Doula support during first-trimester surgical abortion: a randomized controlled trial

Patient navigation in reproductive healthcare

PURPOSE OF REVIEW

This review summarizes evidence about barriers to abortion care pre- Dobbs and post- Dobbs , inequities in abortion access, and approaches to improving access to abortion care with use of patient navigators.

RECENT FINDINGS

The Dobbs decision and resulting state-level restrictions exacerbated economic, knowledge, and logistic barriers to abortion care. Abortion funds and emotional support are two main resources to help address these barriers; however, only with coordination can patients and clinics fully benefit from the resources. Patient navigation provides that coordination. Evidence shows it improves reproductive outcomes, is acceptable to patients and providers, and engages community health workers and community-based organizations.

SUMMARY

Increasing legal restrictions and barriers to abortion care have motivated advocates to identify effective interventions to facilitate patient-centered and culturally competent care. Navigators have improved postpartum care by increasing attendance, education and helping coordinate overall care. They have improved referrals and access to abortion care in statewide programs.

The role of doulas and community birth workers in abortion and contraception care: An international scoping review

OBJECTIVES

Equitable and safe access to abortion and contraception is essential to protecting reproductive autonomy. Despite this, barriers to access remain. Nonclinical support people, may be able to facilitate access to abortion and contraception services and care, but evidence on the scope and efficacy of doulas in abortion and contraception care is lacking. The aim of this scoping review was to synthesize what is known about the role of doulas in abortion and contraception care.

STUDY DESIGN

We followed the Joanna Briggs Institute methodology for scoping reviews. A clinical librarian performed an initial search of all relevant databases. Three reviewers independently screened the titles and abstracts for assessment against the inclusion and exclusion criteria. The populations of interest included doulas, and/or untrained birth attendants and birth companions, and patients who use doula services. The concept of interest was the doula and the context was access to abortion or contraception.

RESULTS

Our review identified relevant studies conducted in different countries, published between 1976 and 2023. Studies broadly focused on three key themes: doulas performing procedural abortions, doulas supporting abortion care, and doulas supporting contraception. Outcomes of interest included client outcomes, barriers to access, doula training, and attitudes.

CONCLUSIONS

Doulas have the potential to improve client satisfaction and mitigate barriers to accessing abortion and contraception services. Further research is needed to identify the training needs of doulas, the potential for their integration into interdisciplinary care teams, and the role in supporting medication abortion.

United States Doula Programs and Their Outcomes: A Scoping Review to Inform State-Level Policies

BACKGROUND

The field of maternal health has advanced significantly over the past decades. However, the United States continues to have poor outcomes in comparison with other industrialized nations. With emerging evidence on the promise of doula care, states are including doula care under their Medicaid programs.

METHODS

We conducted a scoping review across four academic databases and gray literature published between January 1, 2012, and March 10, 2022, to describe the landscape of literature on U.S. doula programs and their outcomes in order to inform state policy makers considering laws or programs related to doula care.

FINDINGS

Of 740 records identified, 100 met inclusion criteria. Outcomes fell into four areas: birthing people's outcomes, infant outcomes, systems of care and implementation, and cross-cutting issues. Data on outcomes related to doula care in the literature were predominantly clinical, even though doulas are not clinical providers. Although some studies have found associations between doula care and improved clinical outcomes for birthing people and infants, the evidence is limited due to small sample sizes, study methodology, or conflicting conclusions. Doula outcomes are underexplored in the literature, with mainly qualitative data describing low levels of diversity and equity within the doula workforce and ineffective payment models. When cost-effectiveness estimates have been calculated, they largely rely on savings realized from averted cesarean births, preterm births, and neonatal intensive care unit admissions.

CONCLUSIONS

As state Medicaid programs expand to include doula care, policymakers should be aware of the limitations in the evidence as they plan for successful implementation, such as the narrow focus on certain clinical outcomes to quantify cost savings and conflicting conclusions on the impact of doula care. An important consideration is the impact of the reimbursement rate on the adoption of doula care, which is why it is important to engage doulas in compensation determinations, as well as the development of improved metrics to untangle the components that contribute to maternal health outcomes in the United States.

Seeking abortion accompaniment: experiences and self-managed abortion preferences of hotline callers after abortion legalisation in Argentina

BACKGROUND

Until the legalisation of abortion in Argentina in 2021, the Socorristas en Red, a network of feminist collectives, provided support and information ('accompaniment') to people self-managing their abortion with medications. Following legalisation, the Socorristas continued accompanying people self-managing or accessing abortion through the healthcare system. We conducted a cross-sectional study to understand preferences, experiences and choices about abortion when contacting a Socorristas hotline after legalisation of abortion in Argentina.

METHODS

We surveyed callers to the Socorristas' hotline in Neuquén, Argentina about their demographics, pregnancy history, reasons for calling, and experiences seeking abortion through the hotline and the healthcare system. We assessed overall prevalence of these experiences, and analysed differences between people who contacted the health system before calling the hotline and those who first called the hotline for services.

RESULTS

Of the 755 callers in the study, the majority (63.3%) contacted the Socorristas because they trusted them, and 21.7% called because they both trusted the Socorristas and did not want to go to the healthcare system. At the end of the call, most people (95.4%) chose to self-manage their abortion with accompaniment outside the healthcare system. People who called the healthcare system prior to contacting the hotline frequently reported being referred to the Socorristas, as well as challenges scheduling appointments.

