“Out of This World”: Norwegian Women’s Experiences of Medical Abortion Pain

Introduction

Unsafe abortion remains a major global health issue and is a leading cause of unnecessary maternal deaths and morbidities.¹ Sixty-one percent of all unintended pregnancies and 29% of all intended pregnancies end in induced abortions.¹ Globally, 45% of all abortions that occur every year are unsafe, and most of these occur in low resource settings.² Access to safe, affordable, timely and respectful abortion care is essential to women’s physical and mental well-being.¹ In recent decades, the dominant abortion method has rapidly changed from surgical to medical in Western countries.^3,4 With the introduction and access to medical abortion, unsafe abortions have decreased and morbidity and mortality related to abortion have improved.² Medical abortion is a non-surgical termination procedure that uses medication, most often a combination of mifepristone and misoprostol, or misoprostol alone.² The procedure may take place in a clinic or at home, administrated by a health professional and/or the woman herself. In early pregnancy, medical abortion is considered a safe, effective and acceptable method.⁵

Pain is a known adverse effect of medical abortion. Some studies have found that medical abortion pain can be compared to menstruation pain.⁶ Other studies have found that approximately one in four women experienced severe pain during medical abortion.^7,8 More recent studies, however, indicate that more than half of the women who carry out medical abortion have severe pain.^9,10 Teenagers tended to report higher levels of pain than adult women. In addition, studies indicate that a medical abortion at home involves more pain and distress than in a hospital.¹¹

Most women who have a medical abortion need help to cope with the pain; pain medication is therefore often offered as prophylactic treatment. Several studies support non-steroidal anti-inflammatories as treatment for women undergoing abortion procedures; acetaminophen (paracetamol), however, has not been found effective in reducing pain.^12,13 A recent study indicates that the majority of women need analgesics in addition to prophylactic pain medication.¹⁰ Alongside the experience of severe pain, inadequate pain management during the abortion has been reported by women.⁹ This represents a challenge because high-quality abortion care depends on appropriate pain management.¹⁴ In Norway, different clinics offer different pain medications, most often acetaminophen (paracetamol) and/or non-steroidal anti-inflammatories (Ibuprofen or Voltaren). Over the counter pain medication may be inadequate for some women, yet stronger pain medication requires a prescription which may represent as a barrier to access.

In Norway, medical abortions were introduced in 1998 and in 2021, 95% of 10841 abortions were medical, which represents nine per 1000 women aged 15–49 years.³ A recent Norwegian study found that women performing a medical abortion at home felt unprepared and received insufficient information about the procedure.¹⁵ Another study found that Norwegian women found the abortion care to be mechanical, like an “assembly line”, and they felt that they were a burden or not full-fledged patients. Many women also felt deceived by health care personnel with regard to information about the level of pain and the nature of the abortion process.¹⁶ Norwegian women report finding the abortion process lonely and challenging, involving feelings of shame, guilt and anxiety.¹⁷ Secrecy about the abortion was important and emotional distancing was described by the women as a pervasive coping strategy.

Pain is a subjective experience that may be impacted by psychological and contextual factors.^18,19 The political, cultural, and social context as well as individual factors are of importance for our understanding of abortion pain. Consequently, the subjective experience of abortion pain may vary between different socio-cultural and political settings. However, few studies have explored women’s subjective experience of pain during a home medical abortion, and we could not identify any studies in the Norwegian context. In this study, we explore Norwegian women’s experiences of pain when performing a home abortion.

Materials and Methods

In this study we have used a qualitative research design from within a phenomenological hermeneutical perspective, which strength lies in the opportunity it provides to explore and describe people’s lived experiences of a phenomenon.^20,21

Recruitment of Participants and Data Collection

The study is part of a larger research project exploring 24 Norwegian women’s experiences of medical abortion at home. A team of five researchers with varied backgrounds in health care and teaching, including public health nursing, psychology and midwifery, are involved in the project. In this study we focus on a subset of the data material, revealing the participants experience of abortion pain.

We recruited participants through an advertisement published on a university website and on Facebook. To be included in the study, women had to have carried out a medical abortion at home before 11 + 6 weeks gestational age. We included 24 women who satisfied the inclusion criterion and confirmed their participation by email. One participant lived in the UK and the remaining participants resided in various parts of Norway, in both urban and rural settings. All abortions took place in Norway. The women were Caucasian, aged 24 to 45 years, and all but one were of Norwegian origin. Education level and civil status varied, and the 24 women had had a total of 28 medical abortions, mainly between 2010 and 2019. Fifteen women had one or more children born before or after the abortion, while eight women were childless.

