Costs and consequences of abortions to women and their households: a cross-sectional study in Ouagadougou, Burkina Faso

Inclusion of abortion-related care in national health benefit packages: results from a WHO global survey

INTRODUCTION

Service inclusion in a country's health benefit package (HBP) is an important milestone towards universal health coverage. This study aimed to explore HBP inclusion of abortion interventions globally.

METHODS

Secondary analysis of the WHO HBP survey, in which officially nominated survey focal points were asked which interventions were included within the HBP of their country or area's largest government health financing scheme. Abortion inclusion was compared by region, income, legal status of abortion and HBP design process variables. Abortion inclusion was compared with other sexual and reproductive health (SRH) services.

RESULTS

Below half (45%) reported that abortion is included, but treatment of complications from unsafe abortion was more commonly included (63%). Fewer fully included essential abortion medications (22% mifepristone, 42% misoprostol). Abortion was less commonly included than any other SRH service in the survey. Unlike most SRH services, higher cost, higher technology care to treat complications of unsafe abortion was more commonly included than the relatively lower cost, lower technology service of induced abortion. Higher-income contexts and less restrictive legal environments had higher abortion inclusion. Some contexts had additional restrictions, with abortion inclusion dependent on the patient's reason for seeking care.

CONCLUSION

This global survey finds that abortion services and medications are often not included within HBPs, while treatment of complications from unsafe abortion is more commonly included. There are opportunities to improve HBP abortion inclusion across different legal contexts, which can improve health outcomes and reduce the need for higher cost treatment of complications from unsafe abortion.

Induced abortion incidence and safety in Burkina Faso in 2020: Results from a population-based survey using direct and social network-based estimation approaches

This study aims to estimate induced abortion incidence and safety in Burkina Faso using direct and indirect methods, overall and by women's background characteristics. Data come from a nationally representative survey of reproductive aged women (n = 6,388). To address social desirability bias in abortion reporting, we asked about respondents' closest female friends' experience with abortion. The one-year abortion incidence in 2020 for respondents was 4.0 (95% CI 2.2-5.9) per 1,000 women aged 15-49 while the adjusted friend incidence was 22.9 (95% CI 15.8-30.0). Although not significant, abortion incidence was higher for adolescents, unmarried women, those with higher education, and those in urban areas among both respondents and their friends. Approximately nine out of ten abortions were unsafe (90% respondents, 95% friends), with respondent and friend findings suggesting higher risk of unsafe abortion among older women, less educated women, and women residing in rural areas. Despite recent increases in contraceptive use and continued legal restrictions, abortion remains common in Burkina Faso and is largely unsafe, with evidence of potential disparities.

Typologies of women's abortion trajectories in Burkina Faso: findings from a qualitative study

BACKGROUND

Abortion is a legally restricted, yet common reproductive life event among women in Burkina Faso; however, women's abortion experiences vary greatly depending on their social and economic capital, partner involvement, and level of knowledge. We sought to classify women's abortion care-seeking experiences across the life course and social conditions into typologies using qualitative data.

METHODS

An initial quantitative survey among a nationally representative sample of women ages 15-49 years collected information on women's induced abortion experiences. Women who reported an abortion in the last 10 years were asked if they would agree to participate in a subsequent in-depth interview (IDI) to learn more about their abortion experience. Twenty-five women, identified via purposive sampling, completed an IDI. Using a process of typology construction, we identified attributes of each woman's condition at the time of her abortion and aspects of her abortion experience, created a matrix of attributes and cases, and identified emerging relationships. Three types were identified through this process.

RESULTS

Twenty-three IDIs were analyzed, and women's abortion experiences were grouped into three types: abortion to delay childbearing in adolescence; abortion to space childbirth among women in union; abortion to avoid childbearing among single mothers. Two cases were identified as outliers. Cases were grouped based on the context of their pregnancy, the reason for the abortion and involved decision-makers, and their patterns of care-seeking, including methods and sources used.

