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Pain and distress during abortion Nancy Wells DNSc, RN
a
a
Strong Memorial Hospital and Pain Treatment Center , University of Rochester , Rochester, New York Published online: 14 Aug 2009.
To cite this article: Nancy Wells DNSc, RN (1991) Pain and distress during abortion, Health Care for Women International, 12:3, 293-302, DOI: 10.1080/07399339109515952 To link to this article: http://dx.doi.org/10.1080/07399339109515952
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
PAIN AND DISTRESS DURING ABORTION Nancy Wells, DNSc, RN
Downloaded by [University of Auckland Library] at 16:30 25 February 2015
Strong Memorial Hospital and Pain Treatment Center, University of Rochester, Rochester, New York
Although there has been recent emphasis on the long-term effects of abortion on women, the distressing aspects of the procedure itself are seldom addressed. The pain and distress experienced by 35 women undergoing first-trimester abortion were addressed. The quality and intensity of pain were measured using the McGill Pain Questionnaire (MPQ) and a pain intensity visual analog scale (VAS). Distress measures included a VAS, state anxiety, observation of behavior, and observer-rated distress. The women reported elevated levels of state anxiety before the abortion and pain and distress during the procedure. The pattern of verbal descriptors on the MPQ was comparable to previously reported descriptors of abor. tion, labor, and menstrual pain. The MPQ dimension scores did not differ by type of anesthesia received. Findings indicate that firsttrimester abortion is a painful and distressing medical procedure and support the use of the MPQ as a measure of the character and intensity of the pain experienced.
First-trimester abortion is a common medical procedure (Tietze, 1983). The psychological effects of abortion have been frequently studied (Adler, 1975; Cohen & Roth, 1984). However, less emphasis has been placed on the pain and distress associated with abortion (Bracken, 1978; Smith, Stubblefield, Chirchirillo, & McCarthy, 1979). These two issues—pain and distress experienced during abortion—are addressed here.
This study was completed with support from National Research Service Award 5 F31 NR05928 from the National Center for Nursing Research and from the Robert Wood Johnson Foundation. The opinions and conclusions of the author do not necessarily represent the views of the funding agencies. The assistance of Man- Derby, MS, MFH, Gcraldine Padilla, PhD, and the staff at Preterm Reproductive Health Services is acknowledged. Health Care for Women International, 12:293-302, 1991 Copyright © 1991 by Hemisphere Publishing Corporation
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Pain is a multidimensional experience, encompassing sensory, affective, and evaluative components (Melzack & Wall, 1982). The sensations experienced are related to manual cervical dilation and suctioncurettage, which have been reported as the most painful stages of abortion (Bracken, 1978; Smith et al., 1979). Abortion was rated as more painful than menstrual pain, headache, and backache and as less painful than toothache and labor by women who had undergone abortion (Smith et al., 1979). In rating pain on a visual analog scale (VAS) at the worst point during abortion, Wells (1988) found scores of pain intensity varied along the full range of the scale with a large standard deviation, suggesting highly individual responses to pain during a standardized medical procedure. Anxiety, which represents one aspect of the affective component of pain, has been investigated in women undergoing abortion. State anxiety has been found to be elevated before compared with postabortion levels (Cohen & Roth, 1984; Fingerer, 1973). Level of preabortion anxiety has been positively associated with pain experienced during abortion (Belanger, Melzack, & Lauzon, 1989; Bracken, 1978; Smith et al., 1979) and is consistent with the role of anxiety in pain perception and response (Taenzer, 1983). One difficulty in drawing conclusions about pain from the abortion literature is the consistent use of single-dimension measures of pain intensity. The McGill Pain Questionnaire (MPQ) assesses three dimensions of pain: sensory, affective, and evaluative (Melzack, 1975). The MPQ has been used to describe pain in one recent study of 109 women undergoing abortion with local cervical anesthesia. Pain was associated with demographic (e.g., age and education) and psychological variables (e.g., anxiety and depression; Belanger et al., 1989). My purpose in conducting the present study was to describe the pain experience of women undergoing first-trimester uncomplicated abortion, with either local anesthesia or intravenous sedation plus local anesthesia, using the multidimensional MPQ. In addition, the relationships between previous gynecological experience, pain, and measures of distress were examined. METHOD A convenience sample of 35 women undergoing first-trimester abortion was drawn from a freestanding private reproductive health clinic in a major northeastern city. This represents a 30% acceptance rate. The clinic offered abortions under either local cervical block or intravenous (IV) sedation (diazepam and fentanyl) plus local cervical block. Women between the ages of 18 and 40 years who provided informed
