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id21 health focus l August 2007 unsafe research findings for development policymakers and practitioners

In this issue The high cost The health dangers of unsafe Unsafe abortion abortion costs in Mexico City very eight minutes a The economic Edies somewhere in a due to complications from impact an unsafe abortion. She most likely had little money or support to Saving women’s obtain safe services. She probably first tried to induce a termination lives herself. Failing that she would have High school students in Bucharest, , examine a condom advice leaflet and other contraceptive turned to an unskilled, but relatively educational materials during a talk on sexual health. inexpensive, provider. Peter Barker (Panos Pictures), 2006 Reducing costs to health systems The cost of unsafe abortion-related ill-health burdens households, health systems and society. and death was the subject of a technical Each year, there are an estimated 19 meeting held at the Institute of Development million unsafe worldwide, most id21 focus reports on research from Studies (UK) on 18 and 19 April 2007. It was in low-income countries. About 5.2 million research institutes, programmes or funded by the Hewlett Foundation and brought of these women are hospitalised for serious projects (particularly in developing together experts on unsafe abortion and complications, while an unknown but possibly countries) who want to disseminate economists specialising in costing methods. The equal number of women suffer similarly serious their research to a wider audience meeting reviewed recent work estimating the complications but cannot obtain treatment. As with support from id21. An cost of unsafe abortion to the health sector. a result, around 68,000 women die each year, occasional series, each issue will focus on one topic. Participants also discussed the economic costs making unsafe abortion a significant cause of to health systems, individuals and house- maternal mortality. This number has remained If you would like to share your holds, and the links between unsafe abortion unchanged since 1990. research findings in this way please and poverty. This issue of id21 health focus In 2000, the consequences of unsafe abortion email [email protected] with a short highlights the findings reviewed at the meeting were greater in Africa than in Asia and Latin proposal. and points to important lessons for decision- America. In Africa, 709 women die per 100,000 makers. unsafe abortions, compared to 324 in Asia This issue of id21 health focus Unsafe abortion carried out by individuals and 100 in Latin America. Nearly half of all was produced in collaboration lacking the necessary skills and/or in unhygienic deaths due to unsafe abortion occur in Africa, with the Realising Rights Research Programme Consortium and conditions, is a major global although Africa accounts for only 13 percent the William and Flora Hewlett problem. The practice occurs where abortion of all women of reproductive age in developing Foundation. is legally restricted, and where access to safe countries. services is inadequate although the law may broadly permit the procedure. Unsafe abortion Abortion service provision is changing causes death and ill health in women, and In recent years, countries such as Nepal have responded by Number of reported unsafe abortions per 1,000 women aged 15 – 44 years, 2000 liberalising 30 their . When 25 accompanied by expanded 20 access to safe services, as in 15 South Africa, this greatly reduces 10 complications 5 and deaths from unsafe abortion. 0 Another All Developing Africa Asia Latin America & Oceania continued at the

countries Caribbean t www.id21.org foot of page 2 id21 health focus u n s a f e a b o r t i o n