CONCLUSION

Structural inequities related to gender and wealth were prominent forces shaping women's abortion experiences. Comprehensive sexuality education coupled with community-based interventions to promote gender-equitable relationships and address social stigma related to women's sexuality could reduce reproductive coercion and unintended pregnancies.

Why does abortion stigma matter? A scoping review and hybrid analysis of qualitative evidence illustrating the role of stigma in the quality of abortion care

Abortion stigma shapes the environment in which abortion is delivered and received and can have important implications for quality in abortion care. However, this has not previously been clearly articulated and evidenced. We conducted a scoping review of existing qualitative evidence to characterize the relationship between abortion stigma and quality in abortion care. Using a systematic process, we located 50 qualitative studies to include in our analysis. We applied the interface of the WHO quality of care and abortion stigma frameworks to the qualitative evidence to capture manifestations of the interaction between abortion stigma and quality in abortion care in the existing literature. Four overarching themes linked to abortion stigma emerged: A) abortion as a sin and other religious views; B) regulation of abortion; C) judgement, labelling and marking; and D) shame, denial, and secrecy. We further characterized the emerging ways in which abortion stigma operates to inhibit quality in abortion care into seven manifestations of the relationship between abortion stigma and quality in abortion care: 1) poor treatment and the repercussions, 2) gatekeeping and obstruction of access, 3) avoiding disclosure, 4) arduous and unnecessary requirements, 5) poor infrastructure and lack of resources, 6) punishment and threats and 7) lack of a designated place for abortion services. This evidence complements the abortion stigma-adapted WHO quality of care framework suggested by the International Network for the Reduction of Abortion Discrimination and Stigma (inroads) by illustrating specifically how the postulated stigma-related barriers to quality abortion care occur in practice. Further research should assess these manifestations in the quantitative literature and contribute to the development of quality in abortion care indicators that include measures of abortion stigma, and the development of abortion stigma reduction interventions to improve quality in abortion care.

Understanding the financial burden of incomplete abortion: An analysis of the out-of-pocket expenditure on postabortion care in eight public-sector health care facilities in Dakar, Senegal

Timely access to treatment is essential for women when they experience abortion complications. Out-of-pocket (OOP) expenditure is a known barrier to health care access. In 2018, we assessed the financial burden of accessing postabortion care (PAC) borne by women in Dakar, Senegal, where studies estimate that half of poor women with complications obtain PAC. We interviewed 729 women following discharge from PAC. Women reported expenditures on transportation, admission, treatment, family planning, hospitalisation, complementary tests, prescriptions, other medicines and materials. We compare women's OOP on PAC by expenditure category, type of treatment and facility type, and use multiple generalised linear regression analysis to explain variation in overall OOP and forecast it under alternate scenarios. The average OOP was USD $93.84. At health centres it was $65.47 and at hospitals it was $120.47. The average cost of PAC using dilation and curettage was $112.37, manual vacuum aspiration was $99.84, and misoprostol $61.80. Overall OOP on PAC amounts, on average, to 15% of the average monthly salary for women living in Dakar. Strategies that emphasise timely access to misoprostol for treating complications in primary care settings will address the contribution of OOP costs to Senegal's appreciable unmet need for PAC among the poor.

Clients' perceptions of the quality of post-abortion care in eight health facilities in Dakar, Senegal

