Factors associated with severe pain during medication abortion at ≤9 weeks’ gestation: A secondary analysis of a multicenter, randomized, placebo-controlled trial

Objectives: This study aimed to identify covariates other than pain management regimen associated with severe pain during medication abortion at ≤9 weeks’ gestation. Study design: This is a secondary analysis of a randomized trial in Vietnam, Nepal, and South Africa investigating two prophylactic pain management regimens during medication abortion. We used multivariable logistic regression models to identify factors associated with severe pain within 8 hours after taking misoprostol. Results: During June 2016 to October 2017, 273 of 556 (49.1%) participants experienced severe pain (score ≥8 out of 10). In multivariable analyses, controlling for study center and prophylactic treatment arm, multiparity (odds ratio [OR] 0.35, 95% CI 0.23–0.53) was associated with reduced odds of severe pain, while dysmenorrhea (OR 1.16, 95% CI 1.07–1.26) and higher gestational duration (OR 1.05, 95% CI 1.01–1.09) were associated with increased odds of pain. Higher anticipated pain score (OR 1.10, 95% CI 0.99–1.23) was marginally associated with severe pain. Among multiparous patients, history of cesarean delivery (OR 3.49, 95% CI 1.24–9.77), severe pain in childbirth (OR 2.36, 95% CI 1.03–5.42), and dysmenorrhea (OR 1.22, 95% CI 1.08–1.39) were significantly associated with severe pain. Higher gestational duration (OR 1.05, 95% CI 0.99–1.11) trended toward an association with severe pain. Sociodemographic variables, including younger age, marital status, financial stability, and anxiety or depression, were not associated with pain. Conclusions: Beyond known risk factors of nulliparity, dysmenorrhea, and gestational duration, this analysis demonstrates that severe pain during medication abortion is significantly associated with history of cesarean delivery and severe pain in childbirth. Depression and anxiety were not associated with severe pain. These findings can inform counseling for patients seeking medication abortion. Implications: Education and counseling prior to medication abortion should include information about the range of factors associated with increased pain. This information can help individuals make informed decisions about their abortion method and, for those choosing medication abortion, better prepare for and optimize their pain management.