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consent were included in the sample. Exclusion criteria included significant psychiatric history and presence of a partner during the procedure. Measures of pain included self-report on the MPQ and a VAS. The MPQ consists of 78 verbal descriptors, rank-ordered by intensity, within 20 subclasses and four dimensions. It was administered and scored using rank values (Melzack, 1975) to provide four dimension scores (sensory, affective, evaluative, and miscellaneous), a total score, and present pain intensity (PPI). Stability of the MPQ (Melzack, 1975) and internal consistency of the total and dimension scores are adequate (Turk, Rudy, & Salovey, 1985). Alpha coefficients in the present study ranged from .85 for the MPQ total to .66 for the miscellaneous dimension. Construct and discriminant validity of the MPQ have been supported (Dubuisson & Melzack, 1976; Turk et al., 1985). Pain intensity was measured on a 10-cm VAS with anchors of no sensation and most intense sensation imaginable to reflect the physical sensations of pain experienced. The pain intensity VAS correlates with graphic and numeric rating scales of pain (Scott & Huskisson, 1976) and MPQ total and PPI values (Taenzer, 1983). Distress was measured subjectively on a VAS and the A state of the State-Trait Anxiety Inventory. Behaviorally, distress was measured using an observation checklist and an observer rating. Subjective distress was measured on a 10-cm VAS, with anchors of not bad at all and most intense bad feeling for me. Distress was described as the amount of bother or unpleasantness caused by the sensations of pain experienced. Participants were instructed to rate pain intensity and distress dimensions independently (Price, McGrath, Rafii, & Buckingham, 1983). State anxiety was measured with the A state (Form Y-l) of the StateTrait Anxiety Inventory. Internal consistency and validity of this instrument have been documented (Spielberger, Goruch, Lushene, Vagg, & Jacobs, 1983). Behavioral distress was measured using the Distress Checklist (DCL; Wells, 1990), which assesses behaviors reflecting distress associated with pain. It includes observation of facial expression, posture, vocalization, and verbalization during the procedure. The behaviors are scored as present or absent, and the number scored as present provides a behavioral distress score. Interrater reliability, construct validity, and discriminant validity have been previously described (Wells, 1990). Internal consistency of the 7-iterh DCL was adequate (Kuder-Richardson, K-R 20 = .71). Observer-rated distress was assessed on a 10-cm VAS by the medical technician assisting during the abortion. The technicians were unaware of the specific purpose of the study. The validity of observer-rated dis-
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tress as a measure of the distress in adult clinical samples has been supported (Belanger et al., 1989). Women were approached while they were in the waiting room. After they provided informed consent, the A state was administered. Participants then received a standard description of the pain intensity, and distress scales to be completed after the procedure. During the procedure, a trained observer recorded the patient's behavior on the DCL. Immediately after the abortion, each woman completed the VAS for the worst pain intensity and distress experienced during the procedure. The medical technician completed the VAS for patient distress observed during the procedure. When the patient entered the recovery room, the MPQ was administered by means of an interview. RESULTS Thirty-five women undergoing abortion with local cervical block (n — 20) and IV sedation (n = 15) made up the sample. Their ages ranged from 18 to 40 years (M = 27 years). Of the 15 women indicating a religious preference, 11 were Catholic. Educational level ranged from 1 to 3 years of high school to completion of graduate school. Most women were White. This was the first abortion for 15 (42.9%) of the women; the remainder (20) had had from one to four previous abortions (M = 0.74, SD - 0.89). Seventeen women (48.6%) had no children, 6 women (17.1%) had one child, 11 women (31.4%) had two children, and 1 woman (2.9%) had four children. All women reported some degree of pain during the abortion, both on the MPQ and on the pain intensity VAS. The MPQ total scores ranged from 6 to 51 (M •= 24.03, SD = 13.2). Considerable variance indicates significant individual differences in response to pain related to abortion. All women selected descriptors from the sensory scale. Some did not select any descriptors from the affective (12, or 34.3%), evaluative (16, or 45.7%), and miscellaneous (3, or 8.6%) scales. To further describe pain during first-trimester abortion, the patterns of responses on individual verbal descriptors were examined. Table 1 presents the verbal descriptors selected by more than 33% of the women. The majority of the sensory descriptors selected reflect different types of pressure. Of these pressure-related verbal descriptors, four (cutting, cramping, tugging, and pulling) were selected by more than 33% of the sample. Only one affective subclass, indicating tension, was consistently selected. Within this subclass, tiring was selected by more than 33% of the sample. Intense, which ranks fourth of five evaluative descriptors, was chosen by approximately 33% of the women. One mis-
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Table 1. Verbal Descriptors Selected by More Than 33% of Subjects Dimension
VertabI descriptor"
% selecting descriptor
Sensory Sensory Sensory Sensory Sensory Affective Evaluative
Cutting (2) Cramping (4) Tugging (1) Pulling (2) Aching (4) Tiring (1) Intense (4)
40.0 77.0 34.3 34.3 34.3 45.7 34.3
•
"Rank of verbal descriptor within subclass is presented in parentheses.
cellaneous subclass was consistently identified; the majority of women chose either numb or squeezing. The correlations among pain (MPQ total, PPI, pain intensity VAS) and distress measures were examined. Subjective distress, as measured by the VAS, was positively correlated with all three pain measures (Table 2). State anxiety, in contrast, was not significantly correlated with any of the pain measures. Behavioral distress, as measured by the DCL, was positively correlated with the pain intensity VAS; observer-rated distress was positively correlated with the pain intensity VAS and the PPI. State anxiety was elevated above the published norms (M - 44.4, SD = 11.5), indicating abortion was associated with increased anxiety. Table 2. Pearson Correlation Coefficients Among Pain and Distress Measures Pain measures Distress measures
MPQ total
PPI
Pain VAS
Distress VAS Behavioral distress (DCL) State anxiety Observer-rated distress
.52** .09 .05 .24
.52** .34 .25 .42**
.55** .36* .20 .49**
MPQ - McGill Pain Questionnaire; PPI — present pain intensity; VAS — visual analog scale; DCL L - distress checklist. *p < .05. **p < .01.