Post-abortion care (PAC) integrates elements that are vital for women's survival after abortion complications and their ability to meet their subsequent fertility intentions. Currently, the utilization of PAC among women in need remains too low, particularly in settings where unsafe abortion is an appreciable cause of maternal mortality. Interventions have aimed at addressing unmet need; however, these still require information on the extent to which women value different aspects of PAC. This paper presents such evidence from Dakar, Senegal. Exit interviews with 729 PAC clients in 2018 at eight health facilities obtained information on patient characteristics, content of services received and women's perceptions of the quality of care, both overall and according to subject-specific domains. These domains reflect aspects of PAC that are relevant to clients' satisfaction: accessibility, facility environment, information and counselling, family planning, provider technical competence and readiness and client-staff interaction. Ordinal logistic regression models were estimated to identify factors that were associated with women's rating of overall quality of care (on a scale of 1 to 5, 1 being lowest). Predictors that were significantly associated with the outcome were used in a multivariate ordinal logistic regression model that estimated the probability of positive differences in the outcome associated with women's classification of each predictor. Women reported a mean rating of 3.7 for overall quality of care. The lowest domain-specific rating was for quality of information and counselling (mean=2.4) and the highest was for client-staff interaction (mean=3.8). Factors associated with clients' higher odds of being more satisfied with PAC were: physical comfort during the procedure, recall of counselling on treatment procedure, privacy, perceived availability of supplies and medicines, facility admission process, facility cleanliness, waiting time, clarity of counselling and access to different contraceptive methods. Interventions that target these factors may improve the utilization of PAC in Dakar, Senegal.

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.

Economic impact of surgery on households and individuals in low income countries: A systematic review

BACKGROUND

Surgical disease in Low Income Countries (LIC) is common, and overall provision of surgical care is poor. A key component of surgical health systems as part of universal health coverage (UHC) is financial risk protection (FRP) - the need to protect individuals from financial hardship due to accessing healthcare. We performed a systematic review to amalgamate current understanding of the economic impact of surgery on the individual and household. Our study was registered on Research registry (www.researchregistry.com).

METHODS

We searched Pubmed and Medline for articles addressing economic aspects of surgical disease/care in low income countries. Data analysis was descriptive in light of a wide range of methodologies and reporting measures. Quality assessment and risk of bias analysis was performed using study design specific Joanna-Briggs Institute checklists. This study has been reported in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) Guidelines.

RESULTS

31 full text papers were identified for inclusion; 22 descriptive cross-sectional studies, 4 qualitative studies and 5 economic analysis studies of varying quality. Direct medical, direct non-medical and indirect costs were variably reported but were substantial, resulting in catastrophic expenditure. Costs had far reaching economic impacts on individuals and households, who used entire savings, took out loans, reduced essential expenditure and removed children from school to meet costs.

CONCLUSION

Seeking healthcare for surgical disease is economically devastating for individuals and households in LICs. Policies directed at strengthening surgical health systems must seek ways to reduce financial hardship on individuals and households from both direct and indirect costs and these should be monitored and measured using defined instruments from the patient perspective.

The Economic Burden of Abortion and Its Complication Treatment Cares: A Systematic Review

Objective: Abortion related procedures contribute to a significant economic burden because it resulted in prolonged hospital stays for patients. We aimed to gather available evidence on the economic burden of abortion and post-abortion complication treatment cares worldwide.

Materials and methods: PubMed, Web of Science, Scopus, and Embase databases were searched through November 2019. Two researchers independently conducted the quality assessment and data extraction process. The latest web-based tool adjusted the estimates of costs expressed in one specific currency and price year into a specific target currency (the year 2016 $US).

Results: Totally, 2082 records were retrieved and 32 studies were deemed eligible for qualitative synthesis. The mean total costs per patient with abortion or post-abortion care ranged from $23 to $564. The annual costs ranged from 189,000 $US to 134 million $US.

Conclusion: Abortion and post-abortion care impose a substantial economic burden on society. Understanding the burdensome of abortion or pregnancy termination among policymakers provides vital information and enables informed decisions to be made to establish health care priorities and allocating scarce resources.

