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Coast E, Lattof SR, van der Meulen Rodgers Y, Moore B, Poss C. The microeconomics of abortion: A scoping review and analysis of the economic consequences for abortion care-seekers. PLoS One 2021; 16:e0252005. [PMID: 34106927 PMCID: PMC8189560 DOI: 10.1371/journal.pone.0252005] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 05/10/2021] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Ernestina Coast
- Department of International Development, London School of Economics and
Political Science, London, United Kingdom
- * E-mail:
| | - Samantha R. Lattof
- Department of International Development, London School of Economics and
Political Science, London, United Kingdom
| | - Yana van der Meulen Rodgers
- Department of Labor Studies and Employment Relations, Rutgers University,
Piscataway, New Jersey, United States of America
- Department of Women’s and Gender Studies, Rutgers University, Piscataway,
New Jersey, United States of America
| | - Brittany Moore
- Ipas, Chapel Hill, North Carolina, United States of
America
| | - Cheri Poss
- Ipas, Chapel Hill, North Carolina, United States of
America
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Moore B, Poss C, Coast E, Lattof SR, van der Meulen Rodgers Y. The economics of abortion and its links with stigma: A secondary analysis from a scoping review on the economics of abortion. PLoS One 2021; 16:e0246238. [PMID: 33600471 PMCID: PMC7891754 DOI: 10.1371/journal.pone.0246238] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 01/18/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Although abortions are a common aspect of people's reproductive lives, the economic implications of abortion and the stigmas that surround abortion are poorly understood. This article provides an analysis of secondary data from a scoping review on the economic impact of abortion to understand the intersections between stigma and economics outcomes at the microeconomic (i.e., abortion seekers and their households), mesoeconomic (i.e., communities and health systems), and macroeconomic (i.e., societies and nation states) levels. METHODS AND FINDINGS We conducted a scoping review using the PRISMA extension for Scoping Reviews. Studies reporting on qualitative and/or quantitative data from any world region were considered. For inclusion, studies must have examined one of the following microeconomic, mesoeconomic, or macroeconomic outcomes: costs, benefits, impacts, and/or value of abortion-related care or abortion policies. Our searches yielded 19,653 items, of which 365 items were included in our final inventory. As a secondary outcome, every article in the final inventory was screened for abortion-related stigma, discrimination, and exclusion. One quarter (89/365) of the included studies contained information on stigma, though only 32 studies included stigma findings directly tied to economic outcomes. Studies most frequently reported stigma's links with costs (n = 24), followed by economic impact (n = 11) and economic benefit (n = 1). Abortion stigma can prevent women from obtaining correct information about abortion services and laws, which can lead to unnecessary increases in costs of care and sizeable delays in care. Women who are unable to confide in and rely on their social support network are less likely to have adequate financial resources to access abortion. CONCLUSIONS Abortion stigma has a clear impact on women seeking abortion or post-abortion care at each level. Programmatic interventions and policies should consider how stigma affects delays to care, access to accurate information, and available social and financial support, all of which have economic and health implications.
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Affiliation(s)
- Brittany Moore
- Ipas, Chapel Hill, North Carolina, United States of America
| | - Cheri Poss
- Ipas, Chapel Hill, North Carolina, United States of America
| | - Ernestina Coast
- Department of International Development, London School of Economics and Political Science, London, United Kingdom
| | - Samantha R. Lattof
- Department of International Development, London School of Economics and Political Science, London, United Kingdom
| | - Yana van der Meulen Rodgers
- Department of Labor Studies and Employment Relations, Rutgers University, Piscataway, New Jersey, United States of America
- Department of Women’s and Gender Studies, Rutgers University, Piscataway, New Jersey, United States of America
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Hill J, McGinn J, Cairns J, Free C, Smith C. A Mobile Phone-Based Support Intervention to Increase Use of Postabortion Family Planning in Cambodia: Cost-Effectiveness Evaluation. JMIR Mhealth Uhealth 2020; 8:e16276. [PMID: 32130166 PMCID: PMC7064963 DOI: 10.2196/16276] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/29/2019] [Accepted: 12/16/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Despite progress over the last decade, there is a continuing unmet need for contraception in Cambodia. Interventions delivered by mobile phone could help increase uptake and continuation of contraception, particularly among hard-to-reach populations, by providing interactive personalized support inexpensively wherever the person is located and whenever needed. OBJECTIVE The objective of this study was to evaluate the cost-effectiveness of mobile phone-based support added to standard postabortion family planning care in Cambodia, according to the results of the MOTIF (MObile Technology for Improved Family planning) trial. METHODS A model was created to estimate the costs and effects of the intervention versus standard care. We adopted a societal perspective when estimating costs, including direct and indirect costