Glancing at the past and course-setting for the future: lessons from the last decade of research on medication abortion in high-income countries.

OBJECTIVE: Although medication abortion has become more common in high-income countries, the procedure has not yet met early expectations for widening access to abortion. High-quality evidence can serve as a catalyst for changes in policy and practice. To direct research priorities, it is important to understand where quality evidence is concentrated and where gaps remain. High-income countries have developed a body of evidence that may have implications for the future of medication abortion. This literature review assesses the characteristics and quality of published studies on medication abortion conducted in the last 10 years in high-income countries and indicates future areas for research to advance policy and practice, and broaden access. STUDY DESIGN: A structured search for literature resulted in 207 included studies. A framework based upon the World Health Organization definition of sub-tasks for medication abortion was developed to categorize research by recognized stages of the medication abortion process. Using an iterative and inductive approach, additional sub-themes were created under each of these categories. Established quality assessment frameworks were drawn upon to gauge the internal and external validity of the included research. RESULTS: Studies in the US and the UK have dominated research on MA in high-income countries. The political and social contexts of these countries will have shaped of this body of research. The past decade of research has focused largely on clinical aspects of medication abortion. CONCLUSION: Researchers should consider refocusing energies toward testing service delivery approaches demonstrating promise and prioritizing research that has broader generalizability and relevance outside of narrow clinical contexts. Although medication abortion is more commonly available worldwide, it is not being used as often as people thought it would be, particularly in high income countries. In order to encourage changes in policy and practice that would allow greater use, we need good quality evidence. If we can understand where we do not have enough research and where we have good amounts of research, we can determine where to invest energies in further studies. Many high-income countries have produced research on medication abortion that could influence policy and practice in similarly resourced contexts. I conducted a literature review to be able to understand the type and quality of research on medication abortion conducted in high-income countries in the past 10 years. I conducted the review in an organized way to make sure that the papers reviewed discussed studies that I thought would be important for answering this question. The literature review found 207 papers. Each of these papers were reviewed and organized them by theme. I also used existing methods to determinine the quality of each study. Most of the research came from the US and the UK. Furthermore, most of the research conducted in the past 10 years was focused on clinical studies of medication abortion. In future studies, researchers should focus more on new ways of providing medication abortion to women that offers greater access. Also, the studies should be designed so that the results have meaning for a broader group of people or situations beyond where the study was done.

Contribuições técnicas e socioculturais da prevenção quaternária para a atenção primária à saúde: caminhos e desafios / Technical and socio-cultural contributions of quaternary prevention for primary health care: paths and challenges / Contribuciones técnicas y socioculturales de prevención cuaternaria para la atención primaria de salud: caminos y desafíos

Introdução: No contexto do Sistema Único de Saúde, o conceito da prevenção quaternária adentra timidamente os níveis de atenção à saúde, no entanto, sofre expansão significativa no âmbito da atenção primária à saúde. Objetivo: Identificar por meio da sistematização de evidências científicas, as contribuições técnicas e socioculturais da prevenção quaternária no âmbito da atenção primária à saúde no Brasil. Métodos: Trata-se de uma revisão integrativa de estudos presentes nas bases de dados científicas da Scientific Electronic Library Online, Biblioteca Virtual em Saúde, biblioteca virtual da Comissão de Aperfeiçoamento de Pessoal do Nível Superior e MEDLINE via PubMed com a utilização dos descritores "prevenção quaternária" e "atenção primária à saúde", em inglês e português. Resultados: O corpus de análise foi composto por 22 artigos, sendo que a produção científica sobre o tema se deu de forma mais intensa a partir do ano de 2015 e, em sua maioria, possuíam como abordagem metodológica ensaios teóricos. Dentre as contribuições técnicas destacaram-se a introdução do ensino da prevenção quaternária de modo continuado aos graduandos e profissionais; a construção de protocolos e documentos de amparo profissional; a utilização de modelos explicativos dinâmicos na socialização do quadro clínico; a conduta profissional com os usuários e as contribuições socioculturais envolvendo mudanças na percepção profissional e comunitária sobre o fenômeno saúde-doença, assim como o incentivo a práticas de desmedicalização sociocultural em relação à dor, incapacidade, desconforto, envelhecimento, nascimento e morte. Conclusão: Apesar do reconhecimento das potencialidades da prevenção quaternária, faz-se necessário fortalecer estratégias que possibilitem o desenvolvimento de políticas públicas para fomentar e gerenciar alianças estratégicas com tomadores de decisão, profissionais de saúde e cidadãos, para fomentar a redução de diagnósticos e tratamentos excessivos, contribuindo com a qualidade do cuidado.