Sexual and reproductive health services in universal health coverage: a review of recent evidence from low- and middle-income countries

If universal health coverage (UHC) cannot be achieved without the sexual and reproductive health (SRH) needs of the population being met, what then is the current situation vis-à-vis universal coverage of SRH services, and the extent to which SRH services have been prioritised in national UHC plans and processes? This was the central question that guided this critical review of more than 200 publications between 2010 and 2019. The findings are the following. The Essential Package of Healthcare Services (EPHS) across many countries excludes several critical SRH services (e.g. safe abortion services, reproductive cancers) that are already poorly available. Inadequate international and domestic public funding of SRH services contributes to a sustained burden of out-of-pocket expenditure (OOPE) and inequities in access to SRH services. Policy and legal barriers, restrictive gender norms and gender-based inequalities challenge the delivery and access to quality SRH services. The evidence is mixed as to whether an expanded role and scope of the private sector improves availability and access to services of underserved populations. As momentum gathers towards SRH and UHC, the following actions are necessary and urgent. Advocacy for greater priority for SRH in government EPHS and health budgets aligned with SRH and UHC goals is needed. Implementation of stable and sustained financing mechanisms that would reduce the proportion of SRH-financing from OOPE is a priority. Evidence, moving from descriptive towards explanatory studies which provide insights into the "hows" and "whys" of processes and pathways are essential for guiding policy and programme actions.

Patient and health system costs of managing pregnancy and birth-related complications in sub-Saharan Africa: a systematic review

BACKGROUND

Morbidity and mortality due to pregnancy and childbearing are high in developing countries. This study aims to estimate patient and health system costs of managing pregnancy and birth-related complications in sub-Saharan Africa.

METHODS

A systematic review of the literature was conducted to identify costing studies published and unpublished, from January 2000 to May 2019. The search was done in Pubmed, EMBASE, Cinahl, and Web of Science databases and grey literature. The study was registered in PROSPERO with registration No. CRD42019119316. All costs were converted to 2018 US dollars using relevant Consumer Price Indices.

RESULTS

Out of 1652 studies identified, 48 fulfilled the inclusion criteria. The included studies were of moderate to high quality. Spontaneous vaginal delivery cost patients and health systems between USD 6-52 and USD 8-73, but cesarean section costs between USD 56-377 and USD 80-562, respectively. Patient and health system costs of abortion range between USD 11-66 and USD 40-298, while post-abortion care costs between USD 21-158 and USD 46-151, respectively. The patient and health system costs for managing a case of eclampsia range between USD 52-231 and USD 123-186, while for maternal hemorrhage they range between USD 65-196 and USD 30-127, respectively. Patient cost for caring low-birth weight babies ranges between USD 38-489 while the health system cost was estimated to be USD 514.

CONCLUSION

This is the first systematic review to compile comprehensive up-to-date patient and health system costs of managing pregnancy and birth-related complications in sub-Saharan Africa. It indicates that these costs are relatively high in this region and that patient costs were largely catastrophic relative to a 10 % of average national per capita income.

Global Abortion Policies Database: a Descriptive Analysis of Financial Coverage for Abortion Care

Purpose of the Review

The purpose of this review is to report on data available in the Global Abortion Policies Database (GAPD) as of February 2020. The GAPD is a repository of publicly available sources related to abortion for all countries.

Recent Findings

Research indicates that where individuals must pay for abortion procedures, costs can often be unaffordable and catastrophic for households. Faced with financial barriers, individuals may be deterred from seeking healthcare or may resort to clandestine practices.

Summary

There are limited countries with publicly available sources related to financial protection for abortion services. Even where legal access may be available on paper, several countries restrict actual access by limiting financial protection to specific types of individuals seeking abortion or certain legal categories of abortion, thus raising questions of equity and possible human rights violations. As countries advance towards universal health coverage (UHC), there is an urgent need to expand the GAPD to include additional data, building the evidence base on national health systems financing, and to consider the implications of financial protection with respect to access to abortion services.

Estimating abortion incidence and unintended pregnancy among adolescents in Zimbabwe, 2016: a cross-sectional study

OBJECTIVE

To estimate age-specific abortion incidence and unintended pregnancy in Zimbabwe, and to examine differences among adolescents by marital status and residence.

DESIGN

We used a variant of the Abortion Incidence Complications Methodology, an indirect estimation approach, to estimate age-specific abortion incidence. We used three surveys: the Health Facility Survey, a census of 227 facilities that provide postabortion care (PAC); the Health Professional Survey, a purposive sample of key informants knowledgeable about abortion (n=118) and the Prospective Morbidity Survey of PAC patients (n=1002).

