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Purcell C, Newton VL, Bloomer F, Hoggart L. Foregrounding pain in self-managed early medication abortion: a qualitative study. BMJ SEXUAL & REPRODUCTIVE HEALTH 2024:bmjsrh-2023-202198. [PMID: 38429082 DOI: 10.1136/bmjsrh-2023-202198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/13/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE To explore experiences of pain in the context of early medical abortion (EMA) in the UK and to guide best practice around anticipatory guidance on pain. METHODS From late 2020 to early 2021, we recruited individuals from across the UK who had undergone abortion during the COVID-19 pandemic to participate in in-depth, semi-structured telephone interviews. A storytelling approach was used and data were analysed thematically using NVivo 12 software. RESULTS Focused coding and thematic analysis addressed accounts of pain, which were prominent in many interviews. We constructed the following subthemes: expected pain is manageable for some; the problem with unexpected pain; pain (co)produces fear; and problematising 'period-like pain'. The key issue which our analysis draws out is that while EMA pain experience might vary, for some it may be much worse than anticipated. Moreover, the common trope of likening it to 'period pain' can be misleading and a source of additional uncertainty at a potentially already challenging time. CONCLUSIONS For some individuals, pain experienced in EMA will be severe and/or worse than expected. Insufficient preparation for pain can result in extremely negative experiences of EMA. Alongside development of improved analgesia, improvements should be made to anticipatory guidance on pain, particularly for those self-manging EMA at home. Framings of 'period-like pain' do not clarify expectations and should be avoided.
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Affiliation(s)
- Carrie Purcell
- Faculty of Wellbeing, Education and Language Studies, The Open University in Scotland, Edinburgh, UK
| | - Victoria Louise Newton
- Faculty of Wellbeing, Education and Language Studies, The Open University, Milton Keynes, UK
| | - Fiona Bloomer
- School of Applied Social and Policy Sciences, Ulster University, Belfast, UK
| | - Lesley Hoggart
- Faculty of Wellbeing, Education and Language Studies, The Open University, Milton Keynes, UK
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Chekol BM, McCaffrey S, Dijkerman S, Acre V, Biru DD, Mehary AB, Muluye S. Person-centered abortion care in public health facilities across four regions of Ethiopia: a cross-sectional quantitative study of client experiences. FRONTIERS IN REPRODUCTIVE HEALTH 2024; 6:1331682. [PMID: 39296346 PMCID: PMC11408316 DOI: 10.3389/frph.2024.1331682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 08/13/2024] [Indexed: 09/21/2024] Open
Abstract
Introduction Ethiopia has made remarkable progress in expanding access to and provision of comprehensive abortion care. However, complications due to unsafe abortion persist. As efforts to increase quality of comprehensive abortion care continue, evaluating service quality is critical. Although "women-centered" abortion care is a central component of Ethiopia's technical guidelines for safe abortion, research has mostly focused on access to care, availability of services, and meeting clinical criteria, rather than examining service quality from abortion clients' perspectives. This study assesses the quality of comprehensive abortion care (CAC) in public health facilities, from clients' perspectives, in four regions of Ethiopia to examine how person-centered care differs based on facility and service characteristics. Methods We conducted 1,870 client exit surveys in 2018 using structured questionnaires with women who received induced abortion or postabortion care services from 76 public health facilities across four regions: Tigray, Amhara, Oromia, and Southern Nations, Nationalities, and People's. We operationalized person-centered care by mapping 30 indicators of quality to five of the six domains in the Person-Centered Care Framework for Reproductive Health Equity developed by Sudhinaraset and colleagues (2017): dignity & respect; autonomy; communication & supportive care; trust, privacy, and confidentiality; and health facility environment. We calculated descriptive, bivariate, and multivariable statistics to examine associations between service characteristics and person-centered care. Results CAC clients reported high levels of person-centered care, with exceptionally positive experiences for outcomes in the dignity and respect and trust, privacy, and confidentiality domains. However, there was notable room for improving client experiences across three domains: autonomy, communication and supportive care, and health facility environment. Client-reported quality outcomes differed significantly by diagnosis (induced or postabortion care), region, health facility type, and procedure type. Clients in Amhara, clients at tertiary and primary hospitals, and clients who received postabortion care reported lower levels of person-centered care. Discussion The positive experiences reported by comprehensive abortion care clients bolster evidence of the impact of the Ethiopian government's strategy to increase abortion access in the public health sector. However, notable disparities exist for key subgroups, particularly those seeking postabortion care and people visiting tertiary and primary hospitals. Quality improvement efforts should concentrate on improving abortion clients' autonomy, communication and supportive care, and the health facility environment. The Ethiopian Ministry of Health and its partners must dedicate resources to improve postabortion care quality, integration of reproductive health services within CAC, and pain management for MA clients as vital interventions.