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Based on previous research, it was anticipated that A state would be correlated with the affective dimension of the MPQ and the PPL To further examine the lack of correlation found, the women were divided by median split (44) into high- and low-anxiety groups. No differences were found on the affective dimension between high and low anxiety, t (33) = 1.35, p > .05, although the means fell in the expected direction. The differences between high- and low-anxiety subjects on the PPI (M = 2.61 and 1.94, respectively) approached significance, t (33) = 1.92, p < .10. State anxiety was not associated with other measures of pain intensity, distress, or type of anesthesia. The number of previous abortions and childbirths were dichotomized into none and one or more. On the basis of r-test results, women experienced with abortion (M = 2.75) had higher affective scores than those without abortion experience (M = 1.27), t (28.85) - 2.18, p < .05. Similarly, women with abortion experience (M •= 2.65) had greater PPI scores than those without abortion experience (M •= 1.8), t (33.77) •= 2.63, p < .05. In contrast, women with children (M — 1.44) tended to have lower affective scores than women with no children (M «= 2.82), t (33) = 1.86, p < .10. This trend was not found between women with and without childbirth experience on the PPI. The differences in MPQ dimension scores by type of anesthesia were examined using t tests. Despite the addition of IV diazepam and fentanyl in women receiving IV sedation, no differences were found for the MPQ dimensions by type of anesthesia using t tests. The selection of subclasses did not vary by type of anesthesia received. DISCUSSION The pattern of pain experienced during first-trimester abortion consists primarily of pressure-related sensations. The verbal descriptors cramping and aching may reflect the contraction of the uterus and are similar to the descriptors used to describe abortion (Belanger et al., 1989) and menstrual cramps (Dubuisson & Melzack, 1976). Two of the three other sensory descriptors frequently chosen—tugging and pulling—may be related to the sensations accompanying vacuum suction. Many women did not select words from the affective and evaluative subclasses. Within the affective dimension, over 50% of women chose a word reflecting tension, most frequently tiring, which is on the low-intensity end of this subclass. Of the evaluative descriptors, intense, a high-ranked descriptor, was most frequently chosen. The descriptors selected to reflect pain during abortion are consistent with those reported by Belanger and colleagues (1989) for abortion pain and Dubuisson and Melzack (1976) for menstrual and labor pain. The
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percentage of women endorsing descriptors increased in the expected direction; that is, increasing from menstrual to abortion to labor pain (Figure 1). In addition, the number of descriptors endorsed by 33% or more of each sample increased with increasing pain intensity. When dimension scores are compared across samples, abortion produces greater sensory scores than menstrual pain (Melzack, 1975; Reading & Newton, 1977) and dental pain (Grushka & Sessle, 1984), but lower affective and evaluative scores. This is inconsistent with the belief that abortion is a highly emotional experience, suggesting: (a) this assumption is incorrect (Baluk & O'Neill, 1980; Fingerer, 1973), (b) the affective dimension of the MPQ is not sensitive to transient emotional states (Van Buren & Kleinknecht, 1979), or (c) the women were well defended during and immediately after the abortion, when the MPQ was administered. Denial may be one method of coping with abortion, as a means of reducing transient emotional responses. Cohen and Roth (1984) found that women who used denial before the abortion were more anxious and depressed than those who did not use denial. Denial, anxiety, and depression were significantly reduced from preabortion to postabortion for 40
Pain Scores
30 -
20
10
"HP I
11
I
Labor (a)
Labor (b)
Abortion Dyamanorrhea IU0 Pain
Menatrual
Type of Pain HI
Total
X//A Sensory
tttffl Affective
K^SI Evaluative
(a) without anaath«ala/analgaala (b) with anaathaala/analgaalt
Figure 1. Comparison of McGill Pain Questionnaire scale scores across types of pain experienced by women. (IUD — intrauterine device. Sources of comparison: Dubuisson & Melzack, 1976; Melzack, Taenzer, Feldman, & Kinch, 1981; Reading & Newton, 1977.)
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all women in their sample; however, high deniers continued to be more anxious and depressed after the abortion than low deniers. Denial was related to an increase, rather than the expected decrease, in emotional response to abortion. Denial, then, may not explain the low affective values found in the present study. State anxiety, while elevated 30 to 90 min before the abortion, was not significantly correlated with any of the pain or distress measures. The lack of association may be related to the timing of the measurement of anxiety or pain and to the small sample size. Belanger and coauthors (1989) found that preprocedure anxiety and depression were significantly correlated with pain and distress measures in their sample and that these psychological variables accounted for an average of 13% of variance in pain measures. The timing of the measurement of state anxiety was similar in both studies; however, Belanger and associates included adolescents (35%) and found that young women experienced greater pain than the adult women in their sample. Perhaps the lack of relationship between anxiety and pain in the current study is associated, in part, to the exclusion of adolescents. Belanger and co-workers (1989) found that previous experience with abortion and childbirth were unrelated to pain. The present data are inconsistent with this relationship in that women with previous childbirth experience reported less pain on two of the MPQ dimension scales than did women with no childbirth experience. However, previous experience with abortion was associated with high affective and PPI values, suggesting this type of experience may have a sensitizing effect on the distress-related measures of pain. Unfortunately, ratings of the quality of previous abortion experiences were not obtained. The MPQ dimensions and subclasses did not discriminate between women undergoing abortion with local and IV sedation anesthesia. This contrasts with Grushka and Sessle (1984), who found the MPQ subclasses discriminated between reversible and irreversible tooth inflammation. The quality of pain, both with tooth inflammation and with abortion under different types of anesthesia, should remain stable but vary on intensity. The observation measures of distress were significantly greater in women receiving local anesthesia alone, yet the subjective measures revealed no differences in quality or intensity of pain. In a larger sample of women undergoing first-trimester abortion, Wells (1988) found a significant effect for type of anesthesia on both pain intensity and distress measured with VASs. Thus the present sample may not have been large enough for differences to be detected. CONCLUSION The quality and intensity of pain experienced during first-trimester abortion were described primarily in sensory terms that were related to
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qualitatively different types of pressure. The similarities among verbal descriptors of menstrual, abortion, and labor pain support the validity of the MPQ in discriminating a specific source of pain. The pain description was consistent across women receiving local cervical block and IV sedation. Neither subclass nor dimension scores differentiated between types of anesthesia administered. It is surprising that IV sedation did not influence the affective dimension of pain, because diazepam has antianxiety effects. The low levels on the affective dimension in comparison to, for example, menstrual pain and toothache requires further investigation. Despite the lack of endorsement of affective descriptors, firsttrimester abortion was related to a significant level of pain. This level of pain intensity and associated distress, despite the administration of anesthetic agents, indicates the need to explore interventions designed to reduce pain and associated distress during first-trimester abortion. REFERENCES Adler, N. E. (1975). Emotional responses of women following therapeutic abortion. American Journal of Orthopsychiatry, 45, 446-454. Baluk, U., & O'Neill, P. (1980). Health professionals' perception of the psychological consequences of abortion. American Journal of Community Psychology, 8, 67-75. Belanger, E., Melzack, R., & Lauzon, P. (1989). Pain of first-trimester abortion: A study of psychosocial and medical predictors. Pain, 36, 339-350. Bracken, M. B. (1978). A causal model of psychosomatic reactions to vacuum aspiration abortion. Social Psychiatry, 13, 135-145. Cohen, L., & Roth, S. (1984). Coping with abortion. Journal of Human Stress, 10, 140-145. Dubuisson, D., & Melzack, R. (1976). Classification of clinical pain descriptions by multiple group discriminant analysis. Experimental Neurology, 51, 480-487. Fingerer, M. E. (1973). Psychological sequelae of abortion: Anxiety and depression. Journal of Community Psychology, 1, 221-225. Grushka, M., & Sessle, B. J. (1984). Applicability of the McGill Pain Questionnaire to the differentiation of "toothache" pain. Pain, 19, 49-57. Melzack, R. (1975). The McGill Pain Questionnaire: Major properties and scoring methods. Pain, 1, 277-299. Melzack, R., Taenzer, P., Feldman, P., & Kinch, R. A. (1981). Labour is still painful after prepared childbirth training. Canadian Medical Association Journal, 125, 357363. Melzack, R., & Wall, P. D. (1982). The challenge of pain. New York: Penguin Press. Price, D. D., McGrath, P. A., Rafii, R., & Buckingham, B. (1983). The validation of visual analogue scales as ratio scale measures for chronic and experimental pain.
Pain, 17, 45-56. Reading, A. E., & Newton, J. R. (1977). On a comparison of dysmenorrhea and intrauterine device related pain. Pain, 3, 265-276. Scott, J., & Huskisson, E. C. (1976). Graphic representation of pain. Pain, 2, 175-184.
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Smith, G. M., Stubblefield, P. G., Chirchirillo, L., & McCarthy, M. J. (1979). Pain of first-trimester abortion: Its quantification and relations with other variables. American Journal of Obstetrics and Gynecology, 133, 489-498. Spielberger, C. D., Goruch, R. L., Lushene, R., Vagg, P. R., & Jacobs, G. A. (1983). Manual for the State-Trait Anxiety Inventory (Form Y). Palo Alto, CA: Consulting Psychologists Press. Taenzer, P. (1983). Postoperative pain: Relationships among measures of pain, mood, and narcotic requirements. In R. Melzack (Ed.), Pain measurement and assessment (pp. 111-118). New York: Raven Press. Tietze, C. (1983). Induced abortion: A world review, 1983 (5th ed.). New York: Population Council. Turk, D. C., Rudy, T. E., & Salovey, P. (1985). The McGill Pain Questionnaire reconsidered: Confirming the factor structure and examining appropriate uses. Pain, 21, 385-397. Van Buren, J., & Kleinknecht, R. (1979). An evaluation of the MPQ for use in dental pain assessment. Pain, 6, 23-33. Wells, N. (1988). Factors modulating distress and pain during abortion. Unpublished doctoral dissertation, Boston University. Wells, N. (1990). Behavioral measurement of distress during painful medical procedures. In O. L. Strickland & C. F. Waltz (Eds.), Measurement of nursing outcomes, Vol. 4. Measuring client self-care and coping skills (pp. 250-266). New York: Springer.
Health Care for Women International Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uhcw20
Pain and distress during abortion Nancy Wells DNSc, RN
a
a
Strong Memorial Hospital and Pain Treatment Center , University of Rochester , Rochester, New York Published online: 14 Aug 2009.
To cite this article: Nancy Wells DNSc, RN (1991) Pain and distress during abortion, Health Care for Women International, 12:3, 293-302, DOI: 10.1080/07399339109515952 To link to this article: http://dx.doi.org/10.1080/07399339109515952
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
PAIN AND DISTRESS DURING ABORTION Nancy Wells, DNSc, RN
Downloaded by [University of Auckland Library] at 16:30 25 February 2015
Strong Memorial Hospital and Pain Treatment Center, University of Rochester, Rochester, New York
Although there has been recent emphasis on the long-term effects of abortion on women, the distressing aspects of the procedure itself are seldom addressed. The pain and distress experienced by 35 women undergoing first-trimester abortion were addressed. The quality and intensity of pain were measured using the McGill Pain Questionnaire (MPQ) and a pain intensity visual analog scale (VAS). Distress measures included a VAS, state anxiety, observation of behavior, and observer-rated distress. The women reported elevated levels of state anxiety before the abortion and pain and distress during the procedure. The pattern of verbal descriptors on the MPQ was comparable to previously reported descriptors of abor. tion, labor, and menstrual pain. The MPQ dimension scores did not differ by type of anesthesia received. Findings indicate that firsttrimester abortion is a painful and distressing medical procedure and support the use of the MPQ as a measure of the character and intensity of the pain experienced.
First-trimester abortion is a common medical procedure (Tietze, 1983). The psychological effects of abortion have been frequently studied (Adler, 1975; Cohen & Roth, 1984). However, less emphasis has been placed on the pain and distress associated with abortion (Bracken, 1978; Smith, Stubblefield, Chirchirillo, & McCarthy, 1979). These two issues—pain and distress experienced during abortion—are addressed here.
This study was completed with support from National Research Service Award 5 F31 NR05928 from the National Center for Nursing Research and from the Robert Wood Johnson Foundation. The opinions and conclusions of the author do not necessarily represent the views of the funding agencies. The assistance of Man- Derby, MS, MFH, Gcraldine Padilla, PhD, and the staff at Preterm Reproductive Health Services is acknowledged. Health Care for Women International, 12:293-302, 1991 Copyright © 1991 by Hemisphere Publishing Corporation
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Pain is a multidimensional experience, encompassing sensory, affective, and evaluative components (Melzack & Wall, 1982). The sensations experienced are related to manual cervical dilation and suctioncurettage, which have been reported as the most painful stages of abortion (Bracken, 1978; Smith et al., 1979). Abortion was rated as more painful than menstrual pain, headache, and backache and as less painful than toothache and labor by women who had undergone abortion (Smith et al., 1979). In rating pain on a visual analog scale (VAS) at the worst point during abortion, Wells (1988) found scores of pain intensity varied along the full range of the scale with a large standard deviation, suggesting highly individual responses to pain during a standardized medical procedure. Anxiety, which represents one aspect of the affective component of pain, has been investigated in women undergoing abortion. State anxiety has been found to be elevated before compared with postabortion levels (Cohen & Roth, 1984; Fingerer, 1973). Level of preabortion anxiety has been positively associated with pain experienced during abortion (Belanger, Melzack, & Lauzon, 1989; Bracken, 1978; Smith et al., 1979) and is consistent with the role of anxiety in pain perception and response (Taenzer, 1983). One difficulty in drawing conclusions about pain from the abortion literature is the consistent use of single-dimension measures of pain intensity. The McGill Pain Questionnaire (MPQ) assesses three dimensions of pain: sensory, affective, and evaluative (Melzack, 1975). The MPQ has been used to describe pain in one recent study of 109 women undergoing abortion with local cervical anesthesia. Pain was associated with demographic (e.g., age and education) and psychological variables (e.g., anxiety and depression; Belanger et al., 1989). My purpose in conducting the present study was to describe the pain experience of women undergoing first-trimester uncomplicated abortion, with either local anesthesia or intravenous sedation plus local anesthesia, using the multidimensional MPQ. In addition, the relationships between previous gynecological experience, pain, and measures of distress were examined. METHOD A convenience sample of 35 women undergoing first-trimester abortion was drawn from a freestanding private reproductive health clinic in a major northeastern city. This represents a 30% acceptance rate. The clinic offered abortions under either local cervical block or intravenous (IV) sedation (diazepam and fentanyl) plus local cervical block. Women between the ages of 18 and 40 years who provided informed