CONCLUSIONS

After legalisation of abortion in Argentina there is continued demand for accompaniment. Globally, ensuring that accompaniment and self-management of abortion is legal and protected will provide individuals with the support and facilitated access to the abortion care they desire.

Experiences with and unmet needs for medication abortion support: A qualitative study with US abortion support providers

INTRODUCTION

Quality abortion care must be person-centered. Although academic literature has focused on full-spectrum and abortion doulas supporting instrumentation abortion (also referred to as procedural abortion) clients, clients undergoing medication abortion remain understudied and may have unique needs. We aimed to understand United States (US) abortion support providers' perceptions of medication abortion clients' support needs by exploring which needs they address, which needs remain unmet, and how remote support provision might help address client needs.

METHODOLOGY

Between April and October 2018, we conducted 60- to 90-min semi-structured, in-depth interviews by telephone with medication abortion support providers. The interviews focused on their experiences providing support to medication abortion clients in the US. We used a deductive thematic analysis approach.

RESULTS

We interviewed 16 abortion support providers affiliated with nine US-based organizations. Six participants provided in-person support to medication abortion clients, five provided remote support, and five provided both remote and in-person support. Both in-person and remote providers described offering support that addressed clients' informational, emotional, physical, spiritual, and logistical needs. Through participant narratives, we identified interwoven benefits and challenges to remote support care provision. Participants highlighted that most medication abortion clients did not have a support provider.

DISCUSSION

Participants revealed that abortion support providers, including remote support providers, can be a critical component of high-quality abortion care provision. More work is needed to ensure all abortion clients have access to support services as the abortion landscape in the US continues to evolve.

Assessing Interest in a Peer Support Person for Patients Experiencing Early Pregnancy Loss: Results from a National Survey

Introduction

The use of a peer support person as an intervention for early pregnancy loss (EPL) is not well studied. In addition, limited literature exists regarding the type of support patients need when experiencing EPL. The objective of this study is to quantify interest in a peer EPL support person intervention, to assess the types of support desired following EPL, and to investigate if there is an association between self-compassion or resilience and coping ability post-EPL.

Methods

We conducted a cross-sectional, web-based survey with 110 individuals who experienced EPL in the past 2 years. Questions explored interest in a peer EPL support person and different types of support, as well as perceived self-compassion and resilience. Analyses of variance were used to test if interest in the peer support intervention and in different types of support varied by demographics, while linear regression modeling was used to test the relationship between self-compassion, resilience, and coping ability.

Results

Nearly all participants (98.2%, n = 108) were interested in peer support. The majority (31.8%, n = 35) of participants prioritized informational and educational support at the time of their EPL and in the months following. There was a positive relationship between self-compassion scores and ability to cope with EPL (p = 0.2) and between resilience scores and coping ability (p < 0.05).

Conclusions

Almost all participants were interested in a peer support person for coping with EPL. Given the types of support participants identified in this study, a peer support person may provide emotional and informational support as well as resilience training.

Local anaesthesia for pain control in first trimester surgical abortion

BACKGROUND

Abortions prior to 14 weeks are among the most common outpatient surgical procedures performed on people capable of becoming pregnant. Various methods have been used to control pain; however, many people still experience pain with the procedure.

OBJECTIVES

To evaluate the benefits and harms of local anaesthesia given for pain control during surgical abortion at less than 14 weeks' gestation.

SEARCH METHODS

We searched CENTRAL (Ovid EBM Reviews), MEDLINE (Ovid), Embase, POPLINE, and Google Scholar to December 2022 for randomized controlled trials of pain control in surgical abortion at less than 14 weeks' gestation using suction aspiration. We searched the reference lists of related reviews and articles.

SELECTION CRITERIA

We selected effectiveness and comparative effectiveness randomized controlled trials that studied local anaesthesia with common local anaesthetics and administration routes given for pain control in surgical abortion at less than 14 weeks' gestation using uterine aspiration. Outcomes included intraoperative pain, patient satisfaction, and adverse events.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We computed mean differences (MD) with 95% confidence intervals (CI) for continuous variables reporting a mean. We assessed the certainty of evidence using GRADE.