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Affiliation(s)
| | - Sarah McCaffrey
- Mailman School of Public Health, Columbia University, New York, NY, United States
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Geta T, Israel E, Kebede C. Client satisfaction with abortion care service and its associated factors among women in Ethiopia: a systematic review and meta-analysis. BMC Womens Health 2024; 24:287. [PMID: 38745273 PMCID: PMC11091994 DOI: 10.1186/s12905-024-03139-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 05/08/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND The client's satisfaction after abortion care is the key to sustaining abortion care and increasing the health status of those who had complications from abortion. Nevertheless, research conducted in Ethiopia stated that the major problem is the need for post-abortion care for females. One of the ways to improve the qualities involved in post abortion care and decrease the mortality and morbidity rates caused by unsafe abortion is by ensuring client satisfaction with abortion care. Strategy making and policy formulation based on systematic review take on the highest priority in developing countries. However, although some independent studies had been carried out in Ethiopia, their findings might not have been representative and conclusive. The main purpose of this systematic review and meta-analysis article is to establish the proportion of abortion clients who are satisfied with their abortion care and the factors that contribute to such satisfaction among clients in Ethiopia. METHODS AND MATERIALS Only published articles were considered in this review. The main databases included Medline/Pubmed, Web of Science, Embase, Cinael, Med Nar, Google Scholar, Scopus, the Ethiopian University Repository Online, and the Cochrane Library. The review includes cross-sectional studies that meet the requirements and were written in English. A random effects model was used to calculate the pooled prevalence of client satisfaction with abortion care. The study heterogeneity was tested using Cochrane Q-Static and I2. Publication bias was checked using the Eggers test and funnel plot. PRISMA was used to select and direct the selection of articles for this review. Statistical analyses were conducted using STATA version 14. RESULT A review of ten studies comprised 2740 women. In summary, the pooled prevalence of client's satisfaction with abortion care in Ethiopia was 56.13% [95% CI (42.35; 69.91), I2 = 99.1%, p < 0.001]. In terms of subgroup analysis, Gambella had the highest prevalence of client satisfaction with abortion care at 87.40% [95% CI: 82.38 and 91.82]. However, Amhara had the lowest: 25.00% [95% CI: 21.59, 28.41]. The review also found that client satisfaction with abortion care had a statistical correlation with the type of procedure [OR: 0.25, CI [0.07, 0.42], I2: 76.9%, p-value: 0.041] and the participant's education level [OR: 0.29, CI [0.09, 0.48], I2: 80.4%, p-value: 0.006]. CONCLUSION This review found that 56% of Ethiopian women were satisfied with their abortion care. Since this requires a boost to the quality of abortion care in the health facility, understanding women's expectations and perceptions, training of health care providers, and strict monitoring of the quality of abortion care services by stakeholders like the Ethiopian government, non-governmental organizations, and high-level management of the health facility would help to improve the level of women's satisfaction with abortion care. Those factors, namely, the type of method to use for the patient and women's educational level, should be changed through improving awareness among the patients about what procedure to conduct and the health education provided to women about abortion care.