after a second trimester abortion, when The health dangers complication rates are higher than in the first trimester. Unsafe abortion of unsafe abortion l Abortions induced by traditional practitioners or self-induced by women costs in Mexico City pose the greatest risk. However, women’s nduced abortion is a safe medical increasing use of – a ntil 2007, when first trimester Iprocedure when carried out by skilled (an ‘abortion pill’) available Uabortion was legalised in Mexico City, practitioners in hygienic environments. in pharmacies – is associated with lower abortion was restricted in Mexico. Even rates of complications. Misoprostol is in cases when abortion was legal, few In places with restrictive abortion laws, mainly used in Latin America, but use is states established effective care systems. untrained providers, unsanitary conditions expanding in other regions. Women often found illegal abortion and limited access to high quality abortion l Delays in reaching care after an unsafe services more accessible. services, women are much more likely to abortion contribute to increased To inform policy decisions on abortion complications and high mortality. services, researchers documented the experience immediate complications, long- economic costs to the health system of caring term disabilities or sometimes death. The Lessons for policy include: for women who undergo unsafe abortion. harm caused by unsafe abortion practices is l Trained are as safe and effective They compared the costs of treating abortion largely preventable. as physicians in providing first trimester complications (as a substitute for costs of Immediate complications from unsafe induced abortion with manual vacuum unsafe abortion) with the costs of performing abortions include severe bleeding, uterine aspiration. safe abortions (in legal public or illegal private perforation, tearing of the cervix, severe l is a recommended settings) in Mexico City. damage to the genitals and abdomen, alternative to first trimester abortion. Costs were estimated for three hospitals internal infection of the abdomen and l For abortions after 12 weeks, preferred providing post-abortion care and some legal options include , abortions, and one private clinic providing blood poisoning. Medium and long-term safe but illegal abortion services. Direct costs complications range from reproductive tract , followed by repeated doses of included personnel, drugs, medical supplies infections (RTI) and pelvic inflammatory a prostaglandin, or alone. and equipment. Indirect costs included patient disease (PID) to chronic pain and infertility: l Services offered at the lowest level of the travel, child care and lost wages. 20 to 30 percent of unsafe abortions health care system and close to women’s Using surveys with hospital staff and may lead to RTI, and of these, 20 to 40 homes offer the best prospects for rapid patients, as well as a review of facility percent result in PID and infertility. Late diagnosis, treatment and referral of records, researchers estimated the total cost complications include increased risk of abortion complications. per woman treated with manual vacuum ectopic , miscarriage or premature l Women seeking treatment for aspiration (MVA), complications need to receive rapid, high (D&C) or medical abortion (MA) using delivery in subsequent . misoprostol. South Africa liberalised its abortion law quality care upon arrival at a health facility. l At the public hospitals, the average cost in 1996 and authorised trained midwives to per woman of MVA was US$111 and the perform induced first trimester abortion in Janie Benson average cost of D&C was US$143, whilst at Ipas, PO Box 5027, Chapel Hill, NC 27514, USA the private clinic, the average cost of MVA public health facilities. Deaths from abortion [email protected] complications decreased by 91 percent from was US$53 and the average cost of MA 1994 to 2001. These changes provide an Marcel Vekemans was US$79. Operating costs at the private incentive for reforms in other countries. International Planned Parenthood Federation, Central clinic were significantly lower than at the Factors that influence the severity of Office, 4 Newham’s Row, London, SE1 3UZ, UK public hospitals. [email protected] l The average cost of treating abortion complications and health outcomes include: complications at the public hospitals ranged l Serious complications are much more See also from US$601 to over US$2,100 depending likely when unsafe abortion occurs in late ‘Unsafe Abortion: The Preventable ’, The on severity. Lancet 368, pages 908-919, by David A. Grimes, Janie pregnancy. Studies in public hospitals in Benson, Susheela Singh, Mariana Romero, Bela Ganatra, l Increasing access to MVA and MA services Kenya and South Africa found that over Friday E. Okonofua and Iqbal H. Shah, 2006 for early abortion reduces Mexico City one third of patients seeking treatment www.thelancet.com/journals/lancet/article/ government costs by 62 percent, with a for abortion complications presented PIIS0140673606694816/fulltext potential saving of up to US$1.6 million per year. Using MVA can reduce the costs of post- abortion care which would benefit Mexico’s continued from page 1 health system and women who have an t unplanned pregnancy. Improving access to promising trend is the increased use of new Susheela Singh safe abortion methods at smaller public and drugs such as mifepristone and misoprostol Guttmacher Institute, 120 Wall Street, New York, NY, private facilities is likely to result in significant 10005, USA cost savings to the health system, by lowering – the ‘abortion pill’ – in very early T +1 212 248 1111 (ext 2264) pregnancy. These are an effective alternative the incidence of complications and moving [email protected] services out of hospitals into less costly to surgery and further reduce the risk and outpatient settings. severity of complications. Iqbal H. Shah UNDP/UNFPA/WHO/World Bank Special Programme in Key policy lessons that emerged from the Human Reproduction, World Health Organization, 1211 Carol Levin workshop include: Geneva 27, Switzerland PATH, 1455 NW Leary Way, Seattle, WA 98107, USA l Women need better access to T +41 22 7913332 [email protected] [email protected] contraceptive information and services Daniel Grossman to reduce unintended pregnancies and Hilary Standing Ibis , 17 Dunster Street, Suite abortion (unsafe and safe). Realising Rights Research Programme Consortium, 201, Cambridge, MA 02138, USA l Where the law broadly permits abortion, Institute of Development Studies, University of Sussex, [email protected] safe services need to be expanded so that Brighton, BN1 9RE, UK [email protected] Sandra G. Garcia women do not need to resort to unsafe Population Council, Escondida 110, Col. Villa methods. See also Coyoacán, Deleg. Coyoacán, C.P. 04000, México, D.F. l Where the law is highly restricted, access Unsafe Abortion: Global and Regional Estimates of the [email protected] to services for permitted criteria should be Incidence of Unsafe Abortion and Associated Mortality in 2000, Geneva: World Health Organization, 2004 See also provided. Advocacy should highlight the www.who.int/reproductive-health/publications/ ‘Estimating Costs of Post-Abortion Services at Dr. unacceptable cost of unsafe abortion and unsafe_abortion_estimates_04/estimates.pdf Aurelio Valdivieso General Hospital, Oaxaca, Mexico’, the benefits of expanding the criteria for Sharing Responsibilities: Women Society and Abortion by Carlos Brambila, Ana Langer, Cecilia García- Worldwide, New York: The Alan Guttmacher Institute, Barrios and Angela Heimburger, in Post-Abortion legal abortion. Care: Lessons From Operations Research, New York: l 1999 The quality and coverage of post-abortion www.guttmacher.org/pubs/sharing.pdf Population Council, edited by Dale Huntington and care in developing countries need urgent Nancy J. Piet-Pelon, 1999 improvement.

