The study team invited and interviewed a total of 42 participants, including 7 parous and 7 nulliparous women from each of the three study countries; no participant declined to be interviewed. All interviews were recorded except for one, where the recording device failed and the interviewer took notes instead. Participants included 15 from the tramadol group (3 in Nepal, 8 in South Africa, and 4 in Vietnam), 16 from the ibuprofen/metoclopramide (ibu/met) group (7 in Nepal, 3 in South Africa, 6 in Vietnam), and 11 from the placebo group (4 in Nepal, 3 in South Africa, 4 in Vietnam). The median age of participants was 23 (range: 1844, IQR=20-32). Most participants in South Africa were single (n=13), while most participants in Nepal and Vietnam were married (Nepal: 11, Vietnam: 8) or partnered (Vietnam: 6). One-third of the sample had completed secondary school, and 64% had completed more than secondary school; 43% of participants were currently in school. All except 3 participants in South Africa lived in urban areas (see Table1). Food insecurity was reported by only one woman in Nepal, who responded that she often went without food in her household.

Among parous participants, the average number of previous pregnancies was 2 in Nepal, 1.7 in South Africa, and 3.1 in Vietnam. One-quarter of the sample reported having a previous abortion (only in Nepal and Vietnam), and three participants had previous MA experience. The average gestational age at presentation was 49days (SD: 7.8, range: 3463days); Nepal and Vietnam had similar averages (47 and 46days respectively) while South Africas average was 55days. On a 10-point scale, the average overall pain level reported with MA was 5.2 (SD: 2.5). The average highest pain in the first 8h after misoprostol was 6.6 (SD: 2.5), ranging from 6.1 in Nepal to 6.7 in Vietnam and 7.1 in South Africa. All participants had a successful medical abortion without any further treatment.

The following four themes emerged from the content analysis: pain and other side effects of the MA; medical abortion pain relative to menstrual, labor, and previous abortion pain; pain management; and emotional experiences (see Table2). We explore these four themes below.

Based on participant descriptions, we identified four types of pain trajectories. Ten respondents reported minimal pain overall (4 Nepal, 4 South Africa, 2 Vietnam). One said, I never had an abortion, so I was expecting more pain but there was no pain. It was just normal; I was doing the house chores I am used to doing (3135 y, South Africa, parous, placebo). Another explained, It wasnt painful at all, not even a little. There was no such feeling of pain. Only when the pregnancy started to discharge, there was a feeling of something coming out, like when Im on my period but there was absolutely no pain (3135 y, Vietnam, parous, tramadol).

Eight participants reported brief intense pain and said it occurred right before expulsion. One participant said, It hurt terribly, it hurt in a way that its very unlike any normal pain I had 30 minutes of intense pain, after that I felt better, then gradually it eased and then I could walk as usual (3135 y, Vietnam, parous, tramadol). Nine participants experienced intermittent pain, which some described as similar to labor contractions: It pained and disappeared and again pained and again disappeared (2125 y, Nepal, nulliparous, placebo). Another participant explained, I think its like labor pain, intermittent pain from light pain to heavy pain (3135 y, Vietnam, parous, ibu/met). And five participants described feeling constant pain for an hour up to several hours: The pains were like 10 for about 3 or 4 hours there was no change. The pains were constant (1820 y, South Africa, nulliparous, ibu/met). There were no distinct trends in pain trajectories by treatment group, age, parity, or country.

The most commonly reported symptoms were chills and shivering (12), nausea (9), vomiting (8), fever (8), and diarrhea (8), with no clear trends by parity, treatment group, or country. One participant said, I felt really cold, and I was shivering even when I was staying in the sun, it still felt cold (1820 y, Nepal, nulliparous, ibu/met). Another reported, Diarrhea was the most intolerable. It made my stomach gurgle and I felt nauseous so I needed to go to the bathroom constantly even though I felt cold and just wanted to stay in my bed the diarrhea and nausea were the worst (2125 y, Vietnam, nulliparous, tramadol). Five participants reported weakness and/or dizziness: I tolerated the pain for half an hour, it was all because of dizziness that I couldnt tolerate the pain (2125 y, Nepal, nulliparous, tramadol). Five participants said they had numbness or immobility (under the tongue or in the limbs). One woman described, it felt so numb with painI think it was because of the pills melting. I think they made me feel that way (3640 y, South Africa, parous, tramadol). Another said, There was no abdominal pain. Only my limbs, it felt like I cant handle it anymore, I felt paralyzedIt hurt terribly, it hurt in a way that its very unlike any normal pain, I have never experienced such kind of pain. My limbs couldnt even move (3135 y, Vietnam, parous, tramadol). All but one participant in Vietnam and over half of the Nepal participants (9) reported at least one symptom beyond pain, while only 6 participants in South Africa reported symptoms.