MAIN RESULTS

Thirteen studies with 1992 participants met the inclusion criteria. Due to heterogeneity of interventions, we could not pool more than two studies for any outcome. We used 13 mm improvement on a visual/verbal analogue scale to indicate a clinically meaningful difference in pain with surgical abortion (pain with dilation, aspiration, or during procedure). Based on type of pain control, we divided studies into three groups. Paracervical block (PCB) effectiveness trials A 20 mL 1% lidocaine PCB reduced pain with dilation (MD -37.00, 95% CI -45.64 to -28.36), and aspiration (MD -26.00, 95% CI -33.48 to -18.52) compared to a sham PCB (1 RCT, 120 participants; high-certainty evidence). A PCB with 14 mL of 1% chloroprocaine resulted in a slight reduction in pain with aspiration compared to a PCB with normal saline injected at two or four sites (MD -1.50, 95% CI -2.45 to -0.55; 1 RCT, 79 participants; high-certainty evidence). PCB comparative effectiveness trials An ultracaine PCB probably results in little to no clinically meaningful difference in pain during procedure compared to topical cervical lidocaine spray (median 1 point higher, interquartile range (IQR) 0 to 3; P < 0.001; 1 RCT, 48 participants; moderate-certainty evidence). A 1000 mg dose of intravenous paracetamol probably does not decrease pain as much as ultracaine PCB during procedure (median 2 points higher, IQR 1 to 3; P < 0.001; 1 RCT, 46 participants; moderate-certainty evidence). Various local anaesthetics in PCB comparative effectiveness trials A 10 mL buffered 2% lidocaine PCB probably does not result in a clinically meaningful difference in pain with dilation compared to a plain lidocaine PCB (MD -0.80, 95% CI -0.89 to -0.71; 1 RCT, 167 participants; moderate-certainty evidence). A buffered lidocaine PCB probably does not result in a clinically meaningful difference in pain with aspiration compared to plain lidocaine PCB (MD -0.57, 95% CI -1.01 to -0.06; 2 RCTs, 291 participants; moderate-certainty evidence). Non-PCB local anaesthesia or PCB technique effectiveness trials PCB: waiting versus no waiting Waiting three to five minutes between 1% lidocaine PCB injection and dilation probably does not result in a clinically meaningful difference in pain with dilation compared to not waiting (MD -0.70, 95% CI -1.23 to -0.17; 2 RCTs, 357 participants; moderate-certainty evidence). Topical cervical analgesia Topical 10 mL 2% lignocaine gel probably does not result in a clinically meaningful difference in pain with aspiration compared to KY Jelly (MD -0.87, 95% CI -1.60 to -0.14; 1 RCT, 131 participants; moderate-certainty evidence). In participants who also received a PCB, 20 mg topical cervical lidocaine spray probably does not result in a clinically meaningful difference in pain during the procedure compared to two pumps of normal saline spray (median -1 point, IQR -2 to -1; P < 0.001; 1 RCT, 55 participants; moderate-certainty evidence). Intravenous paracetamol 1000 mg compared to two pumps of cervical lidocaine spray probably does not results in a clinically meaningful difference in pain procedure (median 1 point, IQR -2 to 2; P < 0.001; 1 RCT, 48 participants; low-certainty evidence). Non-PCB local anaesthesia or PCB technique comparative effectiveness trials Depth of PCB The evidence suggests that a 3-cm deep PCB probably does not result in a clinically meaningful difference in pain with aspiration compared to a 1.5-cm deep PCB (MD -1.00, 95% CI -1.09 to -0.91; 2 RCTs, 229 participants; low-certainty evidence). PCB: four sites versus two sites A two-site (4-8 o'clock) 20 mL 1% lidocaine PCB does not result in a clinically meaningful difference in pain with dilation compared to a four-site (2-4-8-10 o'clock) PCB (MD 8.60, 95% CI 0.69 to 16.51; 1 RCT, 163 participants; high-certainty evidence). Overall, participants reported moderately high satisfaction with pain control and studies reported few adverse events.

AUTHORS' CONCLUSIONS

Evidence from this updated review indicates that a 20 mL 1% plain lidocaine PCB decreases pain during an abortion procedure. Evidence supports forgoing buffering lidocaine and a wait time between PCB injection and cervical dilation. A 1.5-cm deep injection as opposed to a 3-cm deep injection is sufficient. A two-site PCB injection as opposed to a four-site injection has similar effectiveness. Topical cervical anaesthesia (10 mL 2% lignocaine gel or 20 mg topical cervical lidocaine spray) as compared to placebo did not decrease pain based on moderate-certainty evidence, but then when compared to PCB, pain control was similar. Due to this inconsistency in evidence regarding the effectiveness of topical anaesthesia, its routine use is presently not supported. This review did not include studies of pain management with conscious sedation but, based on the results of our prior Cochrane review and the 2022 WHO guidelines, we recommend that the option of combination of pain management using conscious sedation plus PCB and non-steroidal anti-inflammatory drugs should be offered where conscious sedation is available as it further decreases pain.

"I would love for there not to be so many hoops … ": recommendations to improve abortion service access and experiences made by Indigenous women and 2SLGTBQIA+ people in Canada

Acknowledging the barriers in accessing sexual and reproductive health services that disproportionately impact Indigenous women and 2SLGTBQIA+ people, coupled with the lack of knowledge surrounding Indigenous peoples' experiences with abortion, we present qualitative findings from a pilot study investigating Indigenous experiences of accessing abortion services in Canada. We focus on findings related to participant recommendations for improving safety and accessibility of abortion services made by and for Indigenous people in Canada. Informed by an Indigenous Advisory Committee consisting of front-line service providers working in the area of abortion service access and/ or support across Canada, the research team applied an Indigenous methodology to engage with 15 Indigenous people across Canada utilising a conversational interview method, between September and November 2021. With representation from nine provinces and territories across Canada, participants identified with Anishinaabe, Cree, Dene, Haudenosaunee, Inuit, Métis and/ or Mi'kmaq Nations. Five cross-cutting recommendations emerged, including: (1) location, comfort, and having autonomy to choose where the abortion takes place; (2) holistic post-abortion supports; (3) accessibility, availability, and awareness of non-biased and non-judgemental information; (4) companionship, advocacy, and logistical help before and during the abortion from a support person; and (5) cultural safety and the incorporation of local practices and knowledges. Recommendations demonstrate that Indigenous people who have experienced an abortion carry practical solutions for removing barriers and improving access to abortion services in the Canadian context.