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components included were not always l Health systems in low-income countries The economic identified. But it was possible from these to spend large sums treating complications produce a range of probable costs. from unsafe abortion despite the impact of unsafe The second approach broke down all existence of cost-effective alternatives. possible post-abortion treatments into their l These studies offer a conservative abortion constituent inputs (such as the quantity estimate of total costs to already of antibiotics used and the quantity of overburdened developing country health gynecologist’s time used). It covered all systems. The economic impact of unsafe he costs of treating complications costs of the ideal treatments that women abortion is several times larger than Tarising from unsafe abortion are a should receive, which may differ across estimated health system costs. burden on health systems in developing countries. Further, millions of women with serious countries. They divert scarce health The most important findings are: post-abortion complications are not treated. resources when safe, cost-effective l From cost-per-case surveys, the mean This means that the costs to households alternatives are available. per-patient cost for post-abortion care lies and national economies of lost productivity between US$96 and US$131 (2005 US due to abortion-related injury and death Alternatives to unsafe abortion, such as dollars). The global cost to health systems are considerable. There are also substantial contraception or safe abortion services ranges from US$509 million to US$676 costs in terms of orphaning of other (where legal), are cost-effective. million. children. More empirical research is urgently Abortion is a sensitive subject so data on l Using the second costing approach, needed to measure these significant most aspects of unsafe abortion are limited. global health system costs lie between economic and social costs. The research used two methods to develop US$677 million and US$1.08 billion. estimates. Firstly, an extensive literature l Regionally, Africa and Asia each have a Michael Vlassoff search found 28 small-scale studies on 42 percent share of the total global cost, [email protected] post-abortion costs per case. These studies while Latin America and the Caribbean’s See also did not measure all costs, which should share is around 14 percent. Economic Impact of Abortion-Related Morbidity and include direct costs (such as drugs, supplies l Per-patient treatment costs are Mortality: Modeling Worldwide Estimates, paper and personnel) and indirect costs (such as substantially higher in southern, eastern commissioned by the Hewlett Foundation, by Michael Vlassoff, April 2006 overheads and capital). In practice, some and northern Africa. www.eldis.org/go/topics/resource-guides/health&i costs were often excluded and the cost The key policy implications are: d=32275&type=Document

Saving women’s lives Calling for a giant leap in international abortion policy

hile the public health impact of unsafe abortion has Wlong been recognised, little has been done to tackle the strategic and policy barriers to saving women’s lives.

The World Health Assembly identified Community Health unsafe abortion as a serious public health Workers in Sarlahi, problem as early as 1967. Later the 1994 Nepal. They keep track of all families in their International Conference on Population ‘ward’ and alert Area and Development (ICPD) highlighted Coordinators (AC) when the concept of and there has been a birth. established goals and targets, including The AC then comes and universal access to reproductive health checks/weighs the baby (services) by 2015. and mother. Jessica Fleming, PATH, 2004 The ICPD Programme of Action called for all parties to deal with the health impact of unsafe abortion and improve family l prepare and implement national maternal mortality as a priority but fail planning services. It noted that abortion action plans to reduce the incidence to put in place effective interventions to should be safe when it is legal, whilst in all of unwanted pregnancies and unsafe prevent unwanted births. cases, women should have access to quality abortion services to manage complications from l provide safe abortion services to the Iqbal H. Shah fullest extent of the law UNDP/UNFPA/WHO/World Bank Special Programme in abortion. To help to avoid repeat abortion, Human Reproduction, World Health Organization, 1211 post-abortion counselling, education and l educate communities on available safe Geneva 27, Switzerland family planning services should be offered. abortion services as allowed by national T +41 22 7913332 In June-July 1999, the Special Session of laws [email protected] l train health providers in preventing and the United Nations General Assembly urged The author alone is responsible for the views expressed health systems to train and equip health managing unsafe abortion. in this article. The views do not necessarily represent the professionals to provide safe abortion and decisions or the stated policy of the WHO. post-abortion care where legal. Putting plans into action Unsafe abortion is generally accepted as See also In 2004, the World Health Assembly Universal Access to Comprehensive Sexual and approved the Reproductive Health Strategy being an important and preventable cause Reproductive Health Services in Africa: Maputo Plan of the World Health Organization (WHO) of . It is agreed that safe of Action for the Operationalisation of the Continental noting that unsafe abortion must be dealt abortion services should be provided to the Policy Framework for Sexual and Reproductive Health full extent of the law and that post-abortion and Rights 2007-2010, Addis Ababa: African Union, with as part of the Millennium Development 2006 Goal on improving maternal health. care should be provided everywhere. www.unfpa.org/publications/docs/maputo.pdf In September 2006, the Special Session of Expansion of access to family planning Reproductive Health Strategy to Accelerate Progress the African Union Conference of Ministers services for prevention of unsafe abortion Towards the Attainment of International Development is universally supported. However, reducing Goals and Targets, Geneva: World Health Organization, of Health held in Maputo, agreed on a Plan 2004 of Action to: legal restrictions on access to safe abortion www.who.int/reproductive-health/publications/ l enact policies and legal frameworks to services remains a highly contentious issue. strategy.pdf reduce the incidence of unsafe abortion It is paradoxical to identify reducing www.id21.org August 2007 3 id21 health focus u n s a f e a b o r t i o n

