Time lost from work among women choosing medical or surgical abortions

The microeconomics of abortion: A scoping review and analysis of the economic consequences for abortion care-seekers

Background

The economic consequences of abortion care and abortion policies for individuals occur directly and indirectly. We lack synthesis of the economic costs, impacts, benefit or value of abortion care at the micro-level (i.e., individuals and households). This scoping review examines the microeconomic costs, benefits and consequences of abortion care and policies.

Methods and findings

Searches were conducted in eight electronic databases and applied inclusion/exclusion criteria using the PRISMA extension for Scoping Reviews. For inclusion, studies must have examined at least one of the following outcomes: costs, impacts, benefits, and value of abortion care or abortion policies. Quantitative and qualitative data were extracted for descriptive statistics and thematic analysis. Of the 230 included microeconomic studies, costs are the most frequently reported microeconomic outcome (n = 180), followed by impacts (n = 84), benefits (n = 39), and values (n = 26). Individual-level costs of abortion-related care have implications for the timing and type of care sought, globally. In contexts requiring multiple referrals or follow-up visits, these costs are multiplied. The ways in which people pay for abortion-related costs are diverse. The intersection between micro-level costs and delay(s) to abortion-related care is substantial. Individuals forego other costs and expenditures, or are pushed further into debt and/or poverty, in order to fund abortion-related care. The evidence base on the economic impacts of policy or law change is from high-income countries, dominated by studies from the United States.

Conclusions

Delays underpinned by economic factors can thwart care-seeking, affect the type of care sought, and impact the gestational age at which care is sought or reached. The evidence base includes little evidence on the micro-level costs for adolescents. Specific sub-groups of abortion care-seekers (transgendered and/or disabled people) are absent from the evidence and it is likely that they may experience higher direct and indirect costs because they may experience greater barriers to abortion care.

Early Abortion in Ontario: Options and Costs

OBJECTIVE

Early abortions have been predominantly surgical for many years, but medical options with comparable efficacy and safety are now available. This study compares the costs of two medical options and two surgical options.

METHODS

We used a clinical model to compare the costs in Ontario of four options for early abortion: medical abortion using either mifepristone or methotrexate, and surgical abortion by vacuum aspiration in either a hospital or a free-standing clinic. The cost analysis was conducted from the perspectives of society, the health care system, and the patient.

RESULTS

From all perspectives, total costs were highest for hospital surgical abortion, followed by surgical abortion in a clinic. From the patient's perspective, total costs were higher for surgical abortion but direct costs (mainly for medications) were higher for medical abortion. The total cost of mifepristone and methotrexate abortion was equal if the price of mifepristone (200 mg) was $59.52. The model was robust but was sensitive to the price of mifepristone.

CONCLUSION

Early medical abortion costs less than early surgical abortion from the societal and health care system perspectives but more than surgical abortion from the patient's perspective. Surgical abortion costs more in hospitals than in free-standing clinics from the societal and health care system perspectives, but the costs are the same in both settings from the patient's perspective. No method for early abortion can be identified as best, and patients should be free to choose the option they prefer.

Patient costs for medication abortion: Results from a study of five clinical practices

PURPOSE

In 2000, the FDA approved mifepristone as a medication abortion alternative. There is limited understanding of the patient costs associated with use of this method. Our objective was to determine total patient costs for medication abortion. This information may be useful for improving counseling and patient decision making.

METHODS

We surveyed 212 women who received a medication abortion from a convenience sample of 5 health care practices. Patient costs including direct medical costs (pregnancy test costs, charges), direct nonmedical costs (child care, travel, lodging), and productivity losses (value of time away from work or other activities) were determined.

RESULTS

The mean total cost for medication abortion was 351 dollars (0-1,140 dollars). The average charge paid by women themselves for the procedure itself was 306 dollars. Three quarters of total costs were direct medical costs and almost one quarter was time away from work and other activities. Although nearly three quarters of the women were insured, only 1% used insurance to cover their abortion--many (44%) did not know if their insurance covered abortion.

CONCLUSIONS

This study provides descriptive information on patient costs associated with medication abortion that may be integrated into patient counseling to enhance informed decision making by women. The study raises questions about why women who report having insurance are not aware of whether their insurance will cover abortion and suggests that we are unclear about women's and providers' preferences for using insurance. We should continue to develop our knowledge of the clinical and nonclinical trade-offs for women choosing between abortion methods to benefit patient decision making.