We conducted individual interviews with the women from October 2019 to January 2020. The women chose the location, either in their homes or in a neutral setting. Two women were interviewed via telephone or video call, and the others face-to-face. The interviews were semi-structured with three open-ended questions about the women’s experiences of self-administering an abortion at home, their experiences of being informed and supported by health care providers, and the follow-up care they received after the abortion. The introductory question was: “Can you tell me about the abortion you had some time ago?” In addition, we asked:

What was your experience of having a medical abortion at home? How did you find the interaction with the health service during the process? What follow-up were you offered after the abortion?

The interviews lasted between 19 and 71 minutes (mean 47 min) and were digitally recorded and transcribed verbatim.

Data Analysis

We used a phenomenological hermeneutical method for interpretation of the interview texts.^20,21 This method aims to elucidate the meaning of lifeworld phenomena and is influenced by the phenomenology of Husserl and the interpretation theory of Paul Ricoeur.²²

Our analysis was based on the texts of interviews conducted with 24 women with experience of a home medical abortion, and the analysis was conducted by the first and last authors.

The analysis process consisted of three steps or phases: naïve understanding, thematic structural analysis and comprehensive understanding. These steps involved a dialectic movement between explanation (what the text said) and understanding (what the text spoke about), constituting a hermeneutic circle between parts of the text and the text as a whole. When we detected differences in interpretation of the text, these were resolved upon further reflection and discussion.

Naïve Understanding

We started with a naïve or open-minded reading of the interview texts several times to gain an understanding of the women’s lived experiences of pain related to self-administering a medical abortion at home. In this phase, we tried to bracket (set aside) our preunderstandings and switch from a natural to a phenomenological attitude, allowing ourselves to become touched and moved by the text. We formulated the naïve reading as a text, using phenomenological language. This text was used to guide and validate the next steps in the analysis.

Thematic Structural Analysis

Next, we conducted a thematic structural analysis in a word table, starting by dividing the interview texts into meaning units (sentences, parts of sentences or paragraphs with related meaning penetrating all or parts of the text). The process of dividing the text into meaning units involves decontextualization, ie, the text is viewed objectively. We condensed the meaning units to formulate expressions of meaning in concise and everyday language and merged them into sub-themes and themes based on their similarities and differences. The last part of the structural analysis involved reflecting on the themes and comparing them with our naïve understanding for validation. The themes and sub-themes are presented in the Findings section.

Comprehensive Understanding

Continuing the dialectical movement between explanation and understanding, we read the text again as a whole (critical reading) and formulated a comprehensive understanding, taking into account our preunderstandings, the naïve reading, and the thematic structural analysis, in addition to relevant literature. The combination of an open and critical reflective approach helped us to bracket our preunderstandings, and the use of suitable literature enabled us to deepen our understanding of the phenomenon under study. This required the use of imaginative skills, recontextualization and closeness to the text. The comprehensive understanding is presented in the Discussion section.

Ethics

We conducted the study in accordance with the World Medical Association Declaration of Helsinki Principles for Medical Research Involving Human Subjects.²³ It was approved by the Norwegian Center for Research Data (22708) and assessed by the Regional Committee for Medical and Health Research Ethics, which considered it to be outside the remit of the Act on Medical and Health Research (36616). The participants received oral and written information about the study and gave their informed oral and written consent before the interviews started. Their consent included publication of anonymized responses and they were informed about their right to withdraw from the study at any time.

Results

Being in Pain or Becoming Pain

Being in Pain: A Straightforward Experience

For some women, the abortion was less painful than they expected, while for most others it was more painful. The women who described the abortion as less painful than expected, often found the abortion process to be a straightforward experience with tolerable pain, similar to a heavy menstruation. “I didn’t think it was particularly painful. For me, it felt more like that gurgling stomach I get during my period” [participant 4]. They were surprised that the process went smoothly and with less pain than they had imagined.

