When available, pain medications should not be denied to women undergoing postabortion care (172). Often, however, women treated for postabortion complications receive no pain control—neither medication nor counseling. While in some cases drugs, needles, syringes, and intravenous equipment are not available, in others, the lack of pain control—both medical and verbal—may reflect providers' negative attitudes (3, 200, 243). For example, in Kenya some providers said women should be made to feel pain during MVA so that they would avoid future unsafe abortions (243).

Pain medications. Because the procedure lasts only a few minutes and the woman's cervix often is already dilated and soft, MVA usually can be performed with minimal pain (277). Local anesthetics, analgesics, sedatives, or some combination of these three can be used to control pain during MVA, depending on the severity of pain and the availability of the medications (178, 296). Local anesthetics numb physical sensation, while analgesics alleviate pain in the receptors of the spinal cord and brain. Sedatives do not actually reduce pain; they are used to relieve anxiety and relax muscles.

Local anesthesia. When additional dilation of the cervix is needed, local anesthesia, in the form of an injected para-cervical block, is used (296). Two frequently used local anesthetics are lidocaine (Xylocaine) and chloroprocaine (Nesacaine) (178).

Using local anesthesia rather than general anesthesia is safer and less costly and offers several advantages (178, 199):

• The woman is awake throughout the procedure. She can report changes in her condition to providers.
• The woman recovers within 5 to 15 minutes, without the nausea or headache often associated with general anesthesia.
• Depressed breathing and suppressed gag reflex, which can occur with general anesthesia, are avoided, markedly reducing the risk of anesthesia-related death.
• The woman need not be restricted from eating before the procedure. Making women aware that they can eat while awaiting treatment is especially important if women must wait a long time for treatment.

Counseling during the procedure is an important pain control strategy (3, 177, 178, 243, 249, 277). Fear and anxiety can increase pain (30). At six hospitals in Kenya, for example, few women, whether treated with MVA or sharp curettage, received any information about the procedure itself or any counseling before or during the procedure. Only 3% of women treated with MVA received pain medication, and, although sharp curettage is usually done under general anesthesia, only 44% of women treated with sharp curettage received pain medication. Typically, patients became nervous and anxious before the procedure. During the procedure, providers and other staff did not talk to the women, and they became more afraid and physically tense. Whether treated with MVA or sharp curettage, over one-half later described the pain they experienced as "extreme" (243).

The provider's technique when performing MVA also can affect the level of pain (249, 277). Rough handling, as well as quick, jerky movements during MVA, can increase pain (277). In contrast, women's fear and pain levels are less when postabortion care is provided by calm, unhurried providers, without interruptions, in a quiet place (178).

For counseling to help reduce pain, the provider or another member of the clinical team explains each step of the procedure to the woman before it begins (296). During treatment, the provider or another staff member talks to the woman in a relaxed way, focusing her attention away from the discomfort of the procedure (277). Often one counselor or other member of the clinical team stays with the woman throughout the procedure (199, 249).

For many providers accustomed to treating patients who are under general anesthesia, communicating with patients during treatment can be a challenge. Many providers need training to learn how to reassure and counsel women who remain awake during their postabortion treatment (277) (see Chapter 3.3, Counseling for Every Women).