MA was reportedly more painful than menstruation for most participants who commented on the comparison regardless of parity or treatment group (23 vs. 9 who reported MA as less or similarly painful compared to menstruation) and less painful than labor (17 vs. 4 who reported MA as more or similarly painful compared to labor). Respondents compared overall pain of the current MA with pain in menstruation, labor, and previous abortion using one or more of the following factors: pain intensity, pain duration, associated symptoms and side effects, and response to pain medications. One woman ranked her experiences in terms of intensity and duration: the least painful was suction abortion, at level 7-8 but only for a short period of time. The second one would be the recent [medical] abortion, heavy bleeding hurt at level 9-10. Third one is my second labor, pain level was at 7-8 but lasted longer than the abortion. And my first labor hurt the most, pain level 9-10 and lasted incredibly long (3135 y, Vietnam, parous, ibu/met).

With regard to pain intensity, one participant said, This one wasnt that bad at all, I didnt even feel like I was doing an abortion, there wasnt a lot of pains. So the menstruation one is the worse one if I were to compare them (2125 y, South Africa, parous, ibu/met). In contrast, another said, the abortion gave me heavy painit was more painful than the period pains (3640 y, South Africa, parous, tramadol). Several participants who had previous abortions attributed lower pain levels in the current abortion to the use of pain medications: The bleeding was same on both times. But the pain was more in previous abortion than this time. I also didnt have much difficulty as I took [pain] medicine this timeMaybe that is why compared to the previous abortion I didnt feel much pain (2630 y, Nepal, parous, tramadol). Another said that just having pain medications easily available to her made the experience better: During my previous abortion, I wasnt told to do anything if I had pain. So this time I had medicine if I had pain, even though I didnt take it so it felt really good. Instead of going out and buying the medicine, when one has a packet with themselves they can easily take it (3640 y, Nepal, parous, ibu/met). One more explained, If I have to compare, [this time] was painful for less time while using medicine during my last abortionit was 6-7 on scale for 6-7 days. But this time even if the pain was 10 on scale, it got lessened after having medicine (3135 y, Nepal, parous, ibu/met).

Most parous participants explained that the pain intensity of labor was much higher than MA: It was nothing compared to my labor pain, because my labor pain was extremethe labor is the worst, then comes the suction abortion, finally the pain from this abortion using medicine (3135 y, Vietnam, parous, ibu/met). Another explained, labor pains were highermaybe 5 to 1. Labor pain 5 and abortion pain 1 (2125 y, South Africa, parous, tramadol).

Duration of pain in menstruation was shorter and typically predictable for most participants, whereas with MA, it was less predictable and occurred throughout the experience. One participant explained, For menstruation, it pains a little on the first day and then it doesnt pain. But during abortion, it was paining on the first day and on the third day (2630 y, Nepal, parous, tramadol). Another said, I dont get pain during every menstruationI feel pain for one day only. During abortion as well, I had pain for a day only. That is why I feel its the same (3135 y, Nepal, parous, ibu/met). Those who reported previous abortions often determined which experience was more painful by comparing duration of bleeding and pain. One participant said she preferred her previous MA to the current one because the time it took to expel the pregnancy was longer this time and her pain was delayed (4145 y, Vietnam, parous, placebo). Similarly in childbirth, participants attributed higher overall pain to a longer duration of pain: when I delivered my child, the whole day I felt like the time when I had my abortion (3135 y, Nepal, parous, ibu/met).

For many, the comparison of pain in MA with that of menstruation or labor was dependent on symptoms other than pain alone. For example, one participant said, My period pain is just normal, but [with MA] it was twisting and I had diarrhea and fever also, chills and shaking. Thats the difference (2125 y, Vietnam, nulliparous, tramadol). Another said, Normal delivery is painful because of many reasons, for example episiotomy.because theres no factors like that, MA is much less painful (4145 y, Vietnam, parous, placebo). Another added, With giving birth, beside labor pain, you suffer also from the tear of vagina afterward, which prolonged the pain. After the abortion, you only suffer for 1 day (2630 y, Vietnam, parous, ibu/met).