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consent were included in the sample. Exclusion criteria included significant psychiatric history and presence of a partner during the procedure. Measures of pain included self-report on the MPQ and a VAS. The MPQ consists of 78 verbal descriptors, rank-ordered by intensity, within 20 subclasses and four dimensions. It was administered and scored using rank values (Melzack, 1975) to provide four dimension scores (sensory, affective, evaluative, and miscellaneous), a total score, and present pain intensity (PPI). Stability of the MPQ (Melzack, 1975) and internal consistency of the total and dimension scores are adequate (Turk, Rudy, & Salovey, 1985). Alpha coefficients in the present study ranged from .85 for the MPQ total to .66 for the miscellaneous dimension. Construct and discriminant validity of the MPQ have been supported (Dubuisson & Melzack, 1976; Turk et al., 1985). Pain intensity was measured on a 10-cm VAS with anchors of no sensation and most intense sensation imaginable to reflect the physical sensations of pain experienced. The pain intensity VAS correlates with graphic and numeric rating scales of pain (Scott & Huskisson, 1976) and MPQ total and PPI values (Taenzer, 1983). Distress was measured subjectively on a VAS and the A state of the State-Trait Anxiety Inventory. Behaviorally, distress was measured using an observation checklist and an observer rating. Subjective distress was measured on a 10-cm VAS, with anchors of not bad at all and most intense bad feeling for me. Distress was described as the amount of bother or unpleasantness caused by the sensations of pain experienced. Participants were instructed to rate pain intensity and distress dimensions independently (Price, McGrath, Rafii, & Buckingham, 1983). State anxiety was measured with the A state (Form Y-l) of the StateTrait Anxiety Inventory. Internal consistency and validity of this instrument have been documented (Spielberger, Goruch, Lushene, Vagg, & Jacobs, 1983). Behavioral distress was measured using the Distress Checklist (DCL; Wells, 1990), which assesses behaviors reflecting distress associated with pain. It includes observation of facial expression, posture, vocalization, and verbalization during the procedure. The behaviors are scored as present or absent, and the number scored as present provides a behavioral distress score. Interrater reliability, construct validity, and discriminant validity have been previously described (Wells, 1990). Internal consistency of the 7-iterh DCL was adequate (Kuder-Richardson, K-R 20 = .71). Observer-rated distress was assessed on a 10-cm VAS by the medical technician assisting during the abortion. The technicians were unaware of the specific purpose of the study. The validity of observer-rated dis-
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tress as a measure of the distress in adult clinical samples has been supported (Belanger et al., 1989). Women were approached while they were in the waiting room. After they provided informed consent, the A state was administered. Participants then received a standard description of the pain intensity, and distress scales to be completed after the procedure. During the procedure, a trained observer recorded the patient's behavior on the DCL. Immediately after the abortion, each woman completed the VAS for the worst pain intensity and distress experienced during the procedure. The medical technician completed the VAS for patient distress observed during the procedure. When the patient entered the recovery room, the MPQ was administered by means of an interview. RESULTS Thirty-five women undergoing abortion with local cervical block (n — 20) and IV sedation (n = 15) made up the sample. Their ages ranged from 18 to 40 years (M = 27 years). Of the 15 women indicating a religious preference, 11 were Catholic. Educational level ranged from 1 to 3 years of high school to completion of graduate school. Most women were White. This was the first abortion for 15 (42.9%) of the women; the remainder (20) had had from one to four previous abortions (M = 0.74, SD - 0.89). Seventeen women (48.6%) had no children, 6 women (17.1%) had one child, 11 women (31.4%) had two children, and 1 woman (2.9%) had four children. All women reported some degree of pain during the abortion, both on the MPQ and on the pain intensity VAS. The MPQ total scores ranged from 6 to 51 (M •= 24.03, SD = 13.2). Considerable variance indicates significant individual differences in response to pain related to abortion. All women selected descriptors from the sensory scale. Some did not select any descriptors from the affective (12, or 34.3%), evaluative (16, or 45.7%), and miscellaneous (3, or 8.6%) scales. To further describe pain during first-trimester abortion, the patterns of responses on individual verbal descriptors were examined. Table 1 presents the verbal descriptors selected by more than 33% of the women. The majority of the sensory descriptors selected reflect different types of pressure. Of these pressure-related verbal descriptors, four (cutting, cramping, tugging, and pulling) were selected by more than 33% of the sample. Only one affective subclass, indicating tension, was consistently selected. Within this subclass, tiring was selected by more than 33% of the sample. Intense, which ranks fourth of five evaluative descriptors, was chosen by approximately 33% of the women. One mis-
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Table 1. Verbal Descriptors Selected by More Than 33% of Subjects Dimension
VertabI descriptor"
% selecting descriptor
Sensory Sensory Sensory Sensory Sensory Affective Evaluative
Cutting (2) Cramping (4) Tugging (1) Pulling (2) Aching (4) Tiring (1) Intense (4)
40.0 77.0 34.3 34.3 34.3 45.7 34.3
•
"Rank of verbal descriptor within subclass is presented in parentheses.
cellaneous subclass was consistently identified; the majority of women chose either numb or squeezing. The correlations among pain (MPQ total, PPI, pain intensity VAS) and distress measures were examined. Subjective distress, as measured by the VAS, was positively correlated with all three pain measures (Table 2). State anxiety, in contrast, was not significantly correlated with any of the pain measures. Behavioral distress, as measured by the DCL, was positively correlated with the pain intensity VAS; observer-rated distress was positively correlated with the pain intensity VAS and the PPI. State anxiety was elevated above the published norms (M - 44.4, SD = 11.5), indicating abortion was associated with increased anxiety. Table 2. Pearson Correlation Coefficients Among Pain and Distress Measures Pain measures Distress measures
MPQ total
PPI
Pain VAS
Distress VAS Behavioral distress (DCL) State anxiety Observer-rated distress
.52** .09 .05 .24
.52** .34 .25 .42**
.55** .36* .20 .49**
MPQ - McGill Pain Questionnaire; PPI — present pain intensity; VAS — visual analog scale; DCL L - distress checklist. *p < .05. **p < .01.