Reducing Table 1: Mean per case cost of abortion care by health system level and scenario (US$) $60 abortion costs to Restricted-conventional

s Restricted-recommended health systems r $50 $48 a

ll Liberal-conventional $45

o $42 trategies to reduce health system d Liberal-recommended n i $40 $36 Scosts of providing abortion and t $34 s post-abortion care while simultaneously o $30 improving quality of care are well c $30 $27 e $25 documented but infrequently applied. s $24 a c - These strategies include: r $20 l pe using to remove tissue $12

from the rather than cervix dilation an $8 and scraping the uterine lining with a e $10 $7 $6 $6 M curette l providing light sedation rather than $0 general anesthesia Tertiary Secondary Primary Overall l using outpatient facilities rather than operating theatres Health system level l employing mid-level providers instead of specialists to provide care. Savings, a new Excel spreadsheet-based tool setting using recommended interventions developed at Ipas (an international non- (see Table 1). governmental organisation), allows users to Using recommended technical useful web links design and estimate the costs to the health interventions substantially reduced costs system of providing different strategies regardless of the legal setting. The greatest of abortion and post-abortion care. For reduction in costs (86 percent) occurred Guttmacher Institute example, Savings users can estimate the from using recommended interventions www.guttmacher.org costs of the current system of abortion within a liberal legal setting rather than and post-abortion care service delivery in a using conventional interventions within a Ibis Reproductive Health country and compare these with estimates restricted setting. www.ibisreproductivehealth.org of the costs of implementing the WHO Savings workshops are planned in which recommended approach to abortion and policymakers and others will use the model ICDDR,B post-abortion care. at a country level to develop estimates www.icddrb.org In the preliminary application of Savings, of costs to the national health system of Ipas generated per case costs for four different strategies of abortion and/or post- Institute of Development Studies, UK hypothetical policy and service delivery abortion care service delivery. www.ids.ac.uk scenarios using available cost data primarily The model could also include data on from Uganda. Two types of legal settings regional and developing world estimates Ipas are assumed: of the costs to health systems of current www.ipas.org l A restrictive abortion law or policy strategies in abortion care and the – abortion is permitted only to save a difference in costs following a shift to WHO International Planned Parenthood woman’s life. recommended strategies. Federation l A liberal abortion law or policy – first- We would expect this exercise to provide www.ippf.org trimester abortion is available on request. compelling evidence to support a shift Within each type of legal setting, Ipas to safer, more accessible and less costly PATH compared a recommended approach abortion and post-abortion care services to www.path.org to providing abortion services using save women’s health and lives. decentralised services and technically Population Council superior interventions with a conventional Heidi Bart Johnston www.popcouncil.org ICDDR,B, GPO Box 128, Dhaka 1000, Bangladesh approach relying on care centralised at [email protected] higher levels of the health system and Realising Rights Research Programme more costly interventions (such as dilation Janie Benson and Maria Gallo Consortium and curettage performed by specialist Ipas, PO Box 5027, Chapel Hill, NC 27514, USA www.realising-rights.org physicians). [email protected] The mean per case cost of abortion care See also UNDP/UNFPA/WHO/World Bank Special ranged from US$45 where heavy restrictions ‘Reducing the Costs to Health Systems of Unsafe Programme of Research, Development and were placed on elective abortion and a Abortion: a Comparison of Four Strategies’, Journal of Research Training in Human Reproduction Family Planning and Reproductive Health Care 33(4), by www.who.int/reproductive-health/hrp conventional approach to service delivery Heidi Bart Johnston, Maria F. Gallo and Janie Benson, was used, to US$6 within the liberal legal 2007

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Keywords: abortion complications, abortion law, economic costs, first trimester abortion, health policy, health systems costs, maternal health, maternal mortality, post-abortion care, unsafe abortion, women’s health August 2007 4