Introduction: In the context of the Unified Health System, the concept of quaternary prevention shyly enters the levels of health care, however, undergoes significant expansion in the scope of primary health care. Objective: To identify, through the systematization of scientific evidence, the technical and socio-cultural contributions of quaternary prevention within the scope of primary health care in Brazil. Methods: This is an integrative review of studies present in the scientific databases of the Scientific Electronic Library Online, Regional Portal of the Virtual Health Library of the Latin American and Caribbean Center on Health Sciences Information of the Pan American Health Organization, virtual library of the Higher Education Personnel Improvement Commission, and MEDLINE through PubMed using the descriptors "quaternary prevention" and "primary health care", in English and Portuguese. Results: The corpus of analysis consisted of 22 articles, and the scientific production on the topic took place more intensively from the year 2015 and, for the most part, had theoretical essays as methodological approach. Among the technical contributions, we highlight the introduction of teaching on quaternary prevention in a continuous way to undergraduates and professionals; the construction of protocols and documents of professional support; the use of dynamic explanatory models in the socialization of the clinical picture and professional conduct with users and socio-cultural contributions involve changes in the professional and community perception about the phenomenon of illness and health conception, as well as the incentive to practices of socio-cultural demedicalization in relation to pain, disability, discomfort, aging, birth, and death. Conclusion: Despite the recognition of the potential of quaternary prevention, it is necessary to strengthen strategies that enable the development of public policies to foster and manage strategic alliances with decision makers, health professionals and citizens, to promote the reduction of excessive diagnoses and treatments, contributing to the quality of care.

Introducción: En el contexto del Sistema Único de Salud, el concepto de prevención cuaternaria entra tímidamente en los niveles de atención de salud, sin embargo, experimenta una expansión significativa en el alcance de la Atención Primaria de Salud. Objetivo: Identificar, a través de la sistematización de evidencia científica, las contribuciones técnicas y socioculturales de la prevención cuaternaria en el ámbito de la Atención Primaria de Salud en Brasil. Métodos: Esta es una revisión integradora de estudios presentes en las bases de datos científicas de la Biblioteca Electrónica Científica en línea, Portal Regional de la Biblioteca Virtual en Salud del Centro Latinoamericano y del Caribe de Información en Ciencias de la Salud de la Organización Panamericana de la Salud, biblioteca virtual de la Comisión de Mejoramiento del Personal de Educación Superior y MEDLINE a través de PubMed utilizando los descriptores de prevención cuaternaria y atención primaria de salud, en inglés y portugués. Resultados: El corpus de análisis estuvo conformado por 22 artículos, siendo la producción científica sobre el tema más intensiva desde 2015 y, en su mayor parte, tuvo ensayos teóricos como abordaje metodológico. Entre los aportes técnicos, destacamos la implantación de la docencia en prevención cuaternaria de forma continua a estudiantes de pregrado y profesionales; construcción de protocolos y documentos de apoyo profesional, uso de modelos explicativos dinámicos en la socialización del cuadro clínico y conducta profesional con los usuarios y los aportes socioculturales implican cambios en la percepción profesional y comunitaria sobre el fenómeno de la enfermedad y la concepción de la salud, así como el incentivo a prácticas de desmedicalización sociocultural en relación al dolor, discapacidad, malestar, envejecimiento, nacimiento y muerte. Conclusión: A pesar del reconocimiento del potencial de la prevención cuaternaria, es necesario fortalecer estrategias que permitan el desarrollo de políticas públicas para fomentar y gestionar alianzas estratégicas con los tomadores de decisiones, profesionales de la salud y ciudadanos, para promover la reducción de diagnósticos y tratamientos excesivos, contribuyendo a la calidad de la atención.