Emotional, informational, and decision-making support needs among people seeking abortion in the US: perspectives from All-Options Talkline callers

People seeking abortion may need or want emotional or informational support before, during, and after their abortion. Feeling supported and affirmed contributes to perceptions of quality care. The All-Options Talkline offers free, telephone-based, peer counselling to callers anywhere in the United States. This study aimed to explore the types of support received through the Talkline and the ways it supplemented other forms of support received by people who obtained an abortion. Between May 2021 and February 2022, we conducted 30 interviews via telephone or Zoom with callers recruited through the Talkline. We coded the interviews and conducted thematic analysis, focusing on themes related to gaps of support from family, friends, and healthcare professionals, as well as types of support received through the Talkline. We identified four key motivations for calling the Talkline, including the need for (1) decision-making support and validation, (2) a neutral perspective, (3) emotional support to discuss negative or complex feelings, and (4) information about the abortion process. Participants indicated that interactions with family, friends, and healthcare professionals ranged from unsupportive and negative, to substantially supportive. Access to the Talkline was particularly useful prior to clinical interactions and in the weeks or months after an abortion. We found that the All-Options Talkline provided person-centred, remote support for callers, filling gaps or supplementing support from one's community or healthcare professionals. Abortion support from non-medically trained support people contributes to high-quality abortion care, especially in a time of increasing abortion restrictions and use of remote abortion services.

Pain Management in Abortion Care

Both medication and procedural abortion are associated with pain. The experiences of pain depend on both physical and emotional factors. Several pain management options are available for abortion, depending on abortion type, clinical setting, and patient considerations, and a comprehensive approach is necessary to optimize pain management.

Travel for abortion care: implications for clinical practice

PURPOSE OF REVIEW

Traveling long distances to obtain abortion care due to restrictions and scarce availability is associated with significant obstacles. We review clinical strategies that can facilitate abortion access and outline considerations to ensure person-centered and equitable care.

RECENT FINDINGS

Establishing a patient's gestational duration prior to travel may be beneficial to ensure they are eligible for their desired abortion method at the preferred facility or to determine if a multiday procedure is required. If a local ultrasound cannot be obtained prior to travel, evidence demonstrates people can generally estimate their gestational duration accurately. If unable to provide care, clinicians should make timely referrals for abortion. Integration of telemedicine into abortion care is safe and well regarded by patients and should be implemented into service delivery where possible to reduce obstacles to care. Routine in-person follow-up care is not necessary. However, for those who want reassurance, formalized pathways to care should be established to ensure people have access to care in their community. To further minimize travel-related burdens, facilities should routinely offer information about funding and practical support, emotional support, and legal resources.

SUMMARY

There are many opportunities to optimize clinical practice to support those traveling for abortion care.

A Qualitative Analysis of Experiences of Medical Students Serving as Abortion Doulas

INTRODUCTION

Innovative strategies are needed in clinical education to teach empathetic behavior and communication skills. This study aimed to investigate preclinical medical students' experiences volunteering as abortion doulas and to understand the impact of their participation on their professional training.

METHODS

In this qualitative study, the authors conducted semistructured interviews with medical students who had volunteered as abortion doulas in March to July 2016. The interviews described motivations for participating, experiences volunteering as a doula, approach to caring for patients, and acquisition of communication skills and knowledge of abortion. The authors analyzed interview transcripts using a conventional content analysis approach, and themes were identified.

RESULTS

The authors performed 22 interviews. For most participants, this was their first exposure to an abortion procedure or patient care in any capacity. Participants identified acquisition of skills including patient advocacy, communication, and empathy that they were later able to apply throughout their clinical clerkships. This opportunity improved well-being and solidified their decision to apply for residencies in reproductive health fields.

DISCUSSION

After volunteering as abortion doulas, medical students were able to develop communication skills, empathy, and patient advocacy applicable to other areas of patient care. Preclinical students, potentially in other health care professions training, participating in patient care as doulas have the potential to further personal development, professionalism, and activism.

Interest in peer support persons among patients experiencing early pregnancy loss

BACKGROUND

Limited data exist regarding the type of support patients need when experiencing early pregnancy loss (EPL). The objective of this study is to explore how patients emotionally cope with EPL and to assess if there is interest in a peer EPL support program with a self-compassion component.

METHODS

We conducted semi-structured interviews with patients who experienced EPL in the past two years. We evaluated the kinds of support that patients felt were most helpful, interest in a possible peer EPL support person, and suggestions for the creation of such a program. Content analysis was utilized to analyze the data and identify themes.

RESULTS

Twenty-one individuals participated in the study. Approximately 52.3% (n = 11) of interviewees reported expectant management of their EPL, 23.8% (n = 5) reported medication management, and 23.8% (n = 5) reported undergoing dilation and curettage. We identified five themes: (1) therapy and in-person support groups are helpful when experiencing EPL, but are sometimes inaccessible; (2) social media support groups are initially advantageous for creating a sense of solidarity, but in the long term can be triggering; (3) support from a peer who has also experienced EPL is uniquely valuable; (4) developing self-compassion is important in emotionally coping with EPL; and (5) there is a demand for emotional and informational support following EPL.

CONCLUSIONS

Given the unique support participants identified receiving from a peer with shared lived experience, there is interest in a peer EPL support program with a self-compassion component for emotional and informational support following EPL.

"I can be pro-abortion and pro-birth": Opportunities and challenges for full spectrum care among doulas in Georgia

Background

The work of full spectrum doulas (i.e., non-medically trained care workers offering support before, during, and after pregnancy including abortion)-is increasingly important as abortion access decreases across the U.S. Few studies have examined the work of community-based doulas in restrictive abortion settings or how they might further incorporate full spectrum care. As part of the community-engaged mixed methods Georgia Doula Study, this analysis examines the scope of work of community-based doulas regarding full spectrum and abortion services, doula opinions on full spectrum and abortion work, and potential barriers and facilitators for full spectrum doula care in metro-Atlanta, Georgia.