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Based on previous research, it was anticipated that A state would be correlated with the affective dimension of the MPQ and the PPL To further examine the lack of correlation found, the women were divided by median split (44) into high- and low-anxiety groups. No differences were found on the affective dimension between high and low anxiety, t (33) = 1.35, p > .05, although the means fell in the expected direction. The differences between high- and low-anxiety subjects on the PPI (M = 2.61 and 1.94, respectively) approached significance, t (33) = 1.92, p < .10. State anxiety was not associated with other measures of pain intensity, distress, or type of anesthesia. The number of previous abortions and childbirths were dichotomized into none and one or more. On the basis of r-test results, women experienced with abortion (M = 2.75) had higher affective scores than those without abortion experience (M = 1.27), t (28.85) - 2.18, p < .05. Similarly, women with abortion experience (M •= 2.65) had greater PPI scores than those without abortion experience (M •= 1.8), t (33.77) •= 2.63, p < .05. In contrast, women with children (M — 1.44) tended to have lower affective scores than women with no children (M «= 2.82), t (33) = 1.86, p < .10. This trend was not found between women with and without childbirth experience on the PPI. The differences in MPQ dimension scores by type of anesthesia were examined using t tests. Despite the addition of IV diazepam and fentanyl in women receiving IV sedation, no differences were found for the MPQ dimensions by type of anesthesia using t tests. The selection of subclasses did not vary by type of anesthesia received. DISCUSSION The pattern of pain experienced during first-trimester abortion consists primarily of pressure-related sensations. The verbal descriptors cramping and aching may reflect the contraction of the uterus and are similar to the descriptors used to describe abortion (Belanger et al., 1989) and menstrual cramps (Dubuisson & Melzack, 1976). Two of the three other sensory descriptors frequently chosen—tugging and pulling—may be related to the sensations accompanying vacuum suction. Many women did not select words from the affective and evaluative subclasses. Within the affective dimension, over 50% of women chose a word reflecting tension, most frequently tiring, which is on the low-intensity end of this subclass. Of the evaluative descriptors, intense, a high-ranked descriptor, was most frequently chosen. The descriptors selected to reflect pain during abortion are consistent with those reported by Belanger and colleagues (1989) for abortion pain and Dubuisson and Melzack (1976) for menstrual and labor pain. The
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percentage of women endorsing descriptors increased in the expected direction; that is, increasing from menstrual to abortion to labor pain (Figure 1). In addition, the number of descriptors endorsed by 33% or more of each sample increased with increasing pain intensity. When dimension scores are compared across samples, abortion produces greater sensory scores than menstrual pain (Melzack, 1975; Reading & Newton, 1977) and dental pain (Grushka & Sessle, 1984), but lower affective and evaluative scores. This is inconsistent with the belief that abortion is a highly emotional experience, suggesting: (a) this assumption is incorrect (Baluk & O'Neill, 1980; Fingerer, 1973), (b) the affective dimension of the MPQ is not sensitive to transient emotional states (Van Buren & Kleinknecht, 1979), or (c) the women were well defended during and immediately after the abortion, when the MPQ was administered. Denial may be one method of coping with abortion, as a means of reducing transient emotional responses. Cohen and Roth (1984) found that women who used denial before the abortion were more anxious and depressed than those who did not use denial. Denial, anxiety, and depression were significantly reduced from preabortion to postabortion for 40
Pain Scores
30 -
20
10
"HP I
11
I
Labor (a)
Labor (b)
Abortion Dyamanorrhea IU0 Pain
Menatrual
Type of Pain HI
Total
X//A Sensory
tttffl Affective
K^SI Evaluative
(a) without anaath«ala/analgaala (b) with anaathaala/analgaalt
Figure 1. Comparison of McGill Pain Questionnaire scale scores across types of pain experienced by women. (IUD — intrauterine device. Sources of comparison: Dubuisson & Melzack, 1976; Melzack, Taenzer, Feldman, & Kinch, 1981; Reading & Newton, 1977.)