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Affiliation(s)
- Temesgen Geta
- School of nursing, Wolaita Sodo University, Wolaita, Ethiopia.
| | - Eskinder Israel
- School of Public Health, Wolaita Sodo University, Wolaita, Ethiopia
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Harrison L, Puri M, Greene Foster D, Karkia S, Diamond-Smith NG. Predictors and experiences of seeking abortion services from pharmacies in Nepal. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003144. [PMID: 38722984 PMCID: PMC11081245 DOI: 10.1371/journal.pgph.0003144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 04/03/2024] [Indexed: 05/12/2024]
Abstract
Abortion was legalized in Nepal in 2002; however, despite evidence of safety and quality provision of medical abortion (MA) pills by pharmacies in Nepal and elsewhere, it is still not legal for pharmacists to provide medication abortion in Nepal. However, pharmacies often do provide MA, but little is known about who seeks abortions from pharmacies and their experiences and outcomes. The purpose of this study is to understand the experiences of women seeking MA from a pharmacy, abortion complications experienced, and predictors for denial of MA. Data was collected from women seeking MA from four pharmacies in two districts of Nepal in 2021-2022. Data was collected at baseline (N = 153) and 6 weeks later (N = 138). Using descriptive results and multi-variable regression models, we explore differences between women who received and did not receive MA and predictors of denial of services. Most women requesting such pills received MA (78%), with those who were denied most commonly reporting denial due to the provider saying they were too far along. There were few socio-demographic differences between groups, with the exception of education and gestational age. Women reported receiving information on how to take pills and what to do about side effects. Just under half (45%) of women who took pills reported no adverse symptoms after taking them and only 13% sought care. Most women seeking MA from pharmacists in Nepal are receiving services, information, and having few post-abortion symptoms. This study expands the previous limited research on pharmacy provision of MA in Nepal using a unique dataset that recruits women at the time of abortion seeking and follows them over time, overcoming potential biases present in other study designs. This suggests that expansion of the law to allow pharmacy distribution would increase accessibility and reflect current practice.
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Affiliation(s)
- Leila Harrison
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
| | - Mahesh Puri
- Center for Research on Environment, Health and Population Activities (CREHPA), Kathmandu, Nepal
| | - Diana Greene Foster
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Sunita Karkia
- Center for Research on Environment, Health and Population Activities (CREHPA), Kathmandu, Nepal
| | - Nadia G. Diamond-Smith
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
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Taghinejadi N, McCulloch H, Krassowski M, McInnes-Dean A, Whitehouse KC, Lohr PA. Opt-in versus universal codeine provision for medical abortion up to 10 weeks of gestation at British Pregnancy Advisory Service: a cross-sectional evaluation. BMJ SEXUAL & REPRODUCTIVE HEALTH 2024; 50:114-121. [PMID: 38296263 DOI: 10.1136/bmjsrh-2023-201893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 11/29/2023] [Indexed: 04/13/2024]
Abstract
OBJECTIVE To assess patient experiences of pain management during medical abortion up to 10 weeks' gestation with opt-in versus universal codeine provision. METHODS We invited patients who underwent medical abortion up to 10 weeks of gestation to participate in an online, anonymous, English-language survey from November 2021 to March 2022. We performed ordinal regression analyses to compare satisfaction with pain management (5-point Likert scale) and maximum abortion pain score (11-point numerical rating scale) in the opt-in versus universal codeine provision groups. RESULTS Of 11 906 patients invited to participate, 1625 (13.6%) completed the survey. Participants reported a mean maximum pain score of 6.8±2.2. A total of 1149 participants (70.7%) reported using codeine for pain management during their abortion. Participants in the opt-in codeine provision group were significantly more likely to be satisfied with their pain management than those in the universal group (aOR 1.48, 95% CI 1.12 to 1.96, p<0.01). Maximum abortion pain scores were lower on average among the opt-in codeine provision group (OR 0.80, 95% CI 0.66 to 0.96, p=0.02); however, this association was not statistically significant in the model adjusted for covariates (aOR 0.85, 95% CI 0.70 to 1.03, p=0.09). CONCLUSION Our findings suggest that patients have a better experience with pain management during medical abortion when able to opt-in to codeine provision following counselling versus receiving this medication routinely.
