Title: A mixed-methods evaluation of pain management for medical abortion up to 10 weeks’ gestation

Authors: Hannah McCulloch¹, Neda Taghinejadi², Katherine C. Whitehouse¹, Patricia A. Lohr¹

Background: Medical abortion has become the principal method of abortion in England and Wales, making up 87% of all abortions in 2021 (1,2). British Pregnancy Advisory Service (BPAS) provides approximately 80,000 medical abortions up to 10 weeks’ gestation annually across England and Wales.

Pain management is central to the provision of high-quality medical abortion care (3). Studies suggest that when clinicians adequately inform and prepare patients for the pain of medical abortion, patients may have less anxiety and increased satisfaction with overall abortion experience (4,5). Following a change in BPAS policy regarding codeine counselling for medical abortion up to 10 weeks’ gestation, we conducted a cross-sectional mixed-methods service evaluation.

Objective: To understand patients’ experience of pain and pain management during medical abortion up to 10 weeks’ gestation.

Methods: We invited patients who had a medical abortion up to 10 weeks’ gestation at BPAS between 7th November 2021 – 3rd March 2022 by email or text message to complete an online, anonymous, English-language survey. The survey had questions about demographics, medical history, abortion characteristics, pain experience and future abortion preferences. Free text questions included advice they wish they had had prior to abortion, and how they would describe medical abortion pain to a friend. All survey responses were optional.

Patients used an 11-point numerical rating scale (0-10) to report their maximum pain score and a 5-point Likert scale for satisfaction with pain management (primary quantitative outcomes). Thematic analysis principles guided analysis of free text responses (6), where we grouped qualitative data thematically, or by patterns identified across responses.

Results
During the evaluation period, BPAS provided 26,668 medical abortions up to 10 weeks’ gestation, and 2,005 patients responded to the survey (see Figure 1).

Of 1625 participants who responded to core quantitative questions, 1,233 (76%) were satisfied with their pain management. Mean maximum abortion pain score was 6.8 (+/- 2.2), with 59% (953/1625) reporting a score of 7 or above. Almost half experienced more pain than expected (48%, 787/1625). When asked about future method preference, 12%  (202/1625) would choose a surgical abortion, of which 83% (167/202) indicated this related to pain experienced during medical abortion.

Predominant themes from free text responses left by 1745 participants were as follows: comparisons of medical abortion pain to period pain are accurate for some, not for others; pain downplayed by healthcare professionals; more detailed information on pain management desired; practical advice they wished they had been given to improve general experience; and better preparation of what to expect physically at all stages of abortion (see Figure 2).

Conclusions and recommendations
Whilst satisfaction with pain management was high, many patients experienced severe pain, often worse than expected. Participants wanted more considered, detailed information about pain management during medical abortion. To better prepare patients for the possible range of pain experience for medical abortion up to 10 weeks’, we recommend: