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

Background

Despite 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.

Methods

We 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.

Results

A 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.

Conclusion

This 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.

Manual vacuum aspiration: a safe and cost-effective substitute of electric vacuum aspiration for the surgical management of early pregnancy loss

OBJECTIVE

To compare the efficacy, safety and cost-effectiveness of Manual vacuum aspiration (MVA) with Electrical vacuum aspiration (EVA) in the management of first trimester pregnancy loss.

METHODS

A single-centre randomized controlled trial (RCT) was conducted at Maternal and Child Health Centre (MCHC), Unit-I, Pakistan Institute of Medical Sciences (PIMS), Islamabad from April 2007-Dec 2008. A total of 176 cases with early pregnancy loss at < 12 weeks gestation, with a diagnosis of anembryonic pregnancy, incomplete, missed or septic induced abortion and molar pregnancy were randomly allocated to either MVA or EVA in the operation theatre.

RESULTS

A total of 176 women were included out of which 70 underwent EVA and 106 had MVA. Baseline characteristics were similar in the two groups except significantly higher gestational age and gestational sac diameter in MVA group. Majority of EVA were performed under general anaesthesia (95.7%) while majority of MVA were performed under paracervical block (60.3%). Complete evacuation was achieved in 89.6% with MVA vs 91.4% with EVA (p=0.691). MVA was superior in terms of significantly less blood loss (62.08 +/- 32.19 vs 75.71 +/- 35.53; p=0.008), shorter hospital stay (12.26 hours +/- 6.97 vs 19.54 hours +/- 7.95; p=0.000) and less hospital cost (Rs 1419.5 +/- 1337.620 vs Rs. 3222.5 +/- 1816.02; p=0.000). Post-operative pain assessment by visual analogue score (VAS) at 0 and 6 hours showed no significant difference (p=0.845 and p=0.157 respectively). The only complication was uterine perforation in 2 (2.4%) cases both belonging to EVA.

CONCLUSION

MVA is a safe and effective alternative of conventional EVA. It is superior to EVA in terms of reduced cost and need for general anaesthesia and is thus useful at low resource setting with scarcity of electricity and general anaesthesia.

Cost-effectiveness analysis of unsafe abortion and alternative first-trimester pregnancy termination strategies in Nigeria and Ghana

To explore the policy implications of increasing access to safe abortion in Nigeria and Ghana, we developed a computer-based decision analytic model which simulates induced abortion and its potential complications in a cohort of women, and comparatively assessed the cost-effectiveness of unsafe abortion and three first-trimester abortion modalities: hospital-based dilatation and curettage, hospital- and clinic-based manual vacuum aspiration (MVA), and medical abortion using misoprostol (MA). Assuming all modalities are equally available, clinic-based MVA is the most cost-effective option in Nigeria. If clinic-based MVA is not available, MA is the next best strategy. Conversely, in Ghana, MA is the most cost-effective strategy, followed by clinic-based MVA if MA is not available. From a real world policy perspective, increasing access to safe abortion in favor over unsafe abortion is the single most important factor in saving lives and societal costs, and is more influential than the actual choice of safe abortion modality.

VFDs can cut costs and improve control

Phil Giles of Becker Pumps Australia examines the use of variable frequency drives for medical suction plant, and explains the many potential benefits--both practical and economic. The paper on which this article is based was presented at the Institute of Hospital Engineering Australia's (IHEA) 60th National Conference in 2009.

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.

Management strategies for abnormal early pregnancy: a cost-effectiveness analysis

OBJECTIVE

To assess the potential effectiveness and costs of 4 commonly used strategies to manage abnormal early pregnancies (AEPs).

STUDY DESIGN

A decision analysis model was constructed to compare 4 strategies to manage AEPs: (1) observation, (2) medical management, (3) manual vacuum aspiration (MVA), and (4) dilation and curettage (D&C).

RESULTS

MVA was the most cost-effective strategy, at dollar 793 per cure, for a total cost of dollar 377 million per 500,000 women and a cure rate of 95%. D&C was more effective than MVA, with a cure rate of 99%, but was more expensive (dollar 2,333 per cure, for a total cost of dollar 1.2 billion). D&C cured 20,000 more patients than MVA; however, at a substantial cost of dollar 38,925 per additional cure. With other estimates at baseline, MVA remained more cost-effective than D&C until the efficacy of MVA was < 82% or the cost of D&C was < dollar 240.

CONCLUSION

MVA is the most cost-effective strategy for managing AEP and would be appropriate in settings in which resources are limited. D&C remains a reasonable strategy; however, one must spend dollar 38,925 per additional cure. In the United States, MVA would save dollar 779 million per year relative to D&C.