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Affiliation(s)
- Neda Taghinejadi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Hannah McCulloch
- Centre for Reproductive Research & Communication, British Pregnancy Advisory Service, London, UK
| | - Michał Krassowski
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | - Amelia McInnes-Dean
- Centre for Reproductive Research & Communication, British Pregnancy Advisory Service, London, UK
| | - Katherine C Whitehouse
- Centre for Reproductive Research & Communication, British Pregnancy Advisory Service, London, UK
| | - Patricia A Lohr
- Centre for Reproductive Research & Communication, British Pregnancy Advisory Service, London, UK
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Johnson DM, Ramaswamy S, Gomperts R. Experiences with misoprostol-only used for self-managed abortion and acquired from an online or retail pharmacy in the United States. Contraception 2024; 131:110345. [PMID: 38049047 DOI: 10.1016/j.contraception.2023.110345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 11/19/2023] [Accepted: 11/30/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVES This study aimed to understand individual experiences with medication abortion using misoprostol-only among people living in the United States. STUDY DESIGN We conducted 31 semistructured anonymous in-depth interviews with individuals who used misoprostol-only for self-managed medication abortion. Participants were recruited from Aid Access, an online telemedicine organization that provided prescriptions for misoprostol to eligible people in all 50 states in May and June 2020 when a combined mifepristone and misoprostol regimen was unavailable. We coded transcripts with a flexible coding approach and focused on perceptions and experiences with use. RESULTS Participants were knowledgeable about misoprostol. Previous abortion experiences shaped perceptions of misoprostol-only by allowing comparison to the mifepristone and misoprostol regimen. Most participants expressed an unwavering desire for an effective abortion method, regardless of the medications or regimen. Individual physical experiences with misoprostol, including bleeding, cramping, nausea, and diarrhea, varied in intensity and duration. Participants proactively managed symptoms with self-care strategies and drew extensively from their prior experiences with menstruation, miscarriage, abortion, and childbirth. Clear instructions and information on potential complications and what to expect throughout the abortion fostered a sense of preparedness, and personalized interactions with an online help desk brought comfort. CONCLUSIONS Misoprostol offered an essential abortion method for study participants. This regimen was physically challenging for some, and there is potentially a greater need for communication and support for individuals using misoprostol-only regimens. Prior reproductive experiences informed participant's knowledge, preparedness, pain management, and ability to both recognize and manage potential complications. IMPLICATIONS As restrictions on mifepristone continue, more people may use misoprostol-only regimens. All regimens can be supported with detailed instructions, clear expectations, information on signs of potential complications, and personalized support. To achieve reproductive autonomy, people must have access to a range of abortion care options that meet their needs.
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Affiliation(s)
- Dana M Johnson
- Lyndon B. Johnson School of Public Affairs, The University of Texas at Austin, Austin, TX, United States.
| | - Sruthi Ramaswamy
- McKetta Department of Chemical Engineering, The University of Texas at Austin, Austin, TX, United States
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Mifepristone: A Safe Method of Medical Abortion and Self-Managed Medical Abortion in the Post-Roe Era. Am J Ther 2022; 29:e534-e543. [PMID: 35994387 DOI: 10.1097/mjt.0000000000001559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The U.S. Supreme Court's Dobbs v. Jackson Women's Health Organization decision on June 24, 2022 effectively overturned federal constitutional protections for abortion that have existed since 1973 and returned jurisdiction to the states. Several states implemented abortion bans, some of which banned abortion after 6 weeks and others that permit abortion under limited exceptions, such as if the health or the life of the woman is in danger. Other states introduced bills that define life as beginning at fertilization. As a result of these new and proposed laws, the future availability of mifepristone, one of two drugs used for medical abortion in the United States, has become the topic of intense debate and speculation. AREAS OF UNCERTAINTY Although its safety and effectiveness has been confirmed by many studies, the use of mifepristone has been politicized regularly since its approval. Areas of future study include mifepristone for induction termination and fetal demise in the third trimester and the management of leiomyoma. DATA SOURCES PubMed, Society of Family Planning, American College of Obstetrician and Gynecologists, the World Health Organization. THERAPEUTIC ADVANCES The use of no-touch medical abortion, which entails providing a medical abortion via a telehealth platform without a screening ultrasound or bloodwork, expanded during the COVID-19 pandemic, and studies have confirmed its safety. With the Dobbs decision, legal abortion will be less accessible and, consequently, self-managed abortion with mifepristone and misoprostol will become more prevalent. CONCLUSIONS Mifepristone and misoprostol are extremely safe medications with many applications. In the current changing political climate, physicians and pregnancy-capable individuals must have access to these medications.