Efetividade de procedimentos não farmacológicos para o alívio da dor de parturientes: contribuições para a enfermagem obstétrica / Effectiveness of non-pharmacological procedures for pain relief in parturients: contributions to obstetric nursing

Estudo que apresentou como objeto o uso de procedimentos não farmacológicos para alívio da dor em parturientes. O objetivo geral foi conhecer a efetividade de três procedimentos não farmacológicos: o uso do gelo; o uso da água aquecida através do banho; e o uso da massagem na região lombar de gestantes, quanto à sua capacidade de produzir o alívio da dor na fase ativa do trabalho de parto. E os objetivos específicos: medir, a intensidade da dor autoreferida pelas parturientes antes, durante e após cada aplicação dos procedimentos não farmacológicos; analisar os escores numéricos referentes ao alívio da dor e descrever as avaliações das parturientes sobre os efeitos produzidos pelos procedimentos não farmacológicos. A tese é: O uso do gelo, da água aquecida através do banho de aspersão ou da massagem na região lombar de gestantes, quando empregados como procedimentos não farmacológicos na fase ativa do trabalho de parto são eficazes em produzir o alívio da dor. Ao mesmo tempo, contribui para a evolução fisiológica do trabalho de parto e parto. Baseou-se nos princípios da desmedicalização e no emprego de procedimentos não farmacológicos recomendados pela Organização Mundial de Saúde e ratificados pelo Ministério da Saúde no Brasil. Trata-se de um estudo clínico de intervenção prospectivo, não randomizado, que utilizou uma escala numérica como instrumento para medir a dor autorreferida de parturientes antes, durante e após cada aplicação de um dos procedimentos não farmacológicos. Os resultados evidenciaram que: A maioria das parturientes preferiu a aplicação da massagem na região lombar (21) e banho de aspersão (17). O uso de gelo foi realizado em 7 parturientes. Foi possível observar que a quantidade mulheres que referiram de aumento da dor não ultrapassou a quantidade de mulheres que referiram alívio, principalmente quando a dilatação está em 9cm. Pode-se observar, pela descrição dos comportamentos das parturientes, que poucas referiram medo e grande parte se disse confiante e sentindo-se bem. Algumas mulheres cochilaram e a maioria caminhou livremente. Apenas oito parturientes (17,7%) solicitaram interrupção após a aplicação da intervenção na primeira vez e a grande maioria (91,1%) referiu satisfação com o procedimento aplicado. Em relação ao bebê, em nenhum caso foi necessário realizar aspiração, reanimação com emprego de oxigênio, intubação traqueal, massagem cardíaca ou medicação para reanimação. Não foi detectado nenhum caso de bradicardia ou desaceleração dos batimentos cardíacos do feto. Após o parto, todas as parturientes foram encaminhadas ao Alojamento Conjunto com seus bebês sem necessidade de atendimentos de urgência, ou de internação em setores de atendimento a situações de risco. Confirmando a tese proposta, o estudo concluiu que os procedimentos não farmacológicos foram efetivos em produzir o alívio da dor das parturientes, e que são instrumentos facilitadores da ação fisiológica e natural do organismo feminino, no trabalho de parto.

This study approached the use of non-pharmacological procedures for pain relief in parturients. The general objective was to know the effectiveness of three non-pharmacological procedures: the use of ice; the use of heated water through the bath; and the use of lumbar region massage in pregnant women, regarding its ability to produce pain relief in the active phase of labor. The specific objectives were: to measure the self-reported pain intensity by parturients before, during and after each application of non-pharmacological procedures; to analyze numerical scores related to pain relief and to describe the evaluations of parturients about the effects produced by non-pharmacological procedures. The thesis is: The use of ice, warm water through a shower bath or massage in the lower back of pregnant women, when employed as non-pharmacological procedures in the active phase of labor, are effective in producing pain relief. At the same time, it contributes to the physiological evolution of labor and delivery. It was based on the principles of de-medicalization and the use of non-pharmacological procedures recommended by the World Health Organization and ratified by the Ministry of Health in Brazil. This is a prospective, nonrandomized intervention clinical study that used a numerical scale as a tool to measure self-reported pain in parturients before, during and after each application of one of the non-pharmacological procedures. The results showed that: Most of the parturients preferred the application of lumbar massage (n=21) and spray bath (n=17). The use of ice was performed in seven parturients. It was observed that the amount of owmen who described increasing pain did not exceed those who described pain relief, mainly when the cervical dilation was at 9cm. It can be observed from the description of the behaviors of the parturients that few mentioned fear and most of them said they were confident and feeling well. Some women dozed off and the majority walked freely. Only eight parturients (17.7%) asked for interruption after the intervention was applied for the first time and the vast majority (91.1%) reported satisfaction with the procedure applied. Regarding the baby, none of them needed aspiration, oxygen resuscitation, tracheal intubation, cardiac massage or medication resuscitation. No cases of bradycardia or deceleration of the fetal heartbeat were detected. After delivery, all parturients were referred to the rooming-in with their babies with no needs for urgent care or hospitalization in risk care sectors. Confirming the proposed thesis, the study concluded that non-pharmacological procedures were effective in producing pain relief of parturients, and are instruments that facilitate the physiological and natural action of the female organism in labor.

De-medicalization of birth by reducing the use of oxytocin for augmentation among first-time mothers - a prospective intervention study.

BACKGROUND: The use of synthetic oxytocin for augmentation of labor is rapidly increasing worldwide. Hyper-stimulation is the most significant side effect, which may cause fetal distress and operative delivery. We performed an intervention consisting of an educational program and modified guidelines to achieve a more appropriate use of oxytocin. METHODS: This prospective intervention study included 431 first-time mothers at term with spontaneous onset of labor before (October 2012 to May 2013), and 664 after the intervention (April 2014 to April 2015). Our outcomes were prevalence and duration of oxytocin treatment, mode of delivery, indication for operative delivery, episiotomy, anal sphincter tears, bleeding, labor duration, pain relief and the effect of oxytocin on mode of delivery. RESULTS: After the intervention, 52.9% were diagnosed with dystocia, compared with 68.9% before (p < 0.001). Oxytocin was not always used in accordance with the guidelines, but a significant reduction in oxytocin rates from 63.3% to 54.1% (p < 0.001) was obtained. More women without dystocia according to the existing guidelines were augmented after the intervention (18.9% vs 8.4%, p < 0.001). Assessing all labors, the median duration of oxytocin treatment was reduced by 72% (from 90 to 25 min) without increasing the median duration of labor (385 min in both groups). There was a moderate reduction in operative vaginal deliveries from 26.9 to 21.5% (p = 0.04), and dystocia as an indication for these deliveries increased (p = 0.01). There was a moderate increase in caesarean sections from 6.7 to 10.2% (p = 0.05), but no increase in dystocia as an indication for these deliveries. Women receiving oxytocin were more likely to have an operative vaginal birth, even after adjusting for birth weight, epidural analgesia and labor duration, OR: 2.1 (CI 1.1-4.0) before and OR 2.7 (CI 1.6-4.5) after the intervention. CONCLUSIONS: Our intervention led to a significant reduction in the use of oxytocin. However, more than half of the women remained diagnosed with dystocia. Operative vaginal births seem to be associated with oxytocin treatment. Therefore, augmentation with oxytocin should be used with caution and only when medically indicated. Even more modified guidelines for augmentation than the ones applied in this study might be appropriate.

Finger Pricks and Blood Vials: How doctors medicalize 'cultural' solutions to demedicalize the 'broken' hymen in the Netherlands.

This paper provides new perspectives on the scholarship on medicalization and demedicalization, building on an ethnography of hymenoplasty consultations in the Netherlands. By examining how doctors can play an active role in demedicalization, this paper presents novel insights into Dutch physicians' attempt to demedicalize the "broken" hymen. In their consultations, Dutch doctors persuade hymenoplasty patients to abandon the assumed medical definition of the "broken" hymen and offer nonmedical solutions to patients' problems. Drawing from unique ethnographical access from 2012 to 2015 to 70 hymenoplasty consultations in the Netherlands, this paper's original contribution comes from closely examining how demedicalization can be achieved through the process of medicalization. It investigates how Dutch physicians go even further in their efforts to demedicalize by medicalizing "cultural" solutions as an alternative course of action to surgery.

Negotiating intersex: A case for revising the theory of social diagnosis.