Cost savings of manual vacuum aspiration for endometrial sampling in El Salvador

Despite the existence of less costly and less invasive techniques to evaluate abnormal uterine bleeding, sharp curettage continues to be the most common form of endometrial sampling in the less developed world. Because manual vacuum aspiration (MVA) equipment is often associated with abortion care in countries where abortion is illegal, many practitioners have been slow to incorporate its use for other gynecological conditions. In this study, MVA was introduced in a large teaching hospital in El Salvador as an alternative for patients with abnormal uterine bleeding. Hospital cost, length of stay and complication rates were compared in a prospective, nonrandomized controlled study of 163 patients assigned to either traditional sharp curettage or MVA services. Patients were assigned to each group depending on the availability of trained providers. Methodologies for cost-savings analysis were modified to obtain more precise cost estimates. Use of MVA was associated with a significant cost savings of 11% and a hospital stay that was 27% shorter as compared to sharp curettage. Cost savings could be much higher if MVA was institutionalized as an ambulatory procedure with minimal or no preoperative evaluation and postoperative stay.

Treating incomplete abortion in El Salvador: cost savings with manual vacuum aspiration

When manual vacuum aspiration (MVA) was introduced to treat incomplete abortion at a regional training hospital in El Salvador, this study evaluated the impact of replacing sharp curettage with MVA. Hospital cost, length of hospital stay, complication rates and postabortion contraceptive acceptance were compared in a prospective, nonrandomized, controlled study of 154 women assigned to either traditional sharp curettage services or MVA services plus contraceptive counseling. Assignment depended on availability of trained providers. Compared to sharp curettage, use of MVA and associated changes in protocol led to a significant cost savings of 13% and shorter hospital stay of 28%. Dedicated family-planning counseling resulted in a threefold higher rate of contraceptive acceptance. Although the difference in cost was significant, much higher savings could be realized if minimal postoperative stays were implemented for both procedures. Barriers to early discharge include patient expectations, physician attitudes and training and hospital systems administration.

Is pathology examination useful after early surgical abortion?

OBJECTIVE

To study if the pathologist's examination of surgical abortion tissue offers more information than immediate fresh tissue examination by the surgeon. Immediate examination of the fresh tissue aspirate after surgical abortion helps reduce the risk of failed abortion and other complications. Regulations in some states also require a pathologist to analyze abortion specimens at added cost to providers. We conducted this study to evaluate the incremental clinical benefit of pathology examination after surgical abortion at less than 6 weeks' gestation.

METHODS

As part of a prospective case series of women who had early surgical abortions at the Planned Parenthood League of Massachusetts during a 32-month period, we collected data on clinical outcomes and the results of postoperative tissue examinations. Using outcomes verified by in-person follow-up as the "gold standard," we calculated the validity of the tissue examinations by the surgeons and the outside pathologists.

RESULTS

A total of 676 women had documented outcomes and complete tissue examination data. The sensitivity (ability of the examiner to detect an outcome other than complete abortion) was 57% (95% confidence interval [CI] 35, 76) for the surgeons' tissue inspections and 22% (95% CI 8, 44) for the pathologists' examinations. The predictive value of a positive (abnormal) tissue screen was 14% (95% CI 8, 24) and 7% (95% CI 3, 17) for the surgeons and pathologists, respectively.

CONCLUSION

Routine pathology examination of the tissue aspirate after early surgical abortion confers no incremental clinical benefit. Although the surgeons' tissue inspections predicted abnormal outcomes poorly, the pathologists did no better. Our results challenge the rationale for state regulations requiring pathologic analysis of all surgical abortion specimens.

[Use of manual vacuum aspiration in reducing cost and duration of hospitalization due to incomplete abortion in an urban area of northeastern Brazil]

INTRODUCTION

In most developed countries vacuum aspiration has been shown to be safer and less costly than sharp curettage (SC) for uterine evacuation. In many of the developing countries, including Brazil, sharp curettage (SC) is the most commonly used technique for treating cases of incomplete abortion admitted to hospital. The procedure often involves light to heavy sedation for pain control and an overnight hospital stay for patient recuperation and monitoring. Two hypotheses are examined: the first, that the use of manual vacuum aspiration (MVA)--a variation of the vacuum aspiration, would be less costly than SC for the treatment of cases of incomplete abortion admitted to hospital; and the second, that the treatment of incomplete abortion with MVA would substantially reduce the length of hospital stay.

METHODOLOGY

Thirty women with diagnosis of first trimester incomplete abortion were randomly allocated to the SC or MVA group. Rapid-assessment data collection techniques were used to identify factors that contributed to cost reduction and hospital stay.

RESULTS AND CONCLUSION

The results of the study show that, overall, patients treated for incomplete abortion with MVA spent 77% less time in the hospital and consumed 41% fewer resources than similarly diagnosed patients treated with SC. Recommendations are made as to the need of certain changes in patient management. Particularly necessary is information regarding cultural perception and concepts of abortion treatment.

Cost-effectiveness of managing abortions: manual vacuum aspiration (MVA) compared to evacuation by curettage in Tanzania

Cost effectiveness of managing 107 incomplete abortions by manual vacuum aspiration (MVA) is compared with management of 92 incomplete abortions by evacuation by curettage (E by C) at Muhimbili Medical Centre (September-November 1992). Pre-evacuation waiting times, duration of procedures and duration of hospital stay were less for MVA as compared to E by C. The total pre-evacuation waiting time, the durations of the procedure and hospital stay were 15.59 days (55.11%), 10.96 (46.41%) hours and 21.23 (40.53%) days less for MVA as compared to E by C. The direct costs revealed a cost differential of MVA over E by C of Tshs 776.9 (US$2.6). MVA is more cost effective than contemporary E by C and its introduction on a wider scale in our health care delivery system is recommended.

