Women opting for a medical abortion at home are often advised that the procedure is likely to be no more painful than period cramps, suggest the results of a survey, carried out by the British Pregnancy Advisory Service (BPAS), and published online in the journal BMJ Sexual & Reproductive Health.
This leaves many women unprepared for the intensity of the pain they experience, with some survey respondents saying they would have chosen a different option, had they known.
More realistic and patient centred information needs to be provided to enable women to make an informed choice, says the author, noting that BPAS has already changed its approach in light of the findings.
Medical abortion is achieved with pills at up to 10 weeks. It can take place at home and can be delivered by telemedicine without the need for a clinic appointment.
In England and Wales, it is the most common method up to 10 weeks of pregnancy, with nearly all such abortions carried out at home, explain the researchers.
But medical abortion is often painful. And several previously published studies have highlighted the importance of anticipatory counselling about pain management, and the impact that good counselling can have on fear, anxiety, and the level of pain experienced, the researchers add.
To better understand the experience and expectation of pain, and how these might determine choice of abortion method, the researchers invited 11,906 BPAS clients who had had a medical abortion up to 10 weeks of pregnancy to fill in an online questionnaire between November 2021 and March 2022.
They were asked about the pain they experienced, and how they would describe this to a friend; if they had to have another abortion, what their preferred method would be, and if this was influenced by the pain they experienced; and what advice they would like to have been given about what to expect.
In all, 1596 (13.5%) completed the questionnaire, and included at least one free-text comment. Most (85%) were between the ages of 20 and 39.
One in three of the clients (530) had pregnancies that were between 8 and 9 weeks and almost half had not given birth before (49%; 777).
About half (48.5%; 773) of respondents said that the pain they experienced was more than expected, with most (92%) giving their pain a score of at least 4 out of a maximum of 10. In all, 662 (41.5%) scored it 8-10 (severe).
While two thirds (1047) of respondents said they would choose a medical abortion if needed in future, around 1 in 8 (13%; 202) said they would have a surgical abortion. And most of them (83%; 167) cited pain as a factor in this decision.
Those who opted for a surgical abortion if needed in the future reported an average maximum pain score of 8.5 compared with a score of just over 6 for those opting for a medical abortion if needed in the future.
Some respondents felt the pain they experienced was no worse than period pain, but others felt unprepared for the level of pain they experienced, which they attributed to being advised that it was comparable to period pain, as well as a lack of detailed, realistic anticipatory pain counselling.
One respondent said: "Pain was so much stronger than period pain, it was like having contractions in labour. I've given birth three times and the pain really wasn't too much different from that pain, the cramping contraction pain."
Others said the pain they experienced was far greater than expected, with some directly attributing this to language or detail given to pain in consultations or information leaflets as being "washed over", "downplayed," or "sugar-coated."
A substantial number of respondents said that descriptions of medical abortion pain as period-like (for example, "like a period", or "a bad period", "period cramps" or "period cramping") had played directly into their expectations.
One respondent commented: "[Being transparent] might put some women off from abortion, however, I feel that patients have a right to fully understand the risks and benefits. This should be made absolutely transparent; shared and informed decision making is essential."
"Providing accurate, realistic information on pain is not only important for preparing patients for medical abortion, but for supporting informed consent for abortion method choice, in the context of structural constraints," write the researchers.
They acknowledge the potential for misremembering pain intensity among respondents, but say the findings have already changed the information BPAS provides on what to expect if clients choose a medical abortion.
"Patients want detailed, realistic anticipatory pain counselling as well as general preparatory advice, including first-hand experiences which reference a wide and accessible range of descriptions of pain," they conclude.
*Lead author, Hannah McCulloch, comments: "Benchmarking against period pain has long been used as a way to describe the pain associated with medical abortion, despite the wide variability of period pain experienced.
"The results of the survey show that counselling on this aspect of medical abortion needs to improve. For many respondents, using period pain as a reference point for what to expect was not helpful for managing expectations, or in line with their experiences.
"Women want more detailed, realistic information to make choices about treatment and to be prepared for medical abortion if that is their preference. And medical abortion is a very safe and effective choice. This evaluation led us at BPAS to create new patient materials and provide additional staff training, which we are currently in the process of evaluating."
