Improving Care for Women’s Pain
·ÛºìÅ®ÀÉ has made a submission to the Victorian Inquiry Into Women’s Pain.
·ÛºìÅ®ÀÉ
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
In Australia, the Victorian Government recently closed the formal consultation phase of its Inquiry into Women’s Pain. This milestone inquiry will consider experiences and report on opportunities to improve access to care and treatment for women living with pain.
Research shows that chronic pain affects a higher proportion of women and girls than men, yet women are far less likely to receive treatment.
In its capacity as the peak body for women’s health, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (·ÛºìÅ®ÀÉ, the College) contributed via a written submission. Read the College’s submission below.
Thank you for inviting the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (·ÛºìÅ®ÀÉ, the College) to make a submission to the Victorian Government’s Inquiry into Women’s Pain.
·ÛºìÅ®ÀÉ is the lead standards body in women’s health in Australia and New Zealand, with responsibility for postgraduate education, accreditation, recertification, and the continuing professional development of practitioners in women’s health, including both specialist obstetricians and gynaecologists, and GP obstetricians.
Background
As the Terms of Reference of this Inquiry itself states: “It is well established that women and men experience pain differently and respond differently to pharmacological and non-pharmacological pain interventions.” This is sufficient grounds to launch an Inquiry in as much as women make up over half of the Australian population and deserve to have issues as pervasive and prevalent as pain treated seriously by the health care system. Equally, ensuring that health care practitioners have an appreciation of how women experience pain differently to men, and have opportunities for professional development in this area, as warranted by their practice environments, is another clear reason to undertake this Inquiry.
·ÛºìÅ®ÀÉ has gathered input from our membership – both through members sitting on internal Committees and through a public call to comment to our wider membership at large.
While the definition of pain is broad in the scope of the inquiry, ·ÛºìÅ®ÀÉ, as the specialist college for obstetricians and gynaecologists has a focus on obstetric and gynaecological pain. Unless stated otherwise, this submission focuses on pain in the clinical remit of obstetrics and gynaecology.
Specific Feedback
The College has organised this submission to respond to four key questions for consideration by the Inquiry.
What recommendations can be made to the Inquiry to improve models of care and service delivery for women in Victoria?
Firstly, not all pelvic pain in women (or people with a uterus and ovaries) originates in the reproductive organs. A common default, though, is that pelvic pain is reflexively labelled as pain from periods or even endometriosis or other similar conditions (notwithstanding the very real issues with delayed diagnosis of endometriosis).
The preconception of all pelvic pain as ‘reproductive’ in origin can lead to a delayed diagnosis of other conditions. Recognising and designing interventions to address this default is a first step in improving pain management.
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Health professionals could regularly update their knowledge and skills in holistic pain management; like that of specialist pain teams’ approach. To do so though, better access to protected time, and high-quality training resources and opportunities are required. This comes back to capacity in the health system to support practitioners to upskill in areas outside of their base training scope. Supporting the establishment and maintenance of women’s health specialist pain teams throughout the health system, to enhance access to patients and practitioners when planning care with women is vital. It is not enough to simply say that health professionals should train in this area. Health systems should support them in doing so by making time and resources available for this professional development that does not come at an opportunity cost to the practitioner.
Some considerations for operationalising this approach could be:
Implementing gender-specific training programs for healthcare professionals to better address the pain-specific needs and concerns of women. This would highlight the importance of keeping clinical knowledge up to date among healthcare professionals and keep the influence of medical gender bias front of mind.
Conducting regular assessments of existing models of care to identify and address any gaps or deficiencies, involving consumer groups to better understand patient perspectives.
Promoting greater collaboration and integration between different healthcare providers and services to ensure holistic and coordinated care for women.
Advocating for the development of guidelines and protocols that specifically address gender bias in pain assessment and treatment.
Supporting patient-focused initiatives aimed at empowering women to advocate for themselves and challenge instances of bias in their interactions with healthcare providers throughout the health system.
Promoting the use of telehealth and other innovative approaches to improve access to specialised care for women in rural and remote areas or those who cannot access transport and afford the time to travel to urban centres where specialist pain management provision is often concentrated.