I normally have heavy periods, so it hurt a bit more than that. Maybe for only an hour when it was at its worst. But nothing like. I thought it would be a lot more painful, based on what I’d read.[participant 8]

One woman with a previous very painful abortion experience felt surprise and relief at the level of pain “Well, it did hurt, but not as much as the first time, so I was positively surprised, and a bit relieved about it” [participant 2]. Nevertheless, she emphasized that at some point during the abortion, the pain was so intense that she felt sorry for herself.

Some had searched the Internet, where they found stories of other women’s painful abortion experiences, making them dread the abortion and the pain. Surprised that the process went so smoothly, they had expected a totally different scenario.

…but I actually think the whole process went quite well in fact. I was really a bit surprised that it went so well in fact. because of course I’d read. and when you start searching on the Internet, all this yucky stuff comes up. All the worst stuff very often comes up then.[participant 6]

Most of the women, however, experienced the abortion as more painful than expected. They described the abortion process as very painful, and many called the pain “extreme” or like “a day in hell”. Their pain, often accompanied with nausea and a general sick feeling, could last for hours. During the abortion process, women described losing control over their body; they were not only in pain, but in a state of helplessness where they felt that they “became pain”. It was a different state of consciousness where nothing but the painful and sick body existed. “I felt like my body was doing something. like nothing else existed, in fact. I completely lost control of my body because of that pain” [participant 20]. Having become pain, their focus was directed inwards towards the pain and the bodily processes, making it difficult to communicate and reach out for help. One woman described her pain experience as so extreme that it was “out of this world”, finding herself totally incapacitated and doubled up by the pain.

I couldn’t walk, I couldn’t stand up straight. When I went to the toilet, I had to bend forward because it hurt so much to stretch. So it wasn’t much fun, you see. It’s okay to have a bit of stomach pain sometimes, but that was out of this world.[participant 11]

Another woman described the pain as so excruciating that she screamed and cried throughout the entire process, leaving her completely exhausted. The pain medication did not remove the pain, only some of her anxiety.

I cried and screamed for eight hours. I was in bed, all alone, in a huge amount of pain. My husband didn’t know what to do. I called the emergency room to tell them I had terrible pain, and they said it was quite normal. I felt like a goner. Because of the pain… and I was so exhausted. With no strength in my body. I don’t remember walking. Like a sack of potatoes, from the bed to the toilet to the shower. Back to bed - vomited. Back to the toilet.[participant 12]

Afraid that something was wrong, she contacted the emergency room, where she was told that this level of pain and physiological reaction were normal. Another woman described how the pain sensation ended up in her throat, creating a stifling feeling.

I kind of felt like the pain was spreading upwards in my throat anyway, so it felt a bit tight. Like when you get a lot of pain, you almost feel like you’re going to vomit.[participant 15]

At some point the pain was so extreme that she almost regretted what she had done. Some reported panicking because of the extreme pain, afraid that something was wrong or abnormal. Some were afraid of dying “I was scared. I mean, if I’m going to die, or if there’s something wrong, is it really like this?” [participant 20] The women described being tensed up and crumpling to the bathroom floor in pain, feeling trapped with no means of escape. One woman said:

I was just tensing up, because ouch, it hurt, and what could I do to get out of this? There’s nothing I could do, so then you kind of panic, and then you get more tense, and then well. then it actually gets worse. I wouldn’t wish that experience on anyone.[participant 20]

At some point during the abortion, many of the women described feeling totally exhausted and drained. Several eventually collapsed on the bathroom floor, unable to speak or move. A few women described fainting because of the pain. “I actually think I passed out once. like I wasn’t fully conscious. my partner almost called an ambulance several times” [participant 20]. Several women locked themselves in the bathroom. They wanted privacy because they felt they were losing control of their bodies, expelling not only the fetus but also excrement.

So I didn’t want him to be involved in it, so I kept him outside [the bathroom] for quite a while. I don’t think he came in until right at the end in fact, until I almost fell off the toilet.[participant 20]

Participants also mentioned vomiting during the abortion, and reflected that this may have had a negative impact by reducing the effective dosage of pain medication.