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all women in their sample; however, high deniers continued to be more anxious and depressed after the abortion than low deniers. Denial was related to an increase, rather than the expected decrease, in emotional response to abortion. Denial, then, may not explain the low affective values found in the present study. State anxiety, while elevated 30 to 90 min before the abortion, was not significantly correlated with any of the pain or distress measures. The lack of association may be related to the timing of the measurement of anxiety or pain and to the small sample size. Belanger and coauthors (1989) found that preprocedure anxiety and depression were significantly correlated with pain and distress measures in their sample and that these psychological variables accounted for an average of 13% of variance in pain measures. The timing of the measurement of state anxiety was similar in both studies; however, Belanger and associates included adolescents (35%) and found that young women experienced greater pain than the adult women in their sample. Perhaps the lack of relationship between anxiety and pain in the current study is associated, in part, to the exclusion of adolescents. Belanger and co-workers (1989) found that previous experience with abortion and childbirth were unrelated to pain. The present data are inconsistent with this relationship in that women with previous childbirth experience reported less pain on two of the MPQ dimension scales than did women with no childbirth experience. However, previous experience with abortion was associated with high affective and PPI values, suggesting this type of experience may have a sensitizing effect on the distress-related measures of pain. Unfortunately, ratings of the quality of previous abortion experiences were not obtained. The MPQ dimensions and subclasses did not discriminate between women undergoing abortion with local and IV sedation anesthesia. This contrasts with Grushka and Sessle (1984), who found the MPQ subclasses discriminated between reversible and irreversible tooth inflammation. The quality of pain, both with tooth inflammation and with abortion under different types of anesthesia, should remain stable but vary on intensity. The observation measures of distress were significantly greater in women receiving local anesthesia alone, yet the subjective measures revealed no differences in quality or intensity of pain. In a larger sample of women undergoing first-trimester abortion, Wells (1988) found a significant effect for type of anesthesia on both pain intensity and distress measured with VASs. Thus the present sample may not have been large enough for differences to be detected. CONCLUSION The quality and intensity of pain experienced during first-trimester abortion were described primarily in sensory terms that were related to
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qualitatively different types of pressure. The similarities among verbal descriptors of menstrual, abortion, and labor pain support the validity of the MPQ in discriminating a specific source of pain. The pain description was consistent across women receiving local cervical block and IV sedation. Neither subclass nor dimension scores differentiated between types of anesthesia administered. It is surprising that IV sedation did not influence the affective dimension of pain, because diazepam has antianxiety effects. The low levels on the affective dimension in comparison to, for example, menstrual pain and toothache requires further investigation. Despite the lack of endorsement of affective descriptors, firsttrimester abortion was related to a significant level of pain. This level of pain intensity and associated distress, despite the administration of anesthetic agents, indicates the need to explore interventions designed to reduce pain and associated distress during first-trimester abortion. REFERENCES Adler, N. E. (1975). Emotional responses of women following therapeutic abortion. American Journal of Orthopsychiatry, 45, 446-454. Baluk, U., & O'Neill, P. (1980). Health professionals' perception of the psychological consequences of abortion. American Journal of Community Psychology, 8, 67-75. Belanger, E., Melzack, R., & Lauzon, P. (1989). Pain of first-trimester abortion: A study of psychosocial and medical predictors. Pain, 36, 339-350. Bracken, M. B. (1978). A causal model of psychosomatic reactions to vacuum aspiration abortion. Social Psychiatry, 13, 135-145. Cohen, L., & Roth, S. (1984). Coping with abortion. Journal of Human Stress, 10, 140-145. Dubuisson, D., & Melzack, R. (1976). Classification of clinical pain descriptions by multiple group discriminant analysis. Experimental Neurology, 51, 480-487. Fingerer, M. E. (1973). Psychological sequelae of abortion: Anxiety and depression. Journal of Community Psychology, 1, 221-225. Grushka, M., & Sessle, B. J. (1984). Applicability of the McGill Pain Questionnaire to the differentiation of "toothache" pain. Pain, 19, 49-57. Melzack, R. (1975). The McGill Pain Questionnaire: Major properties and scoring methods. Pain, 1, 277-299. Melzack, R., Taenzer, P., Feldman, P., & Kinch, R. A. (1981). Labour is still painful after prepared childbirth training. Canadian Medical Association Journal, 125, 357363. Melzack, R., & Wall, P. D. (1982). The challenge of pain. New York: Penguin Press. Price, D. D., McGrath, P. A., Rafii, R., & Buckingham, B. (1983). The validation of visual analogue scales as ratio scale measures for chronic and experimental pain.
Pain, 17, 45-56. Reading, A. E., & Newton, J. R. (1977). On a comparison of dysmenorrhea and intrauterine device related pain. Pain, 3, 265-276. Scott, J., & Huskisson, E. C. (1976). Graphic representation of pain. Pain, 2, 175-184.
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Smith, G. M., Stubblefield, P. G., Chirchirillo, L., & McCarthy, M. J. (1979). Pain of first-trimester abortion: Its quantification and relations with other variables. American Journal of Obstetrics and Gynecology, 133, 489-498. Spielberger, C. D., Goruch, R. L., Lushene, R., Vagg, P. R., & Jacobs, G. A. (1983). Manual for the State-Trait Anxiety Inventory (Form Y). Palo Alto, CA: Consulting Psychologists Press. Taenzer, P. (1983). Postoperative pain: Relationships among measures of pain, mood, and narcotic requirements. In R. Melzack (Ed.), Pain measurement and assessment (pp. 111-118). New York: Raven Press. Tietze, C. (1983). Induced abortion: A world review, 1983 (5th ed.). New York: Population Council. Turk, D. C., Rudy, T. E., & Salovey, P. (1985). The McGill Pain Questionnaire reconsidered: Confirming the factor structure and examining appropriate uses. Pain, 21, 385-397. Van Buren, J., & Kleinknecht, R. (1979). An evaluation of the MPQ for use in dental pain assessment. Pain, 6, 23-33. Wells, N. (1988). Factors modulating distress and pain during abortion. Unpublished doctoral dissertation, Boston University. Wells, N. (1990). Behavioral measurement of distress during painful medical procedures. In O. L. Strickland & C. F. Waltz (Eds.), Measurement of nursing outcomes, Vol. 4. Measuring client self-care and coping skills (pp. 250-266). New York: Springer.