Methods

From October 2020 to February 2022, the team recruited 20 community-based doulas with 8 who provide full spectrum services including abortion. Surveys covered demographics, doula scope of work, family planning attitudes, and abortion stigma. Survey data were analyzed using descriptive and bivariate statistics. In-depth interviews further explored those topics. They were de-identified and thematically analyzed using a semi-deductive approach.

Results

The findings are organized around five themes: (1) doulas of all kinds center reproductive autonomy; (2) abortion doulas play important roles in reproductive autonomy; (3) doulas have mixed feelings about contraceptive counseling; (4) abortion doulas provide diverse services carrying numerous benefits in a stigmatized environment; and (5) abortion doulas experience challenges including stigma but they offer solutions. All but two doulas in this study were interested in learning how to incorporate contraception and abortion services in their current scope of work, and most participants supported the role of full spectrum doulas.

Conclusion

This analysis highlights the experiences of abortion and full spectrum doulas, reactions of the larger doula community to those services, and facilitators and barriers to full spectrum doula care in a restrictive abortion setting. There are urgent needs and opportunities for full spectrum doulas to offer life-protecting services to pregnant people across the U.S. and globally. Coordination efforts for U.S. abortion care post-Roe v. Wade must include community-based doulas, who are largely open to aiding abortion clients through education, connection to care, and emotional support.

Nonpharmacological pain management interventions in medical and surgical abortion: A scoping review

AIMS

The study aimed to present a broad overview of the research conducted and to synthesize evidence of the utility of nonpharmacological interventions for pain management in medical and surgical abortions.

BACKGROUND

High-quality care for medical and surgical abortion requires pain to be managed effectively. However, women reported low satisfaction with pain management in abortion care.

DESIGN

A scoping review design was employed.

DATA SOURCES

No date limit was set. PubMed, Cochrane Library, EMBASE, Web of Science, CINAHL, PsycINFO, ProQuest and Scopus were searched in April 2021.

REVIEW METHODS

Arksey and O'Malley's framework was used. The Preferred Reporting Items for Systematic reviews and Meta-analysis extension-Scoping Reviews was followed.

RESULTS

Fifteen studies were included. The results revealed that support interventions, music therapy, acupoint stimulation and hypnotic analgesia were nonpharmacological interventions used to decrease abortion pain.

CONCLUSIONS

Clinical nurses, nurse managers and policymakers should attach full importance to the pain management in abortion and may use the study findings to guide the pain management practice.

In-person later abortion accompaniment: a feminist collective-facilitated self-care practice in Latin America

In Argentina, Chile and Ecuador, abortion at later durations of pregnancy is legally restricted. Feminist collectives in these contexts support people through self-managed medical abortion outside the healthcare system. The model of in-person abortion accompaniment represents an opportunity to examine a self-care practice that challenges and reimagines abortion provision. We formed a collaborative partnership built on a commitment to shared power and decision-making between researchers and partners. We conducted 28 key informant interviews with accompaniers in Argentina, Chile and Ecuador in 2019 about their model of in-person abortion accompaniment at later durations of pregnancy. We iteratively coded transcripts using a thematic analysis approach. Accompaniers premised their work in a feminist activist framework that understands accompaniment as addressing inequalities and expanding rights, especially for the historically marginalised. Through a detailed description of the process of in-person accompaniment, we show that the model, including the logistical considerations and security mechanisms put in place to ensure favourable abortion outcomes, emphasises peer-to-peer provision of supportive physical and emotional care of the accompanied person. In this way, it represents supported self-care through which individuals are centred as the protagonists of their own abortion, while being accompanied by feminist peers. This model of supported self-care challenges the idea that “self-care” necessarily means “solo care”, or care that happens alone. The model’s focus on peer-to-peer transfer of knowledge, providing emotional support, and centring the accompanied person not only expands access to abortion, but represents person-centred practices that could be scaled and replicated across contexts.

Pain management in outpatient surgical abortion

PURPOSE OF REVIEW

To review the current literature focusing on pain management and experiences during abortion care.

RECENT FINDINGS

Analgesic options in abortion care address pain associated with the procedure, osmotic dilator insertion, and cervical preparation. The paracervical block (PCB) is effective for pain control in first and second trimester abortions. Lower volume PCBs demonstrate non inferiority with osmotic dilator placement compared with higher volume PCBs with lower potential for toxicity. Self-administered vaginal lidocaine gel is noninferior to PCB in first trimester abortions. Preoperative oral narcotics and sedation do not reduce pain in first trimester abortions; however, the latter may reduce anxiety. For second trimester abortions, narcotics or gabapentin do not improve postoperative pain, yet up to half of patients will use narcotics if offered. Nonpharmacological methods have shown success in pain management. Music and doula support do not improve pain; however, patients would recommend these modalities, indicating some benefit that went unmeasured. Auricular acupuncture and transcutaneous electrical nerve stimulation (TENS) reduce pain and anxiety during first trimester abortions.

SUMMARY

Several modalities reduce pain during abortion care; however, pain alone does not reflect patient satisfaction. Development of multidimensional measures for pain control assessment has the potential to capture the patient's overall experience.