SETTING

PAC-providing health facilities in Zimbabwe.

PARTICIPANTS

Healthcare providers in PAC-providing facilities and women presenting to facilities with postabortion complications.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was abortion incidence (in rates and ratios). The secondary outcome measure was the proportion of unintended pregnancies that end in abortion.

RESULTS

Adolescent women aged 15-19 years had the lowest abortion rate at five abortions per 1000 women aged 15-19 years compared with other age groups. Adolescents living in urban areas had a higher abortion ratio compared with adolescents in rural areas, and unmarried adolescent women had a higher abortion ratio compared with married adolescents. Unintended pregnancy levels were similar across age groups, and adolescent women had the lowest proportion of unintended pregnancies that ended in induced abortion (9%) compared with other age groups.

CONCLUSIONS

This paper provides the first estimates of age-specific abortion and unintended pregnancy in Zimbabwe. Despite similar levels of unintended pregnancy across age groups, these findings suggest that adolescent women have abortions at lower rates and carry a higher proportion of unintended pregnancies to term than older women. Adolescent women are also not a homogeneous group, and youth-focused reproductive health programmes should consider the differences in experiences and barriers to care among young people that affect their ability to decide whether and when to parent.

Mandatory pre-abortion counseling is a barrier to accessing safe abortion services

Empirical research showcases that pre-abortion counseling scarcely reverses the woman’s decision either to terminate a pregnancy or not. Growing evidence regarding the high levels of decisional certainty among women seeking abortions renders a careful rethink of the place of mandatory pre-abortion counseling packages. Mandatory counseling packages, when inscribed in the laws, at times contain false information that can deter women from going in for safe abortions. Mandatory waiting times indirectly label opting for an abortion as not being the right thing to do. In areas where abortion stigma from health care providers and communities remains highly prevalent, women are forced to incur extra expenses by travelling to other countries. I argue that pre-abortion counseling on opting-in grounds is ethically sound (enhances the woman’s reproductive autonomy), since most clients in need of abortions are certain on their decisions before the abortion care provider and do not regret these decisions after the process. Regrets are prone to be more prevalent in areas with high unsafe abortion practices, generally due to complications from excessive bleeding, pain, and post abortion infections. Allowing systematic mandatory pre-abortion counseling practice as the rule in a competent adult is unjustified ethically and empirically, is time consuming and presents the legality of abortions in most settings an oxymoron.

The Unit and Scale-Up Cost of Postabortion Care in Tanzania

INTRODUCTION

Based on research conducted in 2017, we estimated the cost to the Tanzanian health care system of providing postabortion care (PAC). PAC is an integrated service package that addresses the curative and preventive needs of women experiencing complications from abortion. PAC services include treating complications of miscarriage and incomplete abortion, providing voluntary family planning counseling and services, and engaging the community to reduce future unintended pregnancies and repeat abortions.

METHODS

Thirty-one public and private health facilities, representing 3 levels of health care, were selected for data collection from key care providers and administrators in 3 regions. We gathered data on the direct costs of PAC startup (i.e., training and capital costs), as well as the recurrent costs of medicines, supplies, hospitalization, and personnel, and the indirect costs of PAC provision. We also gathered data to estimate PAC clients' out-of-pocket expenses. Estimates of the average cost per client (i.e., unit cost) were calculated for treatment of routine and severe abortion complications, treatment at different levels of health care, postabortion contraception, and various available treatment methods.

RESULTS

We found that the unit cost of PAC training per provider was US$163.43. The total unit cost was $72.91. The unit recurrent cost of treating routine complications, which included 81% of the cases in our sample, was $36.23. The cost of treating incomplete abortion through manual vacuum aspiration was $22.63, while the cost of treatment with misoprostol was $18.74. The average cost of providing voluntary postabortion family planning was $11.56. We estimated an average client out-of-pocket expenditure on PAC of $22.96.