Recommendations on models of care must address the desperate need for enhanced service provision in regional centres and rural areas. Workforce shortages of both frontline health providers and specialists often mean that care for anything, including women’s pain, is neither timely nor accessible.
Finally, prevention strategies must be better supported at a systemic level to keep as many women as possible from delaying treatment for pain or presenting to emergency or urgent care after a lengthy experience with pain. Partly, this means improving health literacy amongst the general population. Public health campaigns can influence socialising the causes and recognition of pelvic pain. Better health literacy in patients, supported by public health and the health care system will also contribute. There are a number of valuable community resources, for instance, the Pelvic Pain Foundation of Australia’s , that can assist in this area.
What is the role medical gender bias and its contribution to women’s experiences of pain and lack of treatment/denial of treatment?
Gender bias in society at large is real, and health care is not immune from the same bias. If women present to a health care provider with any type of abdominal pain, it is often attributed to a gynaecological cause without sufficient consideration of other possible aetiologies for the pain.
An example from a ·ÛºìÅ®ÀÉ member consulted on this submission provides an illustrative point: At one evening handover, staff at the end of shift provided a brief about a patient with abdominal pain and CT findings suggestive of appendicitis. However, because there was a haemorrhagic follicular cyst found on ultrasound scan, the surgical response was that the pain was of gynaecological origin. This describes a common occurrence where pain is associated to a gynaecological cause, if at all possible, potentially due to gender bias, when clearly confounding causes are also current in the presentation.
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This has the unfortunate, but not unpredictable, effect of minimising or dismissing women’s pain. This is well reported, and not incorrect. Once again though, the causes of this gender bias run deeper than medicine, and we must look at the responsibility that society at large has both for the perpetuation of this bias and its resolution. Part of this bias stems from the “social acceptance†(as unfortunate as that term may be) of certain pre-conditions that disadvantage women. For instance, it is a widely held belief that women’s periods are painful and problems with periods are common.
This pre-existing belief has the effect of causing women’s pain (especially pelvic pain) to be thought of – at least to some degree – as normal. This view is often internalised by women themselves and acts as a form of self-censorship in causing self-minimisation of their own pain before even seeking care for it. This extends beyond general pelvic pain into obstetrics, in that, again, it is all too common of a view that pregnancy and especially labour are pain-intensive exercises. Labour is certainly painful. But the effect of assuming pain is a built-in part of the experience makes it more difficult to advocate for pain that may fall outside of normal clinical labour pains. None of this should be read as blaming women for not being better advocates for themselves, collectively or individually. When social norms are deeply entrenched, it is difficult or even impossible to see beyond those parameters as an individual person and, if necessary, break out of them.
When women finally do seek care for pain, the baseline expertise in their usual health care provider (frequently a general practitioner or nurse practitioner) is not necessarily adequate to overcome this bias. Delays in referring women to the correct specialist then contribute to the elongation of the period of suffering before treatment can begin. Better support for multidisciplinary women’s pain clinics that are accessible will assist in addressing system bias over time.
Are there any other forms of gender-based barriers that women face when attempting to access care for pain?
There is still a lack of appreciation of the mind – body interplay with respect to pain in any gender. Specific to women, there is not enough consideration given to the entirety of a woman’s entire psychosocial situation, past and present with respect to the aetiology of pain, the perception and ultimately the meaning of that pain. All pain is real. Its genesis, effect, and the sufferer’s ability to manage that pain and its consequences, with and without help vary. Often that variation is at least in part attributable to the care received from health professionals.
The term ‘care’ rather than ‘treatment’ is used because it is the care that matters for so much of the pain women encounter. It is easy to treat acute gynaecological pain from say adnexal torsion or an ectopic pregnancy. It requires care to manage a patient with chronic pain of a probable multi-factorial origin.
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The 2024 Women’s Health Summit presented by ·ÛºìÅ®ÀÉ in Canberra in March this year intensively covered the topic of intersectionality in relation to women’s experiences with the health care system. Intersectionality as a lens for understanding experiences of pain is also essential. Specifically, how does gender, poverty, race, education, structural barriers, location and so on contribute to women’s experiences accessing healthcare and preventative healthcare. Applying the bio-psycho-social-spiritual framework[1] to an approach to understanding pain experiences also underlines the importance of better appreciating the whole-of-life experience of the individual person when considering pain.