Ten participants (6 Vietnam, 4 Nepal) reported a previous abortion and compared it to their current experience. Some women explained that the lack of instruments helped reduce their pain or anxiety levels with the current MA compared to a previous surgical abortion. One woman said, this time hurt more than last time but was less scary because I didnt have to listen to the sound of the surgical tools, so there was less mental pain the clanking sound of surgical tools scared me (3135 y, Vietnam, parous, ibu/met). Another said it was much less painful, my psyche was much at ease, and it was more privateI feel quite embarrassed every time I have gynecology check. Like taking my clothes off and checking, thats what makes me feel not comfortable at all (3135 y, Vietnam, parous, ibu/met). Another who had experienced three surgical abortions highlighted the importance of supportive, non-judgmental providers:

In my other previous abortions there was just me in the room. The doctors were scary and the things they said really annoyed me, like I don't want to do this. It's just that you asked for it, so I felt very uncomfortable. I had to accept it. I had a wonderful consultation this time, I was able to do self-check at home, and I had my relatives next to me and also someone to talk to during the process. Time went by really fast. I felt stronger mentally not feeling like abandoned in the room like any of those previous abortionsthis time was more painful but more relieved. I felt safer since the surgical ones are scary, not as painful but much more scary. (31-35 y, Vietnam, parous, tramadol).

One participant said the current abortion was worse than her previous experience because she had an incomplete abortion that required her to have multiple follow-up visits (although she did not have additional treatment).

Most reported that the study medications eased MA pain. One participant said, Because they not only gave me medicine when I was in pain but before I had pain they had given me medicine. So I felt my pain got cured after taking medicine. I didnt have to take additional medicine (2125 y, Nepal, parous, tramadol). However, it was not always clear if participants were referring to the study medications or the additional analgesics taken as needed as being responsible for the pain relief. One respondent said, It was very satisfying because if it wasnt for the medication I would have slept in pain (2125 y, South Africa, nulliparous, tramadol). Another commented, After having the medicine, it lessened my pain and I felt like eating as well. I had a fear that if something might happen, after the pain was gone, I felt that I am fine now (3135 y, Nepal, parous, ibu/met).

For managing pain in general (not specific to MA), some South African women reported taking medications including paracetamol and aspirin; only a few women in Nepal and Vietnam reported taking medications for more extreme pain. A woman from Nepal said, If sometimes I have more pain and I have to go for duty, I take paracetamol. Otherwise I dont...If it is paining around 5, I take medicine (3640 y, Nepal, parous, ibu/met).

The use of non-medicinal methods for managing MA pain were most common in Nepal, and less so in South Africa and Vietnam. These methods were similar to those reported for menstrual pain, including most commonly wrapping a piece of cloth around ones abdomen (Nepal), eating or drinking hot foods and liquids (all countries), and using a hot water bottle or massage (all countries). One woman said, I was dependent on hot watermy husband used to give me water frequently. He boiled the water in a thermos and put a glass in front of me. I just took rest by drinking hot water (4145 y, Nepal, parous, ibu/met). Participants in Nepal and Vietnam also reported eating warm foods with protein, such as soup or eggs, to ease pain. One woman in Vietnam explained, Only my sister massaged me. She massaged and pressed on the area where I said was painful (3135 y, Vietnam, parous, tramadol). In South Africa, several women reported taking hot baths and lying flat on the floor to soothe the pain: I just lay down on a cold floor and they become better (3135 y, South Africa, parous, tramadol), and I just took a bath to relax my body (3135 y, South Africa, parous, tramadol).

One participant explained the use of a cloth wrap around the abdomen for menstrual pain:

Because there is just air in our stomach, [so] we have pain in stomach. That is why it gets better after wrapping a piece of cloth. ... I wrap it for 1-2 hours when I have pain. . When I wrap it like that it lessens my back pain as well. When I have menstrual period, we have stomach and back pain, so it also lessens that pain. I havent used any [medicine] to date. (2125 y, Nepal, parous, tramadol)

In South Africa, a participant said, I take the hot water bottle and I put it there or something that is warm and eventually I become okayit helps and sometimes it does notI sleep if nothing works (2125 y, South Africa, nulliparous, ibu/met). One respondent in Vietnam said she tried taking a menstrual regulation pill, a combination of herbal extracts containing traditional medications called Phu Huyet Khang in between periods to prevent pain: The next period, the pain was much less intense this medicine helps regulate the menstrual cycle (2125 y, Vietnam, nulliparous, placebo).

