Knowledge, attitudes, and practices of intrauterine adhesion prevention among healthcare providers and patients: a cross-sectional study in western China

Abstract

Objective

The aim was to assess the current knowledge, attitudes, and practices (KAP) of obstetricians, gynaecologists and women of childbearing age attending gynaecology/hysteroscopy clinics regarding intrauterine adhesions (IUA) by conducting a survey in various hospitals in western China.

Design

In this study, a cross-sectional survey design was used to select seven representative hospitals in western China between January and June 2023.questionnaires were administered to 210 obstetricians and gynaecologists in these seven hospitals and to 306 women of childbearing age visiting the obstetrics and gynaecology/hysteroscopy clinics of these hospitals.

Results

A total of 506 valid responses were obtained. The interviewed doctors exhibited a high level of knowledge regarding postabortion management, which correlated positively with their years of experience and the hospital level. Approximately 96.12% of the doctors expressed a willingness to apply this knowledge in clinical practice. On the basis of their knowledge and attitudes towards abortion management, 87.86% of the doctors would choose to implement these measures effectively to protect patients’ future fertility. The patients’ knowledge significantly improved after treatment, with 92.33% of the patients agreeing that protective measures should be taken during sexual intercourse when procreation is not intended. However, in practice, only 47.67% of the women voluntarily used safety measures.

Conclusion

Enhancing doctors’ understanding of fertility protection and perioperative management can reduce the abortion rate and increase patient awareness of the potential harm caused by abortion. Strengthening reproductive health education for women of childbearing age and improving their access to relevant knowledge during preabortion education can deepen their understanding of uterine cavity adhesions.

Clinical trial number

Not applicable.

Introduction

Intrauterine adhesions (IUA) arises from an abnormal process of the endometrial lining, repair that results from various factors, including intrauterine surgery and infections [1].This abnormal process leads to scarring within the uterine cavity, impairing its function in pregnancy and childbearing. Affected individuals may experience symptoms such as reduced menstrual flow, severe secondary amenorrhea, and cyclic lower abdominal pain, potentially leading to infertility and severe obstetric complications among women of reproductive age [1, 2].

Xiao et al. [4] reported that 94.3% of patients with IUA had a history of uterine cavity surgery. Notably, women who had been pregnant or recently became pregnant were more susceptible to such surgery-induced damage, constituting a high-risk factor for uterine adhesion development. This increased vulnerability might be attributed to the enriched vascular network in the endometrial basal layer during pregnancy, which is influenced by elevated oestrogen levels [5]. The termination of pregnancy results in a sudden decrease in oestrogen, impeding endometrial neovascularization, leading to insufficient local oxygen and nutrient supplies, and inhibiting endometrial proliferation. Furthermore, uterine surgical procedures performed under stress conditions trigger the release of inflammatory mediators, including adhesion factors, altering the intrauterine microenvironment. This disruption further impedes endothelial self-repair and contributes to IUA development [6].

IUA can also result from damage to the endometrial basal layer or even the myometrium during uterine surgery in women who are not pregnant [7]. Therefore, we posit that IUA primarily stem from medical-related endometrial damage and impaired repair processes [8]. It is crucial to explore how physicians can better assess and provide appropriate clinical management for these patients with IUA.Similarly. enhancing reproductive health knowledge among women of reproductive age can mitigate unplanned pregnancies and the subsequent risk of miscarriage. Thus, improved two-way education between healthcare providers and patients holds significant promise in IUA prevention.

Many young women do not pay enough attention to sexual health and contraception, which leads to many unplanned pregnancies and surgical termination of pregnancy (TOP). IUAs may develop postoperatively, which affects their reproductive health.In response to this social situation, we believe that there is a need to educate women of childbearing age, and also that some physicians are not sufficiently aware of the high-risk factors for uterine adhesions. Therefore, we conducted a two-way survey to achieve two-way education.The objective of this study was to survey obstetricians and gynaecologists, practising in hospitals in western China to assess their knowledge, attitudes, and practices (KAP) regarding high-risk factors for IUA through a questionnaire analysis. Additionally, this study aimed to educate women of reproductive age visiting gynaecology and hysteroscopy clinics about surgical TOP and IUA.