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Qian J, Sun S, Wang M, Yu X. Nonpharmacological pain management interventions in medical and surgical abortion: A scoping review. Int J Nurs Pract 2022; 29:e13056. [PMID: 35373419 DOI: 10.1111/ijn.13056] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/14/2022] [Accepted: 03/22/2022] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Jialu Qian
- Zhejiang University School of Medicine Hangzhou China
- Department of Obstetrics, Women's Hospital School of Medicine Zhejiang University Hangzhou China
| | - Shiwen Sun
- Department of Obstetrics, Women's Hospital School of Medicine Zhejiang University Hangzhou China
| | - Man Wang
- Zhejiang University School of Medicine Hangzhou China
- Department of Obstetrics, Women's Hospital School of Medicine Zhejiang University Hangzhou China
| | - Xiaoyan Yu
- Department of Obstetrics, Women's Hospital School of Medicine Zhejiang University Hangzhou China
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Clients' perceptions of the quality of post-abortion care in eight health facilities in Dakar, Senegal. J Biosoc Sci 2021; 54:760-775. [PMID: 34325755 DOI: 10.1017/s0021932021000365] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Post-abortion care (PAC) integrates elements that are vital for women's survival after abortion complications and their ability to meet their subsequent fertility intentions. Currently, the utilization of PAC among women in need remains too low, particularly in settings where unsafe abortion is an appreciable cause of maternal mortality. Interventions have aimed at addressing unmet need; however, these still require information on the extent to which women value different aspects of PAC. This paper presents such evidence from Dakar, Senegal. Exit interviews with 729 PAC clients in 2018 at eight health facilities obtained information on patient characteristics, content of services received and women's perceptions of the quality of care, both overall and according to subject-specific domains. These domains reflect aspects of PAC that are relevant to clients' satisfaction: accessibility, facility environment, information and counselling, family planning, provider technical competence and readiness and client-staff interaction. Ordinal logistic regression models were estimated to identify factors that were associated with women's rating of overall quality of care (on a scale of 1 to 5, 1 being lowest). Predictors that were significantly associated with the outcome were used in a multivariate ordinal logistic regression model that estimated the probability of positive differences in the outcome associated with women's classification of each predictor. Women reported a mean rating of 3.7 for overall quality of care. The lowest domain-specific rating was for quality of information and counselling (mean=2.4) and the highest was for client-staff interaction (mean=3.8). Factors associated with clients' higher odds of being more satisfied with PAC were: physical comfort during the procedure, recall of counselling on treatment procedure, privacy, perceived availability of supplies and medicines, facility admission process, facility cleanliness, waiting time, clarity of counselling and access to different contraceptive methods. Interventions that target these factors may improve the utilization of PAC in Dakar, Senegal.
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Leziak K, Yee LM, Grobman WA, Badreldin N. Patient Experience with Postpartum Pain Management in the Face of the Opioid Crisis. J Midwifery Womens Health 2021; 66:203-210. [PMID: 33661564 DOI: 10.1111/jmwh.13212] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/26/2020] [Accepted: 10/30/2020] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Professional societies have urged providers to reduce opioid use for pain management. Accordingly, the objective of this study was to assess patient experiences related to postpartum pain management in an effort to better understand potential paths to achieve such a reduction. METHODS This is a planned secondary analysis of a prospective observational study of opioid use following birth. In the primary study, women who received opioids as inpatients were queried about their pain management, including questions about pain experience, pain satisfaction, perceived areas for practice improvement, and the opportunity to leave additional comments. Participants who were prescribed opioids upon discharge completed postdischarge surveys with a similar opportunity for qualitative input. Data were analyzed using the constant comparative method to identify themes and subthemes. RESULTS Of the 493 women enrolled in the primary analysis, 125 provided qualitative data. Three overarching themes regarding pain management were identified: positive experiences (n = 22), negative experiences (n = 19), and beliefs and preferences on opioid use and pain management (n = 28). Women with positive experiences reported satisfaction with timely pain medication administration and appreciation of open dialogue with their care team. In contrast, several negative experiences centered on tardy administration of pain medications, resulting in increased pain. Patients also perceived judgment, accusation, and excessive lecturing by staff when requesting opioid medications. Finally, participants expressed the necessity for opioids for postpartum pain management, as well as their desires for limiting opioid use, improved options for multimodal pain management, and increased communication with providers about pain regimens. DISCUSSION Understanding women's perspectives and experiences regarding postpartum pain control is essential to improving care. Amid growing research on the role of maternity care providers in addressing the opioid crisis, women's voices are rarely solicited. These findings stress the importance of open and frequent dialogue between patients and providers and a need for multimodal pain management options.