The Pain is a Mini-Version of Being in Labor

The women in our study compared the physical process of abortion as similar to labor, with painful regular uterine contractions over an extended period of time. “They tell you there will be some strong period pains, but it really wasn’t like that. It was much more like giving birth” [participant 2]. Some even described the abortion as more painful than giving birth. One woman said:

You know, I’ve given birth twice since then, but that was my worst experience ever. It’s much worse than giving birth. It was just so incredibly painful. I vomited from the pain, I was writhing on the floor.[participant 23]

One woman felt as if she was giving birth despite having no previous birthing experience: “Very soon, my body felt that this was a birth, it was a contraction” [participant 7]. She found it strange to experience a “birth” without a positive outcome. “You can’t push, there’s nothing you can do. there’s no baby to be born, so there’s nothing to do” [participant 7]. She struggled to understand why it had to be like that.

The women described how the painful contractions compelled them to move around to try to find a less painful position, crying or screaming in pain, and moving back and forth between the bed and the bathroom. One woman experienced the painful process as somewhat animalistic, where she made sounds that reminded her of cows bellowing.

Being Caught off Guard and Struggling to Cope

Unprepared for the Pain and the Process

Many of the women described receiving insufficient or no information, which left them unprepared for the type and intensity of pain during the abortion. They expressed an element of surprise. “I remember feeling terrible pain. I think it surprised me a bit how much it really hurt” [participant 9]. Most were informed that they might have period-like pain and feel nauseous and sick. Many of the women felt that this was a massive understatement, although they acknowledged that it might be impossible to prepare anyone for the intensity of the pain. They described it like this:

OK, well, you put it (the pill) into your vagina, then it should open, which makes it easier. And then you take these and anti-nausea tablets, because you’ll be nauseous, or you might feel sick, and you’re also going to bleed a bit.” And that was an understatement. So I had a day in hell. She did say: “You shouldn’t be by yourself.” But it wasn’t like: “You might not be able to walk.” [participant 24]

One woman said that she corrected the nurse when she was told that she might have some pain, as she knew from previous experience that the abortion would be very painful.

I had to crawl up those stairs and I’d just got in the front door before I was down on the floor, just screaming in fact, because it was so extremely, unbelievably painful.[participant 18]

Several believed that healthcare providers held back on information about the severity of the pain, because if they told women how painful the process would be, the women would refuse to go home.

I’m sure they don’t dare say it’s going to hurt a lot and you’ll be in excruciating pain. then people will probably say: “Well, I’m not going home then… I don’t want to be at home alone and have that experience.[participant 20]

Some women were assured by the health professionals that they could handle the pain because they had previously given birth. One woman thought that since she was sent home to have the abortion, the pain would not be too bad, and another felt that she did not deserve pain medication because she had been careless and put herself in the predicament. The participants felt that the painful abortion was their punishment for not being careful and in control. “It hurt like hell… to have a medical abortion… that was my punishment for being careless” [participant 16]. The women not only felt unprepared for the pain, but also for the abortion process. They did not expect it to be like labor with severely painful contractions. Some women were also unprepared for the duration of the process. One woman unexpectedly found that the abortion process suddenly started a week after she had inserted the abortion pills, and six weeks later she had two episodes of massive bleeding: “It just kept bleeding, it went on and on and on and on and it never stopped” [participant 18]. When she eventually contacted a doctor, and was told that she was still pregnant, all her bottled-up emotions burst out. In hindsight, she realized that she had needed more information about the abortion process, what was normal, and when to contact the hospital.

The women in our study wanted more concrete and realistic information about the intensity of the pain. They expressed a need to know that even if they experienced intense and excruciating pain, they would not die from the abortion. The participants stated that lack of information led to more insecurity and increased pain. One woman explicitly said that if she had known more about the abortion process, she might have handled the pain better: “Your body cooperates more when you feel confident” [participant 12].

Coping with the Pain

The women described different strategies for coping with the pain. A few of them believed that pain during abortion was natural and to be endured, not medicated away. Some described the female body as born to tolerate being in pain, or felt that it was expected of them to put up with pain. One woman described the ability to endure pain as an ingrained Norwegian character trait. “But in Norway they do what’s most natural, as natural as possible. So then it will hurt a bit, and how much pain can you put up with?” [participant 12] A negative attitude towards pain medication was also reported as a reason for not taking the medication.

Most women in our study, however, felt pain medication to be necessary to endure the process. The participants found the pain medication they received at the hospital to be insufficient. “And that’s when I realized that those tablets, well, they weren’t exactly strong enough” [participant 16]. They felt out of control, and were unable to focus on anything else but being in pain. Based on the painful experience of a previous medical abortion, some stressed the importance of taking a prophylactic dose and then according to their own needs.