The KAP theoretical model is a behavioural change theory that was proposed by G. Cust, a public health and medical education specialist at the Council for Medical Education in the United Kingdom, in the 1960s, and is now widely used as a model for behavioral change in a variety of fields.K stands for knowledge and learning, which is the foundation; A stands for attitude, which is the motivation; and P represents practice, which is the process and goal of behavioural change. KAP-based health education is an important method of chronic disease management and part of the work of medical staff and involves the use of appropriate educational methods to provide individuals, families or groups with relevant knowledge and disease management skills to influence patient knowledge; improve health beliefs to promote health behaviours; improve disease self-management; and address disease risk factors. We aimed to identify gaps in the reproductive health knowledge of women of reproductive age to provide valuable insights to guide efforts in reducing IUA incidence.

Materials and methods

Study population

gynaecologists and obstetricians employed in seven hospitals in western China, as well as women of reproductive age visiting gynaecology/hysteroscopy clinics from January to June 2023, voluntarily participated in this survey.

Inclusion and exclusion criteria

Obstetricians and gynaecologists

Inclusion criteria

(A) Registered physicians whose scope of practice included obstetrics and gynaecology; (B) Physicians with ≥ 2 years of clinical work; (C) Physicians who voluntary signed the electronic informed consent form.

Exclusion criteria

A.Physicians in training and advanced training (due to mobility, which affects the consistency of data); and B. Physicians who did not work in outpatient clinics.

Women of childbearing age

Inclusion criteria

(A) Women of childbearing age between 18 and 49 years old (refer to the World Health Organization (WHO) definition of childbearing age); (B) Women with a regular sexual life history in the last year; (C) Women who had certain communication and expression skills and had good compliance and who could fully understand the questionnaire; (D) Women who were willing to participate in the survey after explanation; (E) Women who were willing to provide information on the real situation; (F) Women who could complete the questionnaire independently in the state of conscious awareness; and (G) Women who could be traced back to the outpatient electronic medical record system.

Exclusion criteria

(A) Women who were not of childbearing age; (B) Women who did not have the ability to communicate and express themselves, had poor compliance, and were unable to understand the questionnaire; (C) Women who were unwilling to participate in this survey after explanation; (D) Women who were unwilling to provide the truth; and (E) Women who were unable to complete the questionnaire independently.

Determination of sample size

According to sample size estimation in questionnaire-based studies, Tabchnick and Fidell suggested that the sample size should be 5 to 20 times the number of scale items. In the present study, 23 physician questionnaire scale items were used, with a sample size of 115–430 participants, and 25 mass questionnaire scale items were used, with a sample size of 125–500 participants.

Methods

Two self-administered KAP questionnaires were designed via a cross-sectional survey epidemiological research approach. The questionnaire was crafted on the basis of consensus knowledge derived from relevant references on IUA epidemiology, the Chinese expert consensus on IUA, and the American Association of Gynecologic.

Laparoscopists(AAGL) clinical guidelines on IUA [9,10,11]. A small pretrial involving 30 participants was conducted to identify any issues with the questionnaire. Subsequently, modifications were made to the questionnaire on the basis of the feedback obtained from the pretrial, and it was then implemented in the formal survey.

All the questionnaires were administered by two methods: (1) Paper-Based Questionnaires: The participants were briefed about the purpose of the survey and questionnaire requirements by the investigator. The participants answered the questionnaires voluntarily, anonymously, and independently, and the completed questionnaires were collected onsite. (2) Questionnaire App: The questionnaire was accessed by the participants via a QR code, and it was answered anonymously and independently. This method facilitated data collection. Approval for the project was obtained from the Research Ethics Committee of the General Hospital of Ningxia Medical University. The survey included an introductory statement explaining the purpose of the survey, assuring the participants of data confidentiality and allowing participants to complete the survey voluntarily, as indicated by their signature. The participants had the option to withdraw from the survey at any time if they felt uncomfortable.

