Percent of women receiving postabortion care services who receive pain medication prior to the uterine evacuation procedure
Of those women receiving either triage, stabilization, or emergency treatment services for complications related to miscarriage or unsafe abortion during the past year, the percentage of women who received pain medication (local anesthetics, analgesics, sedatives, or some combination of these three) prior to the uterine evacuation procedure. If possible, evaluators should disaggregate clients by the following age ranges: 10-14, 15-19, and 20-24.
This indicator is calculated as:
(Number of women who received pain medication prior to the uterine evacuation procedure/ Total number of women receiving postabortion care (PAC) services)x 100
Counts of women presenting to a health facility (private office, health center, or hospital) for emergency treatment of abortion-related complications during a one-year period and who received pain medication
Special studies or service statistics from health facilities providing triage, stabilization, treatment, and/or referral. If possible, evaluators should disaggregate clients by those 25 years and older and youth (≤ 24).
Note: In hospitals in developing countries, treatment of abortion complications may be performed in many different locations within the facility, such as the gynecological ward, emergency room, or operating room; data collection should therefore include encounters from all locations.
The goal of pain management during PAC is to help women remain as comfortable as possible while minimizing medication-induced risks and side effects. A combination of patient education, verbal support, oral medications, paracervical block and gentle operative techniques provides effective pain relief for most women (Ipas, 2009; WHO 2003). A prospective longitudinal study from 1990–1991 conducted in Harare, Zimbabwe, found that 38 percent of the 834 women treated with manual vacuum aspiration (MVA) for incomplete abortion reported experiencing severe pain during the procedure, but virtually all MVA patients (93.6 percent) received no pain medication (Mahomed et al., 1994). Therefore, the administration of pain medication prior to a PAC procedure to alleviate the woman’s anxiety and discomfort is a critical element of quality of care.
Pain has both physiological and psychological aspects. Adequate pain management requires medication for physiological pain and counseling for the psychological aspects of pain. This indicator assesses the administration of medication for physiological pain. “Physiologically, there are two types of pain for MVA patients: the deep, intense pain which accompanies the cervical dilation and stimulation of the internal cervical os and a diffuse lower abdominal pain with cramping from the movement of the uterus” (Solo, 2000: 45, 46, 48). Three types of drugs, either singly or in combination, are used to manage pain during abortion: analgesics, which alleviate the sensation of pain; tranquillizers, which reduce anxiety; and anesthetics, which numb physical sensation. In most cases, analgesics, local anesthesia and/or mild sedation supplemented by verbal support and reassurance, are sufficient (WHO, 2012). However, counseling should not be seen as a replacement for alleviation of pain.
As mentioned above, pain management also requires counseling, which this indicator does not address. There may be instances where the provider understood that pain medication should be administered and intended to use it but was unable to due to lack of available drugs. There may be other instances where a provider administers pain medication, but under- or over-doses due to rationing, inadequate training and/or skills, or the personal belief that women who have induced an abortion should feel pain as a form of punishment for their actions. In these cases, the PAC client may have received pain medication, but not in compliance with quality of care guidelines.
quality, postabortion care
USAID Postabortion Care Working Group. “What Works: A Policy and Program Guide to the Evidence on Postabortion Care”. February 2007.
Castleman L, Mann C. “Manual Vacuum Aspiration (MVA) for Uterine Evacuation: Pain Management”. Ipas, 2009.
Mahomed et al. A comparison of manual vacuum aspiration (MVA) and sharp curettage in the management of incomplete abortion, International Journal of Gynecology & Obstetrics, Volume 46, Issue 1, July 1994.
Solo J. Easing the pain: Pain management in the treatment of incomplete abortion, Reproductive Health Matters, Volume 8, Issue 15, May 2000.
“Safe abortion: technical and policy guidance for health systems (2nd ed.)”, WHO, Geneva, 2012.