The theory of social diagnosis recognizes two principles: 1) extra-medical social structures frame diagnosis; and 2) myriad social actors, in addition to clinicians, contribute to diagnostic labels and processes. The relationship between social diagnosis and (de)medicalization remains undertheorized, however, because social diagnosis does not account for how social actors can also resist the pathologization of symptoms and conditions-sometimes at the same time as they clamor for medical recognition-thereby shaping societal definitions of disease in different, but no less important, ways. In this article, we expand the social diagnosis framework by adding a third principle, specifically that 3) social actors engage with social structures to both contribute to, and resist, the framing of a condition as pathological (i.e. medicalization and demedicalization). This revised social diagnosis framework allows for the systematic investigation of multi-directional, dynamic processes, formalizing the link between diagnosis and (de)medicalization. It also responds to long-standing calls for more contextualized research in (de)medicalization studies by offering a framework that explicitly accounts for the social contexts in which (de)medicalizing processes operate. To showcase the utility of this revised framework, we use it to guide our analyses of a highly negotiated diagnosis: intersex.

Diagnoses in and out of time: historical and medical perspectives on the diagnoses of distress.

Focusing on the medical approach to the subjective forms of distress, this article has a three-fold argument. First, the historical starting point of diagnosing distress was neurasthenia during the last two decades of the 19th century. Second, the diagnosis of neurasthenia that initially contained more somatic than mental symptoms was gradually replaced by the more psychologically conceptualized neuroses. Such a psychiatrization of neurosis gradually separated mental and somatic syndromes into two distinct diagnostic categories, those of mental and somatic. Third, when modern "neuroses" are seen in the framework of distress rather than disease, it provides tools for new kinds of interventions, in which the principal aim is to alleviate the subjective distress with all possible and reasonable means and methods. As the social context constitutes a crucial "etiology" to medicalized forms of distress, we need new, context-based approaches to both analyze and alleviate such distress. In our historical and medical approach to these "diagnoses of distress", we are guided by the belief that analyzing diagnostic categories can provide important insight into the mechanisms behind our changing conceptions of health and wellbeing.

Beyond medicalization: Self-injuring acts revisited.

For too long, medical/psychiatric and psychological studies, with focus on emotional sensitivity, personality traits, and correlation with psychopathology, have dominated research on self-injuring acts. The phenomenon thus has been defined as a predominantly medical issue. However, a large body of community prevalence studies show self-injuring acts to be a common phenomenon in society, and most of those who self-injure are unknown in psychiatric or other clinical settings. This article describes and analyzes the medicalization of self-injuring acts and argues a need to move research on self-injuring acts out of the medical paradigm. There is a need to explicitly explore the impact of social, cultural, structural, and gendered factors surrounding and influencing self-injuring acts. A non-medical approach, beyond the limits of the medical perspective, would feed research forward and create a more nuanced view on this widespread social phenomenon.

Medicalizing to demedicalize: lactation consultants and the (de)medicalization of breastfeeding.

This paper uses the domain of breastfeeding in the U.S. and the work of International Board Certified Lactation Consultants to refine the concept of medicalization-demedicalization. Given lactation consultants' origins and current role in maternity care, they provide a unique lens on these processes because they are positioned at the crossroads of medicalization and demedicalization. Using 150 h of ethnographic observation and 39 interviews conducted between 2008 and 2012, I identify aspects of medicalization-demedicalization in the work of lactation consultants according to four dimensions: medical definition, medical control, pathology, and medical technology. Lactation consultants work to demedicalize breastfeeding by challenging the construction of breastfeeding pathology and limiting intervention. At the same time, they hold a position of medical control and medicalize breastfeeding by reinforcing a medical definition and using medical technology to treat breastfeeding problems. However, lactation consultants are not only working toward demedicalization and medicalization simultaneously, but are also medicalizing to demedicalize. Their position of medical control over breastfeeding provides them with a certain measure of authority that they can use in their efforts to depathologize breastfeeding and limit medical intervention. These findings build upon previous research that has identified cases of medicalization and demedicalization occurring simultaneously and draw attention to the need for an understanding of medicalization-demedicalization as a continuous process. Furthermore, the concept of "medicalizing to demedicalize" provides a novel contribution to the literature.