Preparing patients for medical abortion pain: ongoing evaluation and service development at BPAS

Pain is often reported as one of the worst aspects of a medical abortion, but, as mentioned in a previous BPAS blog,  we don’t have the best evidence on how to manage it. Adequate counselling and accurate management of expectations have been identified as being linked to reduced anxiety during abortion and increased satisfaction with overall abortion experience. Being informed and prepared about what to expect has also be identified as a quality indicator of abortion care in previous CRRC research with abortion patients.  

In 2022, we conducted a service evaluation at BPAS to investigate pain and pain management amongst our patients who had had a medical abortion up to 10 weeks’ gestation; over 1600 of our patients completed a survey following their abortion. Whilst the main aim of this evaluation was to assess the impact of a change in policy change regarding how we counsel about codeine, we also learned a lot from our patients about management of expectations of medical abortion pain and how we (and other abortion providers) could do this better.  

While many survey participants reported experiencing similar or less pain than they expected during their medical abortion, almost half experienced more pain than expected. Free text comments suggested that for some, this could have been due to the information they had read in paper treatment guides or on the website, or had received from nurses or midwives during their consultation. Some felt that pain had been “washed over” or “downplayed” and that comparisons to pain as “like period pain” had left them unprepared for the pain they experienced.  

Survey participants shared the impact of not being adequately prepared for the pain they might (and did go on to) experience during their medical abortion. This included impacting planned pain management strategies, where participants would have timed their abortion and their analgesia differently. In extreme cases it made some participants feel that they might need emergency help when they did experience severe pain outside of their expectations, from how they had been prepared.  

In line with other published research, our survey findings show how pain experienced during a medical abortion has impacts on acceptability of this method and on method choice for future abortion. Our participants also told us that accurately counselling on possible pain is important for informed decision making about method choice. 

Hundreds of participants shared advice they wished they had been given or information they wished they would have known before their abortion, as well as how they would describe medical abortion pain to a friend. From this, we have produced a list of patient recommendations for counselling for medical abortion pain, which includes:  

• Providing detailed, comprehensive advice about possible pain, pain management and coping strategies, including timing of analgesia and alternate routes for pain relief  
• Referencing the broad range of possible pain, highlighting the possibility of severe pain and reassurance for less painful experiences  
• Avoiding singular, subjective comparisons to period pain or cramps; instead use an accessible range of descriptions or comparators in patients own words.  
• Encouraging patients, where possible, to consider being accompanied when self-managing medical abortion at home 
• Before the abortion, creating a comfortable, enabling environment and reviewing supplies to manage side effects, as patients may not want or be able to leave home during the abortion. E.g. food, drink, pain relief, hot water bottles or heating pads, menstrual pads. 

Changes have been made to BPAS patient information in response to evaluation findings, which have been shared across BPAS at all levels. Singular references to period pain or cramping have been removed from online and paper patient literature. Staff training documents, treatment guides and the BPAS website now include links to a range of patient descriptions which shows the broad spectrum of possible pain. An accessible, extended video of descriptions is also available on the website.   

There are future evaluation plans for new patient information material. Since anticipated pain and anxiety are known to be associated with increased pain during abortion, we are conscious to understand whether new content does better prepare patients, or if there were any unintended, negative consequences. Patient involvement in research is a core part of BPAS’ strategy, and we strive for all patient information materials to be developed in collaboration with our patients.  

Authors are writing up the findings of the mixed-method analysis of the pain management evaluation for publication.