But the second time it didn’t hurt as much, and I was better prepared, so that if I felt the pain starting to get worse, I took painkillers before it got really bad.[participant 2]

A few relied on alternative medicine in addition to pain medication. Several said that it was important to receive information about when to take pain medication, and that it was difficult to know what was normal in relation to taking the medication.

Discussion

In this phenomenological-hermeneutical study of women’s experiences of pain during a self-administered medical abortion at home, we identified two main themes: “Being in pain or becoming pain” and “Being caught off guard and struggling to cope”. In this section, we will discuss our findings in relation to contemporary research in the field as well as gendered socio-cultural and existential meanings connected to pain, specifically in relation to female reproductive functions.

Some of the women in our study described their medical abortion as a straightforward experience and the pain as tolerable or as less pain than anticipated, compared to previous medical abortions. Most of the women, however, described the abortion as very, or even extremely, painful and disabling, rendering them unable to function or even walk upright. Some described the abortion pain as the worst pain they had ever experienced in their life, where they finally became so exhausted that they collapsed or fainted on the bathroom floor or in bed. Our findings are supported by recent studies reporting high pain intensity in women undergoing medical abortion.^9,10 Kemppainen et al¹⁰ found that 57.7% experienced severe pain, while Georgsson and Carlsson⁹ found that more than half of their participants recollected moderate to high peak pain during medical abortion. These findings, as well as those of our own study, contradict the findings of the study by Suhonen et al,⁶ namely that medical abortion pain can be compared to period pain. The findings of Suhonen et al seem to agree with the information given to women by health care personnel at the abortion clinic and in abortion information pamphlets in Norway. Most of the women in our study viewed this as a massive understatement, leaving them unprepared for the type and intensity of the pain. They described the experience as not merely having pain as a sensation, but as becoming pain. These descriptions of severe abortion pain can be understood as narratives of insufficient pain medication. Some studies suggest that high doses of non-steroidal anti-inflammatory drugs (NSAIDs), such as 800–1600 mg Ibuprofen, may be effective in managing pain for women undergoing abortion procedures, while acetaminophen (paracetamol) has not been found to be effective.^12,13,24,25 However, there is limited knowledge on effective pain management for abortion pain, indicating a need for further research.^10,13

The participants in our study not only found the pain to be more severe, but also essentially different in quality, than menstruation cramps. Many of the women experienced the abortion as painful contractions similar to or worse than giving birth at full term. Similar findings were reported in Georgsson and Carlsson’s⁹ study, where women compared the abortion pain to other painful conditions, including giving birth. We ask why abortion pain is commonly downplayed and portrayed as similar to period pain, when the majority of women have severe pain and find the process to be more like labor or giving birth. Could this partly be explained by gender bias when estimating others’ pain? Several studies support this hypothesis, reporting that women experience more frequent and greater pain than men, but that their pain is often underestimated, and they tend to receive less adequate treatment than men for their pain.^26,27 Gender bias has been connected to gender-stereotypical beliefs that women are more willing to express pain than men, which can partly explain why their pain complaints are more often psychologized, and why they are more often given sedatives instead of pain medication compared to men.^28–30

Cultural meanings of pain connected to female bodily functions may influence healthcare professionals and the affected women’s perceptions and actions in their respective roles.³¹ Feminist theory of the body argues that the male body is considered as normal and good, while specific female attributes that differentiate women from men are considered as inferior.^32,33 It follows that female bodily functions such as menstruation, pregnancy, abortion, childbirth and lactation become symbols of female inferiority and lead to devaluation. For instance, Roberts et al³⁴ found that reminders of menstruation led to lower evaluations of a woman’s competence and likeability or social status. We know that abortion stigma weighs heavily on women, and is still strongly present in both Western and developing countries.^17,35 These negative cultural norms and values can explain why the women in our study were reluctant to talk about and seek treatment for the pain connected to the abortion.

From an existential perspective, the female reproductive functions may provoke negative feelings because they remind us of our connection to nature and our own mortality.³² De Beauvoir points out that women are given the primary burden of reproduction and continuation of the human species, with the continuous menstruation cycle, pregnancy, childbirth and breastfeeding. She states that these biological considerations are an important element of a woman’s situation, because it is through her body that she grasps and constitutes the world. The reproductive functions, however, represent a form of alienation from her body and restrict her assertion as an individual. Of all the mammals, the female human is the one who most violently resists the alienation or restriction of her individuality. Abortion is the ultimate act of freedom, whereby the woman exercises her subjective will to reject the biological will of her body.