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Affiliation(s)
- Karolina Leziak
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Lynn M Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - William A Grobman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Nevert Badreldin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
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Dragoman MV, Grossman D, Nguyen MH, Habib N, Kapp N, Tamang A, Bessenaar T, Duong LD, Gautam J, Yoko JL, Hong M, Gulmezoglu M. Two prophylactic pain management regimens for medical abortion ≤63 days' gestation with mifepristone and misoprostol: A multicenter, randomized, placebo-controlled trial. Contraception 2021; 103:163-170. [PMID: 33451721 DOI: 10.1016/j.contraception.2020.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 12/08/2020] [Accepted: 12/11/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine if either prophylactic tramadol 50 mg or ibuprofen 400 mg/metoclopramide 10 mg result in lower maximal pain compared to placebo in women ≤63 days' gestation having a mifepristone-misoprostol medical abortion. STUDY DESIGN We conducted a randomized, placebo-controlled trial in Nepal, South Africa, and Vietnam. Participants seeking medical abortion received active treatment or placebo, taken at time of misoprostol and repeated 4 hours later. All had access to additional analgesia. The primary outcome was mean maximum pain score within 8 hours. Participants self-assessed maximum pain using an 11-point numeric rating scale recorded in paper diaries; we analyzed these data using intention-to-treat analysis. Secondary outcomes included use of additional analgesia, side effects, and satisfaction. RESULTS We enrolled 563 patients between June 2016 and October 2017; 5 participants failed to follow up. Mean adjusted maximum pain scores within 8 hours in both active arms were lower than placebo (tramadol: n = 188, 6.78 (95% confidence interval [CI] 6.46, 7.11); ibuprofen/metoclopramide: n = 187, 6.43 (95% CI 6.10, 6.75); placebo: n = 188, 7.42 (95% CI 7.10, 7.74); p = 0.0001). Additional analgesia was used by 97 (52.2%) participants in the tramadol group, 80 (43.0%) in the ibuprofen/metoclopramide group, and 103 (55.7%) in the placebo group, p = 0.04. More dizziness (p = 0.004), headache (p = 0.03), and vomiting (p < 0.001) occurred in the tramadol group. More participants reported experienced pain was the same or less than expected in the ibuprofen/metoclopramide group (p = 0.05); overall abortion satisfaction did not differ by group (p = 0.44). CONCLUSIONS Compared with placebo, tramadol or ibuprofen/metoclopramide co-administered with misoprostol and repeated 4 h later resulted in lower mean maximum pain scores that failed to achieve clinical significance. Women who received ibuprofen/metoclopramide were least likely to use additional analgesia and reported fewer side effects. IMPLICATIONS Given that tramadol, ibuprofen, and metoclopramide are inexpensive, globally available; and, ibuprofen and metoclopramide are included on the World Health Organization Essential Medicines List, these medicines could be considered for prophylactic pain management during medical abortion.
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Affiliation(s)
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, Oakland, CA, United States.
| | - My Huong Nguyen
- Department of Reproductive Health and Research, World Health Organization, UNFP/UNDP/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Geneva, Switzerland
| | - Ndema Habib
- Department of Reproductive Health and Research, World Health Organization, UNFP/UNDP/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Geneva, Switzerland
| | | | - Anand Tamang
- Center for Environment Health and Population Activities (CREHPA), Kathmandu, Nepal
| | | | - Lan Dung Duong
- National Hospital for Obstetrics and Gynecology, Hanoi, Vietnam
| | | | | | - Minh Hong
- National Hospital for Obstetrics and Gynecology, Hanoi, Vietnam
| | - Metin Gulmezoglu
- Department of Reproductive Health and Research, World Health Organization, UNFP/UNDP/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Geneva, Switzerland
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