Patients' experiences with pain and bleeding in first-trimester abortion care

Abortion care is safe and commonly needed. While pain and bleeding are expected, patients' experience of pain and bleeding at the time of abortion can affect patient satisfaction and the abortion experience. There is limited research characterizing factors associated with patient-reported severe pain and heavy bleeding with contemporary abortion methods.

To assess clinical predictors of patient-reported heavy bleeding and pain among first-trimester abortion patients.

We conducted a secondary analysis of a multicenter prospective cohort study of 644 participants undergoing medication or procedural abortion up to 11w6d. The primary outcome was participant-reported severe postabortion pain; secondary outcomes included bleeding severity and discordance between expected and experienced pain and bleeding. We developed logistic regression models assessing clinical factors associated with severe pain, heavy bleeding, more than expected pain, and heavier than expected bleeding.

Of 644 eligible participants, 516 (80%) responded, 347 (67%) of whom had medication abortion and 169 (33%) of whom had procedural abortion. One-fourth reported severe pain, 35.0% heavy bleeding, 31.6% more than expected pain, and 33.5% heavier than expected bleeding. Factors most strongly associated with participant-reported severe pain included medication abortion (odds ratio=4.69 [95% confidence interval: 2.56-8.58]), history of severe menstrual pain (odds ratio=2.60 [95% confidence interval: 1.38-4.89]), and screening positive for depression at baseline (odds ratio=2.13 [95% confidence interval: 1.18-3.85]). Independent risk factors for pain discordance included first abortion experience (adjusted odds ratio=2.03 [95% confidence interval: 1.18-3.48]), nulliparity (adjusted odds ratio=2.21 [95% confidence interval: 1.26-3.85]), history of a prior cesarean delivery (adjusted odds ratio=2.06 [95% confidence interval: 1.14-3.72]), and baseline depression (adjusted odds ratio=1.72 [95% confidence interval: 1.05-2.82), adjusted for gravidity, abortion method, and location of care. Self-reported heavy bleeding was most strongly associated with medication abortion regimen (adjusted odds ratio=9.19 [95% confidence interval: 5.09-16.61]) and screening positive for depression at baseline (adjusted odds ratio=2.15 [95% confidence interval: 1.28-3.61]). Abortion method and gestational length were the only significant predictors of discordance between bleeding expectations and experience.

While most patients were prepared for the pain and bleeding experienced after abortion, the patient experience may be improved by anticipatory guidance that incorporates risk factors for severe pain and heavy bleeding.