerable global unmet contraceptive need, with almost 200 million women reporting desire to limit or space childbearing without contraceptive use. Researchers have documented worldwide interest in an oral, on-demand contraceptive option were it available. Candidates for use include ulipristal acetate (UA), levonorgestrel and cyclo-oxygenase-2 (COX-2) inhibitors alone or in combination. METHODS: We performed an exploratory, prospective study of matched menstrual cycles: one baseline cycle and one treatment cycle of UA 30 mg plus meloxicam 30 mg just prior to ovulation. The primary outcome was ovulation disruption, defined as unruptured dominant follicle for 5 days. Secondary outcomes included comparing cycle length, endometrial stripe thickness, and side effects. RESULTS: Nine participants completed all study procedures in both cycles. Ovulatory disruption occurred in 66.7% (n=6) of treatment cycles and all but one demonstrated features of ovulatory dysfunction. Cycle length (mean±SD) was longer in the treatment cycle (31.9±4.0 vs 28.6±3.5 days, p<0.01). Secondary outcomes did not differ between the two cycles. CONCLUSIONS: UA plus the COX-2 inhibitor meloxicam disrupts ovulation at peak luteal surge and is a promising candidate for evaluation as a pericoital oral contraceptive. TRIAL REGISTRATION NUMBER: NCT03354117.

Urban-rural differences in China's crude death rate changes.

BACKGROUND: From 1982 to 2010, the country's crude death rate (CDR) dropped sharply, fluctuated, and finally slightly declined. There is a big difference in CDR between urban and rural areas. From 1982 to 1990, the CDR in the country and the countryside declined, and the CDR in cities and towns rose. After 1990, the CDR in cities gradually decreased, the CDR in towns first fell and then rose, and the CDR in the countryside steadily increased. The CDR is affected by changes in the age-specific death rate (ASDR) and age structure. METHODS: This paper decomposes CDR changes into the influence of declines in ASDR and the impact of age structure changes based on 1982, 1990, 2000, and 2010 census data. RESULTS: The decline in ASDR reduces the CDR, and the aging population increases the CDR (including cities, towns, and the countryside). At the same time, decomposing the difference between the countryside and cities (or the countryside and towns) CDRs found that after 1990, the influence of ASDR differences and age structure differences increased with time. Our results revealed a more significant effect of ASDR differences. The combined effect of two factors (ASDR and age structure) makes the 0, 1-14, 15-64 age groups reduce the CDR, and the 65+ age group increases the CDR. In addition, the 0-year-old group has a not negligible impact on the changes in CDR, although it accounts for a small proportion of the total population. CONCLUSIONS: The influence of ASDR and age structure differs over time (1982 to 1990, 1990 to 2000, and 2000 to 2010) and across regions (cities, towns, the countryside). Considering the slow decline in ASDR and the accelerated aging population, we can infer that the CDR in 2020 will stabilize or even rise slightly instead of dropping significantly (compared with the CDR in 2010). This study provides a basis for the formulation of relevant public health policies.

Clinic Staff Perspectives on Barriers and Facilitators to Integrating Transgender Healthcare into Family Planning Clinics.

Purpose: Although some research exists about transgender and nonbinary people's reproductive health needs, little research has explored the expansion of transgender health care in a family planning clinic context. This study investigates the expansion of transition-related care in family planning clinics in the United States from the perspective of clinic staff members. Methods: Between 2018 and 2019, 25 in-depth interviews with family planning clinic staff across the United States explored themes in incorporation and continuation of transgender care. Qualitative data were also collected at several national reproductive health professional conferences in sessions focused on transgender health care. Content analysis on the type of care available at clinics from public websites was analyzed using descriptive statistics. Results: Family planning clinics became invested in offering transition related care through existing patient requests and community requests, including from staff members themselves. Clinics faced administrative and scheduling challenges in adding care. They reported that medical protocol components were easiest to learn. Analysis of clinic websites indicates that ∼10% of nationally networked clinics offer transgender care compared to 21% of independent member clinics of the Abortion Care Network. Conclusions: Family planning clinics should consider adding transgender care based on patient or community demand as an extension of existing expertise in providing patient-centered care. Clinics should be aware that tool kits and protocols already exist to support integrating transition related care in family planning clinics.