"Going through it together": Being accompanied by loved ones during birth and abortion

We sought to understand the meaning people who have given birth and have had an abortion ascribe to being accompanied by partners, family members and friends during these reproductive experiences. Incorporating this knowledge into clinical practice may contribute to improving the quality of these services, especially in abortion care, in which loved ones are often excluded. The study took place in Northern California in 2014. We conducted semi-structured, intensive interviews with twenty cis-women about their birth and abortion experiences and analyzed their narratives with respect to accompaniment using grounded theory. The roles of loved ones were complementary yet distinct to those of medical personnel. They were also multifaceted. Participants needed familiar individuals to bear witness, share the emotional experience and provide protection from perceived or possible harm associated with medical care. In some cases, more often in the context of abortion than childbirth, participants shielded their loved ones from emotional burdens of the reproductive process. Some pregnant people of color faced gendered racism, which also influenced their accompaniment needs. Male partners played a distinct role of upholding dominant social ideals related to pregnancy. As is commonplace in birth-related care, abortion services could be formally structured to include partners, family members and friends when desired by pregnant people to improve their experiences. Such integration should be balanced with considerations for privacy, safety and institutional resources. Working toward this goal may reduce structural abortion stigma and help alleviate pregnant people's burdens associated with reproduction.

Nonpharmacological interventions to improve the psychological well-being of women accessing abortion services and their satisfaction with care: A systematic review

How women perceive and experience abortion impacts their subsequent psychological well-being. This systematic review evaluated nonpharmacological interventions designed to support women undergoing abortion services and improve their psychological well-being and satisfaction with care. Searches were conducted in MEDLINE, CINAHL, the Cochrane Library, PsycINFO, Sociological Abstracts, Social Services Abstracts, and PTSD Pubs. All searches were limited to peer-reviewed articles published in English from January 2010 to February 2020. Two reviewers independently assessed study eligibility. Ten studies were included, involving four types of interventions: music therapy; social support; information support; and mandated waiting and counseling requirements on abortion access. Outcome measures were divided into four categories comprised of cognitive domains, emotional and psychological well-being, clinical symptoms, and satisfaction with care. However, there is limited evidence on intervention effects. Most studies report null or mixed intervention effects. Even though some positive effects on women's cognitive outcomes and satisfaction with care were seen, findings across studies were inconclusive. Findings also show that methodological limitations such as lack of theoretical basis, inadequate reporting and no power sample size calculation were apparent across studies. There is limited evidence about nonpharmacological interventions designed to improve women's satisfaction with abortion services or psychological outcomes subsequent to accessing abortion services. Well-designed interventions that meet the needs of service-users should be developed and rigorously tested.

Advances in abortion care technology and management

PURPOSE OF REVIEW

To review emerging evidence specific to abortion care, including diagnostic testing and pain management.

RECENT FINDINGS

Recent advances in abortion care include improvements in gestational age dating, Rh status testing, and pain management methods. When ultrasound technology is available, the use of crown-rump length (CRL)-based dating is more accurate up to 13 weeks and composite CRL and biometry between 13 and 14 weeks. Evidence supports using updated fetal foot length-to-gestational age reference ranges for postprocedure gestational age confirmation. Serum tests for two placental proteins, pregnancy-associated plasma protein A and a disintegrin and metalloproteinase 12, show potential for identifying pregnancies with gestational age more than 70 days. Early research using flow cytometry demonstrates that fetal RBC exposure after first-trimester uterine aspiration is insufficient to cause maternal Rh-sensitization, supporting elimination of Rh testing and anti-D-immunoglobulin provision prior to 8 weeks gestation. Recent studies exploring pain management strategies have not generated a standardized approach. Auricular acupuncture appears to be promising.

SUMMARY

Emerging data on improvements in gestational age dating and eliminating laboratory testing prior to early abortion procedures could have important implications for expanding access to early abortion care and telemedicine. Person-centered, novel pain management modalities, such as auricular acupuncture, help to improve client experience, by addressing both pain and anxiety.

Community-informed models of perinatal and reproductive health services provision: A justice-centered paradigm toward equity among Black birthing communities

Perinatal health outcomes in the United States continue to worsen, with the greatest burden of inequity falling on Black birthing communities. Despite transdisciplinary literature citing structural racism as a root cause of inequity, interventions continue to be mostly physician-centered models of perinatal and reproductive healthcare (PRH). These models prioritize individual, biomedical risk identification and stratification as solutions to achieving equity, without adequately addressing the social and structural determinants of health. The objective of this review is to: (1) examine the association between the impact of structural and obstetric racism and patient-centered access to PRH, (2) define and apply reproductive justice (RJ) as a framework to combat structural and obstetric racism in PRH, and (3) describe and demonstrate how to use an RJ lens to critically analyze physician-led and community-informed PRH models. We conclude with recommendations for building a PRH workforce whose capacity is aligned with racial equity. Institutional alignment with a RJ praxis creates opportunities for advancing PRH workforce diversification and development and improving PRH experiences and outcomes for our patients, communities, and workforce.

A Constructivist Vision of the First-Trimester Abortion Experience

How might the abortion experience look in a world without the existing regulatory constraints? This paper critically assesses the evidence about how a high-quality abortion experience might be achieved in the first trimester. There would need to be positive obligations on states in pursuance of women's reproductive rights. The onus would be on states and state actors to justify interferences and constraints upon a woman's right to terminate in the first trimester of her pregnancy. In this vision, abortion is person-centered and normalized as far as possible. High-quality information about abortion would be freely available through multiple sources and in varying formats. Whenever possible, abortion would happen in a place chosen by the woman, and in the case of medical abortion, could be self-managed with excellent clinical backup on hand should the need arise. The overarching purpose of this paper is to highlight the broader environment and framework of state obligations necessary to underpin the lived experience of abortion.

Gabapentin for Perioperative Pain Management for Uterine Aspiration: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effect of oral gabapentin in conjunction with usual oral pain management regimens of lorazepam, ibuprofen, oxycodone, and acetaminophen for surgical abortion on pain 5 minutes postprocedure.

