The costs and cost effectiveness of providing first-trimester, medical and surgical safe abortion services in KwaZulu-Natal Province, South Africa

Abstract

BackgroundDespite a liberal abortion law, access to safe abortion services in South Africa is challenging for many women. Medication abortion was introduced in 2013, but its reach remains limited. We aimed to estimate the costs and cost effectiveness of providing first-trimester medication abortion and manual vacuum aspiration (MVA) services to inform planning for first-trimester service provision in South Africa and similar settings.MethodsWe obtained data on service provision and outcomes from an operations research study where medication abortion was introduced alongside existing MVA services in public hospitals in KwaZulu-Natal province. Clinical data were collected through interviews with first-trimester abortion clients and summaries completed by nurses performing the procedures. In parallel, we performed micro-costing at three of the study hospitals. Using a model built in Excel, we estimated the average cost per medical and surgical procedure and determined the cost per complete abortion performed. Results are presented in 2015 US dollars.ResultsA total of 1,129 women were eligible for a first trimester abortion at the three study sites. The majority (886, 78.5%) were eligible to choose their abortion procedure; 94.1% (n = 834) chose medication abortion. The total average cost per medication abortion was $63.91 (52.32–75.51). The total average cost per MVA was higher at $69.60 (52.62–86.57); though the cost ranges for the two procedures overlapped. Given average costs, the cost per complete medication abortion was lower than the cost per complete MVA despite three (0.4%) medication abortion women being hospitalized and two (0.3%) having ongoing pregnancies at study exit. Personnel costs were the largest component of the total average cost of both abortion methods.ConclusionThis analysis supports the scale-up of medication abortion alongside existing MVA services in South Africa. Women can be offered a choice of methods, including medication abortion with MVA as a back-up, without increasing costs.

The cost of maternal health services in low-income and middle-income countries from a provider’s perspective: a systematic review

“…Thus, 22 studies were included in our narrative review of which 15 provided disaggregated component cost for our analysis (figure 1). Nineteen of the included studies were retrieved from peer-review literature, [27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45] while the remaining three were sourced from grey literature. [46][47][48] distribution and quality assessment of included studies Thirteen studies were conducted in low-income countries (LICs) including four in Rwanda, 35 41 45 46 two each in Tanzania 32 36 and Uganda 29 34 and one each in Burkina Faso, 43 Democratic Republic of the Congo, 27 Ethiopia, 33 Haiti 48 and Somalia.…”

“…30 Four studies were done in uppermiddle-income countries (UMICs) including Brazil, 40 Colombia, 31 Peru 38 and South Africa (figure 2). 44 Eleven studies were assessed as high quality, 31 34 35 37-39 41-45 eight were average quality 27-30 32 33 36 40 and three were low quality. [46][47][48] The criteria warranting the least scores were those related to detailing a breakdown of costs incurred for providing the service and incorporating indirect costs in the analysis (online supplementary table S3 in file 1).…”

“…28 29 37 39-43 Two studies each used a retrospective cross-sectional study 32 38 or a mixed methods design, 36 45 and one was a cost-effectiveness analysis. 44 Four studies reported using the Post-Abortion Care Costing Methodology (PACCM). 31 33-35 Five studies did not specifically state the study design used.…”

Doing more for less: identifying opportunities to expand public sector access to safe abortion in South Africa through budget impact analysis

“…We obtained health-service costs per abortion type from two prior economic evaluations conducted in South Africa [21,22]. The first evaluation presented the costs and cost-effectiveness of first-trimester services: MVA and medication abortion using mifepristone and misoprostol [22]. The economic evaluation was performed as part of a larger cohort study conducted at public hospitals in KwaZulu-Natal Province from 2009-2011 [23].…”

“…We decreased the proportion of second-trimester procedures from 25% to 15% over the 10-year period. For first-trimester procedures, we also increased the proportion of services provided via medication abortion (from an estimated 30% to 65%) because medication abortion has been shown to be more cost-effective than MVA in South Africa [22]. We did not eliminate MVA services in the model as they are required as a backup for medication abortion, and because offering women a choice of services has been shown to be important for acceptability [29,30].…”