The true cost differential between mifepristone and misoprostol and misoprostol-alone regimens for medical abortion

Our objective was to evaluate relative differences in direct and total (direct and indirect) costs for medical abortion regimens using mifepristone and misoprostol or misoprostol alone. We created formulas to evaluate relative differences in costs in the United States, Chennai (Madras), India, and a hypothetical developing country based on published protocols and efficacy data. Follow-up visits and suction aspiration procedures in the United States were evaluated over a range of costs. American indirect costs were estimated using earning data. Indirect costs in India and the hypothetical developing country were based on mifepristone cost differences between the United States and India. Although mifepristone costs US dollar 83.33 for every 200-mg tablet in the United States, the actual excess cost of using a mifepristone regimen, as compared with a misoprostol-alone regimen, is only US dollar 22 to US dollar 32. The actual cost of a mifepristone regimen is lower than that of a misoprostol-alone regimen in India. In a hypothetical developing country, a mifepristone regimen is likely to be less expensive than regimens using misoprostol alone. Because of the higher efficacy of medical abortion regimens using mifepristone and misoprostol and the need for fewer follow-up evaluations, such regimens are less expensive or only minimally more expensive than those using misoprostol alone.

Medical versus surgical abortion efficacy, complications and leave of absence compared in a partly randomized study

To provide optimal information to women choosing between early medical and surgical abortion, rigorous comparisons of the two methods are warranted. We compared the outcome of 1135 consecutive women with gestational age (GA) < or = 63 days receiving either a medical (600 mg mifepristone and 1 mg gemeprost) or a surgical abortion (vacuum aspiration in general anesthesia). One hundred eleven of these women were randomized for abortion method. Surgical interventions and complications leading to readmission within the following 15 weeks were identified through a computer system. Information about antibiotic treatment, leave of absence and number of contacts to the health care system were obtained from mailed questionnaires. The number of complications was identical after the two methods, but surgical abortion was associated with a higher success rate [97.7% (708/725) vs. 94.1% (386/410), p < .01] and also with a higher risk of antibiotic treatment than medical abortion [7.8% (37/467) vs. 3.7% (13/356), p < .05]. The median leave of absence was shorter in women choosing a medical (1 day) than a surgical termination (2 days), p < .05. On average, one third of all the women requested at least one extra unscheduled consultation apart from a routine follow-up visit. We conclude that the chance of a primary successful termination at GA < or = 63 days is higher after a surgical abortion in general anesthesia compared to a medical abortion induced with 600 mg mifepristone and 1 mg gemeprost. A surgical abortion is associated with an increased risk of antibiotic treatment compared to medical abortion. The women's need for follow-up might be higher than we expect.

Pharmacoeconomics of medical abortion: a review of cost in the United States, Europe and Asia

Procedures for the termination of pregnancy have existed for many years. Vacuum aspiration, otherwise referred to as 'surgical' abortion, is a very common and safe procedure. Its efficacy and acceptability has been established and its complication rate is low. Medical abortion is a much more recent phenomenon. It is defined as early pregnancy termination with the use of abortion inducing medications, without surgery [1]. In contrast to surgical abortion, medical abortion is not as routinely offered, nor are many providers comfortable with its use. Medical abortion regimens currently available throughout the world include mifepristone (Mifeprex trade mark, Aventis Pharma AG) and a prostaglandin analogue (usually misoprostol), methotrexate and misoprostol and misoprostol (Cytotec trade mark, CD Searle & Co.) alone. In the US, minimal information exists directly comparing medical to surgical abortion. Most abortion surveillance data was collected by the Centers for Disease Control prior to the approval of mifepristone. In contrast, there is over a decade's worth of experience from Europe with both the use and provision of medical abortion. A complete review of these issues must include background information on the history and incidence of abortion, who chooses to get an abortion, who provides that service and at what cost. The cost issue is discussed using three different viewpoints: cost to the patient, cost to the provider, cost to society - mainly in the form of government expenditure and savings. Following the cost analysis, there is a summary of relevant information from countries in Europe, primarily the UK, France, Sweden and countries in Asia, mainly China and India.