Lack of information about the abortion process and the severity of the pain were described by the women in our study; consequently, they felt unprepared and insecure or anxious during the abortion. Women presenting for abortion in Norway are routinely given information that the abortion process and pain are similar to menstruation. When the abortion turns out to be much more painful than expected, of a longer duration or a different type, it may cause anxiety and troubling thoughts that something may be wrong. Studies show that psychological and contextual factors may affect the perception and experience of pain.^18,19 Higher levels of anxiety and attachment insecurity have been associated with higher levels of perceived pain following abortion and during birth.^36,37 In this connection, unnecessary medical examinations may prolong the waiting time between making an appointment and obtaining abortion services at an outpatient clinic, leading to an increase in gestational age. For instance, routine ultrasound has not been found to reduce serious adverse events.³⁸ The women in our study found this waiting period to be extremely difficult and meaningless, also increasing their feelings of shame and guilt.

Social and sexism-related stigma, like abortion stigma, have been associated with a lower pain threshold.³⁹ Our beliefs, thoughts and feelings about painful conditions are shaped by our previous experience, cultural factors and received information. If the pain is believed to be purposeful or productive, it may be experienced as non-threatening and more tolerable.¹⁸ If the pain is believed to be a punishment, or connected to feelings of guilt and shame, as was the case for participants in our study, it may then be exacerbated, leading to anxiety and social withdrawal. Such factors may prevent women from seeking adequate abortion care from healthcare providers.

Although pain is undoubtedly physical, it also has important psychological, social and existential dimensions.⁴⁰ According to Merleau-Ponty,⁴¹ pain is experienced within a horizon of cultural meaning (our lifeworld), which in(forms) our experience of the pain. Reciprocally, our painful embodied consciousness constitutes our lifeworld. In order to understand the meaning of abortion pain for women, we need to treat pain not only as a physical process, but also with important psychological and socio-cultural dimensions which (in)form the pain experience. With this in mind, pain treatment should include not only appropriate medication, but also interventions that reduce feelings of shame, guilt, anxiety, and loneliness.

Methodological Discussion

Qualitative in-depth interviews are well suited to explore women’s experiences of medical abortion.⁴² Open and flexible questions during the interview allowed the women to freely express their experiences, which provided rich data. Recruitment through an advertisement in the social media channel Facebook allowed us to rapidly reach out to many people, who would view the content of the advertisement while it was online and open for recruitment. Such a selection process may reduce the risk of systematic recruitment bias; however, we cannot rule out the possibility that women with negative experiences of medical abortion were more inclined to participate in the study.⁴³ Using a Norwegian advertisement on Facebook excludes individuals who do not use the platform or understand the language. Additionally, since all but one participant were ethnic Norwegians, there is a risk of missing important insights from immigrant women in Norway. Nevertheless, our results yield generalized meanings that can be transferable to other women who perform a home medical abortion in similar socio-cultural settings.⁴⁴ Factors that strengthened the transferability of the results were that the participants lived in geographically diverse areas in Norway and received health care from hospitals in different health regions.

Implications

Ensuring effective pain medication for a home medical abortion is of vital importance for securing high-quality abortion care. Women who present for medical abortion need realistic information about the type and intensity of pain, as well as evidence-based pain medication. Psychological and cultural factors may affect the experience of abortion pain and should therefore be considered in pain care. More research is needed on how to best ensure sufficient pain medication at home, in addition to research on how to provide adequate psychological support before, during and after a medical abortion.

Conclusions

According to the WHO,¹ management of pain is an important public health concern; however, abortion pain still appears to be a neglected issue. Most of the participants in this hermeneutical-phenomenological study described suffering through severe pain when performing a medical abortion, which can be interpreted as narratives of insufficient pain medication. It seems expected of women who opt for a medical abortion to suffer through severe pain as a normal part of the procedure. A timely question is whether this is humane and ethical treatment of women in today’s society. We argue that realistic information about the type and intensity of the pain, and sufficient pain medication, are vital for high-quality abortion care. In addition, adequate psychological support may affect the pain experience and should be considered as part of pain care and treatment.