CONCLUSION

We applied our unit cost estimates to those on PAC utilization and provision and unmet need for PAC that were derived from research conducted in Tanzania in 2013-2016, and we estimated an annual national cost of PAC of $4,170,476. We estimated the cost of providing PAC for all women who have abortion complications, including those who do not access PAC, at $10,426,299. Investing more resources in voluntary family planning and PAC treatment of routine complications at the primary level would likely reduce health system costs.

Economics of abortion: a scoping review protocol

INTRODUCTION

Abortion is a common feature of people's reproductive lives. However, the economic implications of abortion and policies affecting abortion provision are poorly understood. This scoping review aims to systematically review social science literature for studies that have investigated the impact of abortion care (ie, un/safe abortion, post-abortion care) or abortion policies on economic outcomes at the micro-levels (ie, abortion seekers and their households), meso-levels (ie, communities and health systems) and macro-levels (ie, societies and nation states). Informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline for protocols, this protocol details the scoping review's methodological and analytical approaches.

METHODS AND ANALYSIS

This scoping review will utilise the PRISMA extension for Scoping Reviews (PRISMA-ScR) tool. Studies reporting on qualitative and/or quantitative data from any world region will be considered. For inclusion, studies must examine one of the following economic outcomes at the micro-levels, meso-levels and/or macro-levels: costs, benefits, impacts and/or value of abortion care or abortion policies. Searches will be conducted in eight electronic databases. We will conduct the searches and application of inclusion/exclusion criteria according to the PRISMA-ScR flow approach. No assessments of items' quality will be made, as the purpose of this scoping review is to synthesise and describe the coverage of the evidence. After extracting all data, we will inductively develop an economic framework around the economics of abortion. The analysis will synthesise the evidence base and identify knowledge gaps on the costs and benefits of abortion to stakeholders at various levels.

ETHICS AND DISSEMINATION

Formal ethical approval is not required, as primary data will not be collected in this study. The findings of this study will be disseminated through peer-reviewed publications, conference presentations, and condensed summaries for key stakeholders and partners in the field.

Comparing women's financial costs of induced abortion at a facility vs. seeking treatment for complications from unsafe abortion in Zambia

Although abortion is legal in Zambia under a variety of broad conditions, unsafe abortion remains common. The purpose of this project was to compare the financial costs for women when they have an induced abortion at a facility, with costs for an induced abortion outside a facility, followed by care for abortion-related complications. We gathered household wealth data at one point in time (T1) and longitudinal qualitative data at two points in time (T1 and T2, three-four months later), in Lusaka and Kafue districts, between 2014 and 2015. The data were collected from women (n = 38) obtaining a legal termination of pregnancy (TOP), or care for unsafe abortions (CUA). The women were recruited from four health facilities (two hospitals and two private clinics, one of each per district). At T2, CUA cost women, on average, 520 ZMW (USD 81), while TOP cost women, on average, 396 ZMW (USD 62). About two-thirds of the costs had been incurred by T1, while an additional one-third of the total costs was incurred between T1 and T2. Women in all three wealth tertiles sought a TOP in a health facility or an unsafe abortion outside a facility. Women who obtained CUA tended to be further removed from the money that was used to pay for their abortion care. Women's financial dependence leaves them unequipped to manage a financial shock such as an abortion. Improved TOP and post-abortion care are needed to reduce the health sequelae women experience after both types of abortion-related care.

Factors Associated with Management Outcome of Incomplete Abortion in Yirgalem General Hospital, Sidama Zone, Southern Ethiopia

Background

Each year, several millions of women who underwent abortion also bear several consequences, including infection, massive blood loss, chronic pelvic pain, infertility, and death. Poor treatment outcomes also cause disability and death. The aim of this study was to determine factors associated with management outcomes of incomplete abortion in Yirgalem General Hospital.