For managing labor pain, many reported walking, keeping busy, and massaging their bodies during labor; only three reported receiving pain medications for labor pain (one in South Africa and two in Vietnam). One woman said, my mother massaged me with oil all over my stomachmy mother told me that the pain might lessen if I stayed in a hanging positionbut I just stayed clenching my teeth (2630 y, Nepal, parous, tramadol). Another woman answered, Nothing, I was just walking and screaming (3135 y, South Africa, parous, placebo). A participant in South Africa said, With my first child I asked them to bring me black forest [cake]I would eat, when that pain comesI ate that thing almost twelve hours with my second-born I was betterI realized that I should nurse the pain. The more you walk the more you relieve stress (3640 y, South Africa, parous, tramadol).

Many participants said they felt conflicted or guilty about having an abortion, but no one expressed regret about the decision. One woman said, Half of me wanted to have an abortion and the other half wanted to keep the child, but I couldntI stayed strong and went forward because I could not just sit and let the pain take over, I had to get up and get going, as sitting and crying will not help (3135 y, South Africa, nulliparous, placebo). Another participant said, And after I had the abortion, I felt happy and securedI didnt feel anything emotionally. I didnt want this pregnancy, I only thought about how this pregnancy will go and I will feel relieved (3135 y, Nepal, parous, ibu/met). In Vietnam, one woman said, I feel like Im such a terrible human being for having an abortion (1820 y, Vietnam, nulliparous, ibu/met), and another explained, I feel guilty about what I have done, yet I think it was the best thing that we could do provided our situation (2125 y, Vietnam, nulliparous, placebo). Others were not emotional at all about the experience: I didnt have any feelings as such. I just wanted it to finish as quickly as possible (3135 y, Nepal, parous, ibu/met). Another explained, If I had thought of keeping it then I would have been emotional. But when I had thought of having abortion, then I didnt feel anything about it (Nepal, parous, tramadol, 2125y). One woman said, I just wanted to get rid of this pregnancy. Thats all I was thinking (2125 y, Nepal, nulliparous, placebo).

Most who struggled emotionally or were conflicted said their emotions did not affect their physical pain. However, many explained that having emotional support from family and friends during the process made them feel more secure and in some cases more physically at ease. One woman from Nepal said, If our husband is with us, then it will be a lot easier (2125 y, Nepal, nulliparous, tramadol). Another Nepali woman said, Because I was feeling really bad from inside, so my emotional pain was a lot more than my physical pain, so I think that was the reason that helped me to not focus on my physical pain (2125 y, Nepal, nulliparous, ibu/met). Several participants from Vietnam discussed the importance of family or partner support:

I think the mental state really affects how we feel during abortion. If were more relaxed, then we will feel less pain. Maybe I was unhappy and not so comfortable about this, so I felt more pain. if [patients] have someone to comfort them that would be the best mental remedy to reduce the pain (21-25 y, Vietnam, nulliparous, placebo).

I felt that I wasnt abandoned, so that pain was better...I can feel less scared even when my boyfriend just holds my hands (18-20 y, Vietnam, nulliparous, placebo).

Basically when you're taking that pill you'd better have someone next to you. That's for the best. Firstly, just in case something happens there would be someone next to you to calm you down and help you. Secondly, it's better to have someone to talk to rather than being alone (31-35 y, Vietnam parous, tramadol).

In South Africa, participants shared similar sentiments. One participant said, I cried a bit in the afternoon and at night I was fine because my friend was there (1820 y, South Africa, nulliparous, placebo), and another said, I dont think I would have coped [without mama]. Imagine if I had to go get the water on my own, get the pain killers, the water bottle, all of that (1820 y, South Africa, nulliparous, ibu/met).

Those who lacked support explained that it would have helped. One participant said, I contained everything within myself and I did not tell anyone, so I am thinking maybe if I had shared with someone I do not think I would have felt that much pain (2125 y, South Africa, nulliparous, ibu/met). Another explained:

I was the only one who knewThere was no one to help me, no one to talk to.I wish we had already been married so he could be by my side and everyone could know. If the pain got worse, everyone could have taken care of me or told me what to do. (2125 y, Vietnam, nulliparous, tramadol)

Women who had previous experience with abortion appeared more prepared psychologically to handle the MA pain. For example, one woman said, I accept that pain because I know it should happen like that. It is what I must accept because I had reckoned it before.because I was prepared beforehand, I already knew all the steps, the pain that I had to endure, I can mentally be ready to overcome it easilyso I can be less nervous (3135 y, Vietnam, parous, tramadol). Another said, I had to abort it anyhow so my focus was on abortion only. I felt normal as I had done abortion previous to this as well (3640 y, Nepal, parous, ibu/met).

Read more here:
Experiences with pain of early medical abortion: qualitative results from Nepal, South Africa, and Vietnam - BMC Blogs Network

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