METHODS

This was a randomized, double-blind, placebo-controlled trial of patients from 6 0/7-14 6/7 weeks of gestation scheduled to undergo surgical abortion at the Duke Family Planning Clinic. Participants were administered 600 mg of oral gabapentin compared with placebo with usual oral pain management. Pain score was assessed using a 100-mm visual analog scale, with the primary outcome being pain score 5 minutes after the procedure. The effect of gabapentin was assessed using a linear regression model controlling for baseline pain. We also measured pain perception 24 hours after the procedure. Secondary outcome measures included anxiety, side effects, and usage of opiate pain medication in the 24-hour postoperative period.

RESULTS

Out of 113 women screened for this study; 96 women were recruited, enrolled, and randomized to study treatment arm from August 2016 to June 2018. Pain at 5 minutes after the procedure was similar between the gabapentin and placebo groups ((Equation is included in full-text article.)=3.40; 95% CI -8.20 to 15.0; P=.56). Gabapentin and placebo were well tolerated, with no statistically significant difference in side effects or anxiety levels. Although prescription of opioids after the procedure was not standardized among patients, 73% of women received a short-term prescription for oxycodone. A lower percentage of women in the gabapentin group self-reported taking opioids in the 24 hours postprocedure (18% vs 47%; odds ratio 0.26; 95% CI 0.09-0.75).

CONCLUSION

The addition of gabapentin to usual oral pain management regimens with paracervical block did not reduce postoperative pain for patients undergoing outpatient surgical abortion. Although the addition of gabapentin was well tolerated and reduced oral opiate use 24 hours postprocedure, it did not affect the experience of pain during and immediately after the procedure.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02725710.

Experiences with pain of early medical abortion: qualitative results from Nepal, South Africa, and Vietnam

Background

Medical abortion (MA) has become an increasingly popular choice for women even where surgical abortion services are available. Pain is often cited by women as one of the worst aspects of the MA experience, yet we know little about women’s experience with pain management during the process, particularly in low resource settings. The aim of this study is to better understand women’s experiences of pain with MA and strategies for improving quality of care.

Methods

This qualitative study was conducted as part of a three-arm randomized, controlled trial in Nepal, Vietnam, and South Africa to investigate the effect of prophylactic pain management on pain during MA through 63 days’ gestation. We purposively sampled seven parous and seven nulliparous women with a range of reported maximum pain levels from each country, totaling 42 participants. Thematic content analysis focused on MA pain experiences and management of pain compared to menstruation, labor, and previous abortions.

Results

MA is relatively less painful compared to giving birth and relatively more painful than menstruation, based on four factors: pain intensity, duration, associated symptoms and side effects, and response to pain medications. We identified four types of pain trajectories: minimal overall pain, brief intense pain, intermittent pain, and constant pain. Compared to previous abortion experiences, MA pain was less extreme (but sometimes longer in duration), more private, and less frightening. There were no distinct trends in pain trajectories by treatment group, parity, or country. Methods of coping with pain in MA and menstruation are similar in each respective country context, and use of analgesics was relatively uncommon. The majority of respondents reported that counseling about pain management before the abortion and support during the abortion process helped ease their pain and emotional stress.

Conclusions

Pain management during MA is increasingly essential to ensuring quality abortion care in light of the growing proportion of abortions completed with medication around the world. Incorporating a discussion about pain expectations and pain management strategies into pre-MA counseling and providing access to information and support during the MA process could improve the quality of care and experiences of MA patients.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12613000017729, registered January 8, 2013.

Experiences of Community Doulas Working with Low-Income, African American Mothers

Purpose: The aim of this study was to learn from doulas the components of their services that might best serve low-income, African American (AA) women and to show the significance of doulas in helping these women have healthy, positive, birth experiences.

Methods: Ten doulas were recruited from a local community doula program and through word-of-mouth referrals from participants and completed in-depth interviews. Interviews were transcribed verbatim and analyzed using Atlas.ti software to identify emerging themes. Thematic saturation was achieved in interviews.

Results: Several themes emerged from the interviews including: (1) The influence of similarities of race, culture, and lived experience on doula care; (2) How doulas often provide birthing persons with support and resources beyond birth; and (3) How doulas recognize the institutional biases that exist in the health care system and try to mediate their effect on birthing persons.

Conclusions: These themes highlight how doulas can support birthing persons to mitigate the negative effects of social determinants of health, specifically racism and classism, and highlight potential avenues for doulas to consider when working with birthing persons who have low income and are AA.

Expectant Mothers' Experiences with Lay Doulas in Maternity Units of Hospitals in Impoverished Areas of Iran: A Qualitative Study

BACKGROUND

Qualitative research methods can help investigators ascertain the depth of people's needs and their perceptions. This study was designed to describe mothers' experiences and perceptions of lay doula services during labor and delivery.

MATERIALS AND METHODS

This study was conducted using a qualitative approach and conventional procedures of content analysis. The participants consisted of 13 nulliparous women at three hospitals affiliated with Zahedan University of Medical Sciences in 2016. Data were collected using face-to-face semi-structured interviews. Purposive sampling continued until data saturation was ensured. All interviews were tape-recorded and transcribed in verbatim.

RESULTS

Participants' experiences were categorized into 11 subthemes and five major themes including (1) achieving self-esteem and empowerment, (2) more trust in God, (3) promoting mental health of the mother, (4) willingness toward normal childbirth, and (5) lay doula as a listener and perceiver.