Methods

Health facility-based cross-sectional study design was used. Medical record review of 186 women who received abortion service from July 1^st 2015 to June 30 2017 was done. Then the data were entered into the computer using epi info version 7.2 and exported into SPSS version 20, Descriptive analysis was done to determine social, demographic characteristics, and bivariate and multivariate logistic regression analysis were done to identify factors associated with management outcome of incomplete abortion, 95% CI and odds ratio used to present the result.

Results

A total of 180 (96.7%) of cases managed for incomplete abortion was included in the study. Of this, 53.3% of patients with incomplete abortion belonged to age group of 18-25 years old. More than half incomplete abortion cases were managed surgically 122 (67.8%). Of the total, 36 (19.4%) of the patients developed unfavorable management outcome. Gestational age at which abortion occurs AOR = 3.39, 95% (1.29, 8.89) and delayed seeking of medical help AOR = 2.96, 95% (1.04, 8.4) were found to be significantly associated with unfavorable management outcome.

Conclusion

High numbers of cases managed for abortion resulted unfavorable management outcome. However, no death occurred and major surgery done as the result of abortion management. Delayed seeking of medical care and seeking care past 1st trimester are significantly associated with unfavorable management outcomes. Therefore, awareness creation for adolescent and youth about prompt health-care seeking after the start of the first sign and symptom of spontaneous abortion should be strengthened.

How User Fees Influence Contraception in Low and Middle Income Countries: A Systematic Review

Accessible and quality reproductive health services are critical for low‐ and middle‐income countries (LMICs). After a decade of waning investment in family planning, interest and funding are growing once again. This article assesses whether introducing, removing, or changing user fees for contraception has an effect on contraceptive use. We conducted a search of 14 international databases. We included randomized controlled trials, interrupted‐time series analyses, controlled before‐and‐after study designs, and cohort studies that reported contraception‐related variables as an outcome and a change in the price of contraceptives as an intervention. Four studies were eligible but none was at low risk of bias overall. Most of these, as well as other studies not included in the present research, found that demand for contraception was not cost‐sensitive. We could draw no robust summary of evidence, strongly suggesting that further research in this area is needed.

Methodological Issues to Consider When Collecting Data to Estimate Poverty Impact in Economic Evaluations in Low-income and Middle-income Countries

Out-of-pocket spending is increasingly recognized as an important barrier to accessing health care, particularly in low-income and middle-income countries (LMICs) where a large portion of health expenditure comes from out-of-pocket payments. Emerging universal healthcare policies prioritize reduction of poverty impact such as catastrophic and impoverishing healthcare expenditure. Poverty impact is therefore increasingly evaluated alongside and within economic evaluations to estimate the impact of specific health interventions on poverty. However, data collection for these metrics can be challenging in intervention-based contexts in LMICs because of study design and practical limitations. Using a set of case studies, this letter identifies methodological challenges in collecting patient cost data in LMIC contexts. These components are presented in a framework to encourage researchers to consider the implications of differing approaches in data collection and to report their approach in a standardized and transparent way.

The politics of unsafe abortion in Burkina Faso: the interface of local norms and global public health practice

In Burkina Faso, abortion is legally restricted and socially stigmatised, but also frequent. Unsafe abortions represent a significant public health challenge, contributing to the country's very high maternal mortality ratio. Inspired by an internationally disseminated public health framing of unsafe abortion, the country's main policy response has been to provide post-abortion care (PAC) to avert deaths from abortion complications. Drawing on ethnographic research, this article describes how Burkina Faso's PAC policy emerged at the interface of political and moral negotiations between public health professionals, national bureaucrats and international agencies and NGOs. Burkinabè decision-makers and doctors, who are often hostile to induced abortion, have been convinced that PAC is ‘life-saving care’ which should be delivered for ethical medical reasons. Moreover, by supporting PAC they not only demonstrate compliance with international standards but also, importantly, do not have to contend with any change in abortion legislation, which they oppose. Rights-based international NGOs, in turn, tactically focus on PAC as a ‘first step’ towards their broader institutional objective to secure safe abortion and abortion rights. Such negotiations between national and international actors result in widespread support for PAC but stifled debate about further legalisation of abortion.