Objective To assess the comparative health and economic outcomes associated with three alternative first-trimester abortion techniques in Mexico City and to examine the policy implications of increasing access to safe abortion modalities within a restrictive setting.Design Cost-effectiveness analysis.Setting Mexico City.Population Reproductive-aged women with unintended pregnancy seeking first-trimester abortion.Methods Synthesising the best available data, a computer-based model simulates induced abortion and its potential complications and is used to assess the cost-effectiveness of alternative safe modalities for first-trimester pregnancy termination: (1) hospitalbased dilatation and curettage (D&C), (2) hospital-based manual vacuum aspiration (MVA), (3) clinic-based MVA and (4) medical abortion using vaginal misoprostol.Main outcome measures Number of complications, lifetime costs, life expectancy, quality-adjusted life expectancy.Results In comparison to the magnitude of health gains associated with all safe abortion modalities, the relative differences between strategies were more pronounced in terms of their economic costs. Assuming all options were equally available, clinic-based MVA was the least costly and most effective. Medical abortion with misoprostol provided comparable benefits to D&C, but cost substantially less. Enhanced access to safe abortion was always more influential than shifting between safe abortion modalities.Conclusions This study demonstrates that the provision of safe abortion is cost-effective and will result in reduced complications, decreased mortality and substantial cost savings compared with unsafe abortion. In Mexico City, shifting from a practice of hospital-based D&C to clinic-based MVA and enhancing access to medical abortion will have the best chance to minimise abortionrelated morbidity and mortality.

Objective-The purpose of this study was: (1) to estimate the direct medical costs of 7 major noncervical human papillomavirus (HPV)-related conditions, including genital cancers, mouth and oropharyngeal cancers, anogenital warts, and juvenile-onset recurrent respiratory papillomatosis; and (2) to approximate the economic burden of noncervical HPV disease.Study Design-For each condition, we synthesized the best available secondary data to produce lifetime cost per case estimates, expressed in present value. Using an incidence-based approach, we then applied these costs to develop an aggregrate measure of economic burden.Results-The economic burden associated with noncervical HPV 6,11,16, and 18-related conditions occurring in Americans in the year 2003 approximates $418 million (range, $160 million-$1.6 billion). Conclusion-The economic burden of noncervical HPV disease is substantial. Analyses that assess the value of investments in HPV prevention and control programs, should take into account the costs, morbidity, and mortality associated with these conditions.

The goals of the current study were to: (1) estimate the prevalence of forced sex among women accessing services at a women's health clinic in rural Haiti; and (2) examine factors associated with forced sex in this population. Based on data from a case-control study of risk factors for sexually transmitted diseases (STDs), a cross-sectional analysis to examine factors associated with forced sex was performed. A number of factors related to gender inequality/socioeconomic vulnerability placed women in rural Haiti at higher risk of forced sex. The strongest factors associated with forced sex in multivariate analyses were: age, length of time in a relationship, occupation of the woman's partner, STD-related symptoms, and factors demonstrating economic vulnerability. The findings suggest that prevention efforts must go beyond provision of information and education to the pursuit of broader initiatives at both local and national levels. At the community level, policy-makers should consider advancing economic opportunities for women who are vulnerable to forced sex. Improving access to community-based income-generating activities may begin to address this problem. However, the viability of these local projects depends largely upon Haiti's 'macro-economic' situation. In order to ensure the success of local initiatives, external humanitarian and development assistance to Haiti should be supported. By broadening the definition of "prevention" interventions, we may begin to address the systemic problems that contribute to the occurrence of forced sex and the increasing incidence of HIV infection throughout the world, such as gender inequality and economic vulnerability. Taking into account factors influencing risk at the local level as well as the macro-level will potentially improve our capacity to reduce the risk of forced sex and the spread of STDs, including HIV infection, for millions of women living in poverty worldwide.

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