The doctor’s questionnaire consisted of general information (sex, job title, years of work experience, educational background, etc.), five knowledge-related questions, six attitude-related questions, and six questions related to practices concerning uterine adhesions.

The questionnaire for women of childbearing age included general information (age, educational background, ethnicity, age at first sexual intercourse, etc.), five knowledge-related questions, four attitude-related questions, and five questions concerning reproductive health practices and uterine adhesions.

Statistical methods

Data analysis was conducted using SPSS 26.0 software. The measurement data are presented as the means ± standard deviations (x ± s). Independent samples t tests were used for comparisons between two groups, whereas one-way ANOVA was used for comparisons between multiple groups. Multiple comparisons between groups were conducted using the LSD-t method. Count data are presented as cases (%), and statistical significance was considered at P < 0.05.

Result

A total of 517 questionnaires were distributed in this study, and 506 valid questionnaires were returned, resulting in a response rate of 97.87%.

Questionnaire data from obstetricians and gynaecologists

Basic information

Among the 210 questionnaires distributed to obstetricians and gynaecologists, 206 valid questionnaires were returned, indicating a valid recovery rate of 98.10%. Among the participating doctors, the majority were female (188, 91.26%), and senior physicians constituted the largest group (104, 50.49%). The distribution of years of working experience was highest in the 16‒25 years category, with other years of experience being evenly distributed, providing a representative reflection of the KAP results among doctors with varying levels of experience. Most doctors worked in secondary and tertiary level hospitals (Table 1).

Table 1 Basic information of the responding obstetricians and gynaecologists (n = 206)

Knowledge data from obstetricians and gynaecologists

A significant portion of these doctors, 83.98% (173), demonstrated a high level of knowledge about postsurgical TOP management. They emphasized the importance of assessing patients’ maternal history and reproductive needs (74, 35.92%). Additionally, 41.75% (86) of the doctors had a clear understanding of individualized patient management for cases involving “residual foetal tissue.” Nearly half of the doctors, 49.51% (102), were knowledgeable about the high-risk factors and surgical procedures that can lead to IUA in nonpregnant patients. Furthermore, 43.2% (89) of the doctors correctly identified key issues when treating postsurgery patients (Table S1).

Attitude data from obstetricians and gynaecologists

A high percentage, 96.12% (198), of the doctors expressed their willingness to provide standardized peri-TOP management to patients, which included paying attention to assessing medical history (169, 82.04%) and monitoring symptoms related to menstruation during follow-up (134, 65.05%). Approximately 50% (103) of these doctors recommended options that minimize the impact on fertility for women with high-risk factors. Moreover, 34.95% (72) of these doctors had a clear understanding of postoperative patient management for intrauterine procedures(Table S2).

Practice data from obstetricians and gynaecologists

In line with their knowledge and attitudes towards peri-TOP management, 87.86%(181) of the doctors implemented effective practices to protect their patients’ fertility. They paid attention to both the frequency and motivation of these practices. Additionally, they appropriately evaluated and managed patients with “incomplete TOP” on the basis of the presence or absence of clinical symptoms such as “heavy vaginal bleeding” (Table S3).

Questionnaire data from women of childbearing age visiting gynaecology/hysteroscopy clinics

Basic information

A total of 307 questionnaires were distributed, and 300 valid questionnaires were collected, resulting in a valid recovery rate of 97.72%. The majority of the participants were aged between 26 and 35 years (169, 56.33%). A significant portion of the women had received a university education (125, 41.67%), and the majority belonged to the Han population (238, 79.33%). The highest percentage of women had their first experience of sexual intercourse between the ages of 21 and 25 years (170, 56.67%), but the proportion of women with early childbearing did not correspondingly increase (38, 12.67%). Approximately 70.67% (212) of the women had a history of TOP, with 57.08% (121) undergoing surgical TOP. Most women (52.36%, 111) preferred tertiary care hospitals for their TOP procedures. 59% (177) of the respondents had IUA, with 37.29% (66) undergoing hysteroscopic surgery or curettage before IUA diagnosis. Additionally, 38.42% (68) of the women sought medical attention because of hypomenorrhea (Tables 2 and 3).