Inevitably, we must also appreciate the ingrained bias in society at large that discounts women’s pain. This manifests often in health care experiences which apply procedural lenses that do not fully appreciate women’s pain, for example “basic†procedures such as cervical dilation done without adequate analgesia, or insufficient pain management during childbirth stemming from the “natural†view of labour. These social biases must be unwound with persistent effort equivalent to the intensity of the ingrained bias. This will take time.
Finally, it cannot go unremarked that birth trauma, and the pain associated with the experience (either physical or psychological) is very prevalent in the national discourse right now. ·ÛºìÅ®ÀÉ is committed to reducing the incidence of birth trauma. The College’s view is that the best way to do this is through improved training for safe, effective and respectful maternity care, with all health professions involved in maternity working together in a truly multi-disciplinary way.
Does locality impact women’s experiences of pain/ability to access quality services? What recommendations regarding care provision in regional and remote locations can be provided to the Inquiry?
In remote, rural, and even larger regional areas it is often very hard to provide the multifaceted, multi-disciplinary care needed to manage and care for women with complex pain. It may require general and specialist medical practitioners, social workers, psychologists, dieticians, physiotherapists, and chronic pain specialists to provide care unique to their specialities.
These multi-disciplinary teams are difficult to assemble in smaller areas that are often struggling to provide basic general obstetric and gynaecological services or basic health care services generally.
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This is a symptom of health workforce deficits currently being experienced across Australia, magnified in rural areas. This is, in part, natural. When resources are concentrated at better funded hospitals in urban centres, urban practice becomes more appealing to more health professionals. As this cycle perpetuates, it becomes harder to ensure adequate resourcing of facilities in regional areas, with enough qualified professionals to staff them.
While this challenge goes beyond obstetrics and gynaecology, ·ÛºìÅ®ÀÉ is already working to combat these issues in regional areas, as described in our recently released Rural, Regional and Remote Women’s Health Strategy.
Health professionals of all stripes must have better opportunities for equitable training in regional areas. ·ÛºìÅ®ÀÉ’s Obstetrics and Gynaecology Education and ·ÛºìÅ®ÀÉ (OGET) project is an example of how multidisciplinary training can be effectively carried out in regional areas. This project is funded by the Commonwealth, and funding is currently time limited (February 2025), though ·ÛºìÅ®ÀÉ is strongly advocating for its permanent continuation, and would welcome the support of the States to help make this happen.
Summary
While this Inquiry is clearly a listening forum at this stage, and a welcome one, several thematic areas for recommended action to address the care of women’s pain have been discussed in this submission.
·ÛºìÅ®ÀÉ’s view is that the Inquiry should consider making recommendations for action in the following areas, and the College would be pleased to continue collaborating with the Victorian Government on these initiatives:
More and better support for training opportunities, especially in regional and rural areas of Victoria (see ·ÛºìÅ®ÀÉ’s OGET project, and other similar initiatives). ·ÛºìÅ®ÀÉ in rural areas makes practicing there more likely, which in turn improves access to care for patients;
Support general health literacy through community health awareness and prevention programs;
Consider how best to establish specialist, multi-disciplinary women’s pain clinics, and where, so that both patients and health professionals can better access the benefits that a multi-disciplinary approach to care brings;
Collaborate on better workforce data planning, workforce development and workforce distribution strategies.
·ÛºìÅ®ÀÉ acknowledges with thanks, the contributions of Dr Marilla Druitt, the collective members of the ·ÛºìÅ®ÀÉ Women’s Health Committee and all members who responded to our call for input into for this submission.
For media enquiries
Bec McPhee
Head of Advocacy & Communications
+61 413 258 166
bmcphee@ranzcog.edu.au
[1] Taylor LEV, Stotts NA, Humphreys J, Treadwell MJ, Miaskowski C. A biopsychosocial-spiritual model of chronic pain in adults with sickle cell disease. Pain Manag Nurs. 2013 Dec;14(4):287-301. doi: 10.1016/j.pmn.2011.06.003. Epub 2011 Dec 14. PMID: 24315252; PMCID: PMC3857562.