CONCLUSIONS

In our study, the mothers evaluated the presence of a lay companion as an effective helper during childbirth and someone who promoted a remarkable willing toward normal childbirth. Healthcare professionals must be cognizant of the needs, values, beliefs, preferences, and emotional well-being of disadvantaged women during labor and delivery in poverty-stricken areas of Iran. Also, this study highlighted that it is important to include the perspective of support persons (such as husbands) in research design of future studies.

Integrating Doulas Into First-Trimester Abortion Care: Physician, Clinic Staff, and Doula Experiences

INTRODUCTION

Balancing the need to provide individual support for patients and the need for an efficient clinic can be challenging in the abortion setting. This study explores physician, staff, and specially trained abortion doula perspectives on doula support, one approach to patient support.

METHODS

We conducted separate focus groups with physicians, staff members, and doulas from a high-volume, first-trimester aspiration abortion clinic with a newly established volunteer abortion doula program. Focus groups explored 1) abortion doula training, 2) program implementation, 3) program benefits, and 4) opportunities for improvement. Interviews were transcribed and computer-assisted content analysis was performed; salient findings are presented.

RESULTS

Five physicians, 5 staff members, and 4 abortion doulas participated in separate focus group discussions. Doulas drew on both their prior personal skills and experiences in addition to their abortion doula training to provide women with support at the time of abortion. Having doulas in the clinic to assist with women's emotional needs allowed physicians and staff to focus on technical aspects of the procedure. In turn, both physicians and staff believed that introducing doulas resulted in more patient-centered care. Although staff did not experience challenges to integrating doulas, physicians and doulas experienced initial challenges in incorporating doula support into the clinical flow. Staff and doulas reported exchanging skills and techniques that they subsequently used in their interactions with patients.

DISCUSSION

Physicians, clinic staff, and doulas perceive abortion doula support as an approach to provide more patient-centered care in a high-volume aspiration abortion clinic.

Doulas for surgical management of miscarriage and abortion: a randomized controlled trial

BACKGROUND

Women undergoing office-based surgical management of a failed or undesired pregnancy often report fear of pain and anxiety pertaining to the procedure. Doulas are trained to specifically address women's physical and emotional needs in obstetric care, and recently have extended their practice to support women through all pregnancy outcomes.

OBJECTIVE

We sought to evaluate the impact of doulas on patients' physical and emotional responses to surgical management of a first-trimester failed or undesired pregnancy under local anesthesia.

STUDY DESIGN

In this nonblinded, randomized trial, women received doula support or routine care during office uterine aspiration for failed or unwanted pregnancies in the first trimester. The primary outcome was pain measured on a 100-mm visual analog scale. Secondary outcomes included satisfaction, emotional state, sense of personal empowerment, and ability to cope immediately and 1 month after the procedure, as well as medical assistants' assessment of the doula's utility. A sample size of 35 per group (N = 70) was planned to detect a 20% difference in pain score.

RESULTS

From April 2014 through January 2015, 129 women were screened and 70 were randomized. The 2 study groups were similar on all baseline characteristics. The primary outcome was not different between the doula and control groups (pain score 70.7 ± 24.5 mm vs 59.7 ± 32.5 mm, P = .11, respectively), even after controlling for procedure indication (P = .20). While 97% of women who received doula support reported this helped with their experience, there was no statistically significant difference in satisfaction, emotional response, sense of empowerment, or perceived ability to cope between the 2 groups of women immediately following or 1 month after the procedure. Of all study participants, 72% reported that it was important to have someone with them during the procedure, but that the support person did not have to be a doula.

CONCLUSION

Doula support during office uterine aspiration for failed or undesired pregnancies is well received and desired by women undergoing this procedure despite no significant effect on physical comfort or emotional responses related to the procedure. This may suggest an unmet psychosocial need for procedure-related support among such women.

Women's experiences with doula support during first-trimester surgical abortion: a qualitative study

OBJECTIVE

To explore how doula support influences women's experiences with first-trimester surgical abortion.

STUDY DESIGN

We conducted semistructured interviews with women given the option to receive doula support during first-trimester surgical abortion in a clinic that uses local anesthesia and does not routinely allow support people to be present during procedures. Dimensions explored included (a) reasons women did or did not choose doula support; (b) key aspects of the doula interaction; and (c) future directions for doula support in abortion care. Interviews were transcribed, and computer-assisted content analysis was performed; salient themes are presented.

RESULTS

Thirty women were interviewed: 19 received and 11 did not receive doula support. Reasons to accept doula support included (a) wanting companionship during the procedure and (b) being concerned about the procedure. Reasons to decline doula support included (a) a sense of stoicism and desiring privacy or (b) not wanting to add emotion to this event. Women who received doula support universally reported positive experiences with the verbal and physical techniques used by doulas during the procedure, and most women who declined doula support subsequently regretted not having a doula. Many women endorsed additional roles for doulas in abortion care, including addressing informational and emotional needs before and after the procedure.

CONCLUSION

Women receiving first-trimester surgical abortion in this setting value doula support at the time of the procedure. This intervention has the potential to be further developed to help women address pre- and postabortion informational and emotional needs.

IMPLICATIONS

In a setting that does not allow family or friends to be present during the abortion procedure, women highly valued the presence of trained abortion doulas. This study speaks to the importance of providing support to women during abortion care. Developing a volunteer doula service is one approach to addressing this need, especially in clinics that otherwise do not permit support people in the procedure room or for women who do not have a support person and desire one.