Pain in Medication Abortion WELS Research & Scholarship Presentation August 2024

Abstract

Introduction  

Pain in the context of sexual and reproductive health (SRH) is under-theorized in medical sociology and adjacent disciplines. Some specific areas have established bodies of literature, notably around childbirth and its medicalization. However, pain is in many cases addressed obliquely rather than foregrounded. The literature on women’s sexual difficulties, from Tiefer (2001) onward, addresses pain more directly, but typically takes a biopsychosocial focus that leans heavily on social psychology. Pain has been addressed explicitly in relation to chronic conditions such as endometriosis (Denny 2018), though reducing endometriosis to a condition of ‘reproductive health’ is also acknowledged to be problematic. While key contributions to sociological theorizing of intersections of pain and gender, initiated by Bendelow (2000), have included childbirth, other areas such as abortion, intrauterine contraceptive placement, and assisted conception have drawn little sustained attention.  

One context in which physical pain can be acute is medication abortion, one of the most commonly accessed SRH procedures. Self-management of early medication abortion (EMA) comprises an increasing proportion of abortions in the United Kingdom (UK) and elsewhere. In the UK, this has necessitated reconsideration of how pain is addressed, as women and pregnant people increasingly undertake the medication abortion process without direct health professional supervision. This is in part underpinned by normative assumptions that pain is a necessary or unavoidable part of that process (Authors under review). Pain is a contributing factor in negative experiences of abortion, and thus a potential barrier to equitable access, acutely so for those experiencing the greatest socioeconomic disadvantage. As such, abortion pain becomes an intersectional issue of sexual and reproductive justice (SRJ).  

Methodology 

This paper introduces one case study from a larger project on SRH-related pain. A reproductive justice lens is utilized as a means of grounding a broader exploration of SRH-related pain and the nexus of gender and health inequalities at which it sits.  

As part of a study of abortion experiences during the Covid-19 pandemic, we conducted telephone interviews with twenty people living across the UK who had sought abortions during pandemic restrictions. Existing literature informed a flexible topic guide, and we took a narrative storytelling approach to data production. We asked participants to recount their ‘abortion story’ in as much detail as possible, from learning they were pregnant to the time of the interview. Follow-up questions clarified key information, where absent. Recruited through social media and a targeted advertisements, participants were aged 22-43, and all self-identified cisgender women.  

Since inductive thematic analysis from the broader study highlighted pain as a prominent feature of the data, subsequent focused coding, and an iterative process of interpretation, were used to develop four sub-themes: expected pain is manageable for some; the problem with unexpected pain; pain (co)produces fear; problematizing ‘period-like pain’.  

Results  

Our analysis highlights that EMA pain experiences varied. For some, pain was manageable, particularly where it aligned with expectations, though some expectations were highly negative. For others, pain was much worse than anticipated, underlining the importance of effective expectation-setting. Participants aligned EMA pain with punishment, described it as ‘excruciating’, a source of significant worry, and as something they could not go through again. Physical pain was also closely intertwined with emotional distress. Cultural silences around abortion (exacerbated in this case by isolation associated with the pandemic context) were seen as contributing to unclear expectations around EMA pain, which in turn generated fear. Interviewees expressed incredulity that a healthcare procedure which was proceeding normally could be so intensely painful. Likening the EMA experience to ‘period pain’ is potentially misleading and a source of further uncertainty.  

From an SRJ perspective, our findings indicate a need to improve information provision around abortion pain (particularly in self-management), in order to reduce unnecessary distress for those seeking routine SRH care, and to minimize potential barriers to future use of SRH services. As use of medication abortion increases, our findings also highlight an urgent need for improved pain management options for this commonly accessed procedure.      

Conclusions  

An SRJ lens highlights the impact and implications of abortion pain as a source of gendered inequity in healthcare, in which pain experienced by women and other people with a uterus, in the course of routine SRH care, may be framed as unavoidable and something to be endured. While a limitation of this work is that data were generated early in the Covid-19 pandemic, learning from that time nonetheless has longer-term relevance. Key areas for action include avoiding the potentially misleading trope of ‘period-like pain’, establishing more effective anticipatory guidance and, overall, prioritizing the elimination of pain in this routine component of sexual and reproductive healthcare. Further work is needed to unpick the cultural assumptions underpinning pain as an unavoidable element of EMA.