Table 2 Basic information of the interviewed (n = 300)

Table 3 Information on the history of miscarriage and uterine adhesions in the patients interviewed (n = 300)

Knowledge data from women of childbearing age visiting gynaecology/ hysteroscopy clinics

In general, a high percentage of the women with a history of surgical TOP (234, 78%,) possessed “complete or basic knowledge” about contraception, and 31% (93) of them acquired their knowledge about contraception through the internet. The percentage of patients with “no knowledge at all” about IUA decreased from 12% (36) after their first consultation with their doctor to 4% (12) after treatment.82.07% (174) of t the women with a history of TOP had a basic understanding of contraception, while only 68.18% (68) of the women with a history of TOP had a basic understanding of contraception(Table S4).

Attitude data from women of childbearing age visiting gynaecology/ hysteroscopy clinics

Among the women diagnosed with IUA (145) 81.92% had a negative attitude towards “TOP due to unplanned pregnancy”, and a greater number of women (277, 92.33%) agreed that precautions should be taken during sexual intercourse when reproduction is not intended(Table S5).

Practice data from women of childbearing age visiting gynaecology/ hysteroscopy clinics

Although 92.33% (277) of the patients agreed on the importance of using safeguards when reproduction is not intended, only 47.67% (143) of the women actually used condoms or other types of contraception during intercourse. Furthermore, 83.02% (176) of the women with a history of TOP were willing to follow the doctor’s recommendations for follow-up. Among these women, 52.33% (212) were willing to share their knowledge and experiences with friends. This willingness was positively correlated with the level of education and negatively correlated with the age of the woman. The rate increased to 88.70% (157) for patients treated for IUA, with the highest percentage of patients with IUA (168, 94.92%) complying with their doctor’s advice after treatment(Table S6).

Discussion

In the early 1970s, China began to implement a family planning policy that called for later and fewer births, which led to an increase in the number of TOP. In the 1980s and 1990s, the supply of contraceptives was insufficient (especially in rural areas), and the promotion of long-acting contraceptives (such as intrauterine devices) was limited by technical and economic conditions, leading to a high rate of unwanted pregnancies. There was also a lack of sex education and inappropriate use of contraceptive methods (e.g., miscalculation of the safe period, irregular use of condoms) by some groups of the population, which further increased the rate of unintended pregnancies. Compared to the economic and time costs of long-term contraceptive methods, TOP is seen as a “more immediate” short-term solution.

The KAP survey conducted among obstetricians and gynaecologists revealed that as their years of experience, rank, and hospital grade increased, their knowledge and willingness to practice in the management of women of childbearing age undergoing the TOP procedure also steadily increased. They placed greater emphasis on evaluating the patients’ medical histories and considering their future desires for childbearing. Additionally, their clinical decisions regarding the TOP procedure tend to prioritize fertility preservation. This trend can be attributed to several factors. First, as their years of work experience increase, these healthcare professionals accumulated valuable knowledge and skills, enabling them to better address the clinical needs of their patients. Furthermore, China’s historical family planning policies have led to a significant number of induced TOP procedures. Consequently, the detection rate of IUA among women with “secondary infertility” has been increasing annually [12]. The increasing number of patients seeking reproductive clinic services has made doctors increasingly aware of the importance of TOP-related health education and management. Notably, 70.87% (146) of the doctors in our survey provided patients with information on postabortion care (PAC) and offered guidance on medication usage. Research has demonstrated that PAC services provided by doctors can substantially increase effective contraceptive utilization and reduce the likelihood of repeat TOP procedures among women [13,14,15]. This two-way survey has enhanced the physicians’ knowledge of the risk factors for uterine adhesions.

