Measuring pain better – a step towards improved pain management

Medical abortion is known to be a painful process, however, there is limited evidence for how best to manage this pain. The existing data suffer from a lack of validated measures for pain during this procedure. A robust, validated tool for measuring pain during abortion would be valuable to the field both in terms of research and, potentially, clinically.

The Cochrane Fertility Regulation (now the Cochrane Sexual and Reproductive Health) Group conducted a prioritisation exercise identifying areas of contraception and abortion care that needed updated systematic review and evidence synthesis. Pain management during abortion of any kind was identified as a priority and divided into 4 systematic review calls – medical abortion before and after 14 weeks, and surgical abortion before and after 14 weeks.

My review team conducted the systematic review of pain interventions for medical abortion at gestations less than 14 weeks. We only identified 5 studies at the time and meta-analysis was not possible due to their disparate nature (different interventions, study designs and measurement tools). During this process it became apparent that a meaningful, validated, and consistent measure of pain during medical abortion was not available and would be highly useful to the field going forward. Particularly as the Standardising Abortion Research Outcomes (STAR) project has recently developed a core outcome set for research studies of abortion care – this includes the reporting of pain experienced during abortion.

A validated pain measurement tool would be very useful to researchers designing trials of pain relief for medical abortion in the future and would better allow meta-analysis and meta-synthesis of results. It is also possible that a pain measurement tool for medical abortion could be useful for surgical abortion and indeed other gynaecological procedures, both in research projects and possibly for use as a clinical measure.

Pain is a complex process and can be affected by myriad factors. Historically, women’s experiences of pain have been marginalised and dismissed. The starting point for developing a new measure of pain requires rich, expansive, detailed qualitative data to determine the best way to measure pain and to best elicit the exacerbating and mitigating factors for pain, and how to record these.

Following an initial qualitative research study, the next steps to develop the pain tool will include extraction of quantifiable items from the qualitative data, pilot testing of these items with patients undergoing medical abortion and further refinement until a scale can be developed for use during the medical abortion process.

This pain measurement tool would help in the comparison of the many different candidate pain interventions that could help reduce pain during abortion and ultimately help those ending their pregnancies have a more acceptable, comfortable, and safe experience.

A research-orientated pain measurement tool might not be immediately usable in a clinical environment, where an abbreviated tool might be more helpful in the triage of patients receiving medical abortion at home and calling for advice on how to manage pain. This will take further development and refinement before it could be used in practice, but I believe should be part of the long-term goals of the current formative work on this project.