A time and cost analysis of the management of incomplete abortion with manual vacuum aspiration

OBJECTIVES

Traditionally, management of incomplete abortion involves use of D&C or suction curettage in the operating room. Such management is costly and time-consuming. In order to potentially save time and money, we studied the use of manual vacuum aspiration curettage (MVAC) for the management of this problem.

METHODS

Data on hospital charges and times (e.g. waiting time, procedure time) were obtained for all cases of incomplete abortion presenting to hospital between January 1990 and July 1992. Between January 1990 and July 1991, all cases were managed traditionally. After July 1991, all cases were managed using MVAC in either the emergency room or the labor ward.

RESULTS

Compared to the use of electrical suction equipment in the operating theatre, MVAC procedures resulted in significant savings in terms of both waiting times and costs. Waiting time was reduced by 52% and procedure time was reduced from a mean of 33 min to 19 min (P < 0.01). Total hospital costs were reduced by 41% (P < 0.01).

CONCLUSIONS

Use of manual vacuum aspiration curettage in the management of incomplete abortion can reduce hospital costs and save time for both patients and clinicians.

[Ambulatory abortion, its advantages and economic effectiveness]

Presents data on abortions carried out by vacuum aspiration method in the earliest periods of unplanned pregnancy with the menses delay of up to 20 days in 622 women. The operation was performed in an outpatient setting. The incidence of immediate complications has made up 2.2%, late ones 4.13%; these values are much lower than after abortions during pregnancy weeks 6-12 (6.6 and 14.6%, respectively). The cost of such abortions, including the cost of treatment of late and immediate complications, makes up 9 rubles, whereas routine D&C costs 49 rubles. Vacuum aspiration abortion, carried out if menstrual bleeding is delayed by 16 to 20 days, is an effective, simple, and economic method of pregnancy discontinuation.

Induced abortion: Chlamydia trachomatis and postabortal complications. A cost benefit analysis

The overall prevalence of Chlamydia trachomatis among 873 abortion-seeking women was 9.3% during 1985. Significantly higher age-specific prevalences of C. trachomatis occurred among younger women (p less than 0.001). None of 17 women treated for C. trachomatis before the abortion was carried out, was readmitted to the hospital. Of 64 Chlamydia-positive women, who commenced treatment within the first 2 weeks after the abortion was carried out, 14.1% were readmitted to the hospital, compared with 5.7% of Chlamydia-negative women (p less than 0.02). Postabortal salpingitis was verified at readmission among 10.9% of Chlamydia-positive women and 3.2% of Chlamydia-negative women (p less than 0.01). An analysis of screening of all abortion-seeking women is estimated to be worthwhile when the prevalence of C. trachomatis exceeds 4.3%. We recommend screening for Chlamydia trachomatis of all abortion-seeking women, 30 years or younger, at the pre-abortion visit, provided that treatment can be completed before the abortion is carried out.

Repeat curettage after evacuation of hydatidiform mole. An appraisal

In the management of patients with molar pregnancy, a repeat uterine curettage is generally advocated after evacuation of the hydatidiform mole. To assess the usefulness of a repeat curettage, we reviewed our experience with this procedure over an 8-year period. We found that it was unnecessary in 90% of the cases and did not predict or influence the outcome in all but one case of invasive mole. We feel that the procedure is not cost-effective and should be reserved for patients with specific indications such as incomplete evacuation and abnormal uterine bleeding.

Office hysteroscopy and suction curettage: can we eliminate the hospital diagnostic dilatation and curettage?

The hospital diagnostic dilatation and curettage is the most widely used method in investigating abnormal uterine bleeding. This procedure is expensive and inconvenient and poses some surgical and anesthetic risks. As an alternative to hospital dilatation and curettage, the procedure of office hysteroscopy and suction curettage was evaluated in 406 patients. The indications for the procedure are similar to the classic indications for a diagnostic dilatation and curettage. The method is convenient, safe, and relatively inexpensive. The diagnostic accuracy of office hysteroscopy and suction curettage surpasses prior reports of the accuracy of diagnostic dilatation and curettage. Office hysteroscopy and suction curettage should be the method of choice in the evaluation of abnormal uterine bleeding.

Diagnostic dilation and curettage: a reappraisal

Diagnostic dilation and curettage (D & C) is widely considered to be the method of choice for obtaining samples of endometrium for histologic examination, although the scientific basis for this assumption is elusive. Despite extensive use of D & C, the tissue yield and diagnostic accuracy of this technique have not been adequately evaluated. More is known about these features of a newer diagnostic procedure, Vabra aspiration (VA). VA also appears to be safer, less expensive, and more convenient than D & C. Until the alleged benefits of diagnostic D & C can be shown to outweigh its risks and costs (approaching one billion dollars per year in the United States alone), D & C probably should not be the primary procedure used for obtaining most samples of endometrium.