Furthermore, hysteroscopic surgery has become the standard procedure for addressing intrauterine diseases. Physicians are now cognizant that this nonpregnancy-related surgery can also lead to the development of IUA. With increasing clinical experience and professional advancement, practitioners demonstrate growing ambivalence toward routine second-look hysteroscopy following hysteroscopic electrosurgical procedures. Paradoxically, senior clinicians exhibit diminished emphasis on postoperative reassessment, despite clinical evidence showing recurrence rates of 33.3% in mild-to-moderate IUA cases and 66.7% in severe cases postoperatively. Current guidelines advocate systematic cavity reevaluation 2–3 menstrual cycles post-intervention as a clinically valuable practice, underscoring the necessity of integrating second-look procedures into standardized postoperative protocols.This discrepancy may originate from clinical overconfidence - wherein accumulated successful outcomes potentially erode adherence to evidence-based guidelines. Implementation of structured competency evaluations is recommended to mitigate such cognitive biases in surgical decision-making [16]. The KAP survey also highlighted that the participants generally had higher levels of education than the average women of childbearing age in our country. These women tend to delay their first sexual intercourse experience, but they have a higher rate of TOP procedures. It is worth exploring whether these trends are related to prolonged periods of schooling and increased job demands, a subject that warrants further research.

We observed that women with a history of TOP had a better understanding of contraception (Fig. 1), which can be attributed to their personal experiences providing them with more information about safe contraception and causing them to place greater value on this knowledge.Interestingly, a majority of these women reported obtaining their knowledge about “access to safe contraception” from the internet.This decentralized learning model carries significant risks: Algorithmic Reinforcement of Information Cocoons (e.g., disproportionate emphasis on contraceptive side effects through personalized content feeds).Profit-Driven Misinformation (e.g., private clinics promoting misleading claims about pain-free abortion safety).To counter these systemic flaws, we propose establishing a dual-track knowledge delivery framework: Institutional Integration:1.Develop standardized contraceptive information modules for seamless integration with hospital EHR systems, enabling automated generation of evidence-based patient advisories during clinical encounters.2.Peer-to-Peer Dissemination: Identify and train high-engagement social influencers to distribute vetted scientific content through trusted community networks. Additionally, this approach would allow doctors to allocate more of their clinic time to other essential tasks. For patients diagnosed with IUA, our survey revealed that there was limited improvement in their knowledge of this condition after the initial consultation with a doctor. As primary educators, clinicians’ expertise and patient-centered communication strategies directly shape health literacy outcomes, with our data revealing a positive correlation between providers’ IUA knowledge mastery and patients’ preventive health behaviors.This suggests that the specialized nature of this knowledge may present communication barriers, particularly when certain medical terminologies are involved. Doctors can employ various communication methods, such as visual aids including images and interactive content (e.g., flash animations), to overcome this challenge. These tools can facilitate the transfer of information, enhancing patients’ comprehension and retention of specialized knowledge related to IUA. This, in turn, can lead to improved patient cooperation and understanding of the treatment plan for IUA.

Fig. 1

Knowledge of contraception among patients with or without a history of abortion

78% of patients self-assessed their knowledge of contraception, of which 31% relied on online channels (of which 62% obtained information through short social media videos [17, 18]).Such fragmented learning has serious drawbacks: algorithmic recommendations lead to information cocooning (e.g., over-exaggerating the side effects of contraceptives), and commercial interests drive misleading content (e.g., private hospitals exaggerate the safety of painless abortions), so it is recommended to build a “dual-track knowledge supply system”:1.A standardized contraceptive knowledge base should be developed, and personalized advice should be automatically generated by embedding it in the hospital’s electronic medical record system; 2.social diffusion layer: training groups with high willingness to spread the word to become “health communication ambassadors”, and distributing vetted popular science content through social networks [19].

Women who had undergone TOP procedures tended to possess better knowledge of contraception and were more willing to share their knowledge and experiences with friends. Notably, a greater percentage of patients with IUA were willing to share their experiences (Fig. 2). This willingness was positively associated with their educational level and inversely correlated with their age. We believe that women with higher educational backgrounds tend to place greater value on their reproductive health and have a greater capacity to understand and explain reproductive health knowledge to others. As women age, they may have completed their planned fertility, which could explain a decreased emphasis on this knowledge. For patients with IUA, undergoing longer-term treatment enables them to better appreciate the psychological distress caused by the condition and their concerns about reproductive disorders. Consequently, they become more receptive to information and education provided by their doctors and are more inclined to share their experiences with friends to prevent similar situations from recurring.

Fig. 2

Women with different levels of education who are willing to pass on their knowledge to others

Our survey also revealed interesting findings: while most women believed that safeguards should be used during sexual intercourse when they do not wish to conceive, only 47.67% (143) of the women actually put their knowledge and attitudes into practice by using condoms or other forms of protection during sexual activity [20] (Fig. 3). This highlights that knowledge and attitudes do not always translate into action, and the willingness of sexual partners to cooperate may also play a role. Therefore, efforts to promote reproductive health education and educate women about reproductive health should not be limited to women alone [21]. Patients with unplanned pregnancies are recommended to visit a professional institution for evaluation and an optimal abortion plan, especially for unmarried women of childbearing age, who do not choose informal institutions for abortion out of fear, which may have a great impact on their reproductive health [22].Nguyen-Thi Thu Ha et al. conducted a reproductive health KAP survey of post-abortive adolescents in Viet Nam and found that the majority of adolescents seeking abortions had poor KAP in reproductive health, emphasizing the need for reproductive health care information and services for adolescents [23]. Muhammad Zakaria et al.‘s KAP study on sexual and reproductive health among adolescent girls in Bangladesh also recommended strengthening comprehensive education programs related to sexual reproductive health, effective use of mass media, and provision of behavior change communication materials [24]. In this way, “lifelong sexuality education” can be used as a model for establishing a graded contraceptive counselling system in colleges and universities and in the workplace, as well as for developing mobile contraceptive decision support tools for people in the early stages of sexual activity.Digital interventions could disrupt this cycle through anonymous contraceptive consultation platforms integrated with geospatial mapping of free medication access points, thereby enhancing service accessibility while addressing confidentiality needs.

Fig. 3

Comparison of women’s attitudes and behaviours towards contraceptive use

Conclusion

This two-way survey enhanced the doctors’ concept of fertility protection and perioperative management, which can reduce the abortion rate and allow patients to better understand the harm abortion causes to their bodies; preabortion education work strengthens the reproductive health education of women of childbearing age and their access to relevant knowledge and deepens patients’ knowledge of IUA. It is very fortunate that China has lifted family planning and fully liberalized the fertility policy since 2016, encouraging people to have children, and college students in universities have received reproductive health education.

What does this study adds to the clinical work

The purpose of this study was to conduct a questionnaire survey regarding the IUA-related KAPs of gynaecologists and women of reproductive age visiting gynaecology and hysteroscopy clinics in hospitals in western China. Our survey revealed that efforts to promote and educate individuals about reproductive health should not be limited to women alone.

Strengths and limitations

Strengths

IUA are a medical condition that is the result of a lack of knowledge and unhealthy behaviours among women of childbearing age, which is particularly pronounced in many developing countries. The KAP model is a novel research paradigm, and KAPs that address both doctors and patients are currently very rare.

Limitations

Our survey was limited to women of childbearing age visiting hospitals, and it had a greater representation of individuals with TOP experiences and a history of IUA than did the population at large. Therefore, the study population may not fully reflect the overall demographic characteristics of our country. Future efforts should also target younger girls, including students in schools, to gain a better understanding of the specific areas of reproductive health promotion that need to be strengthened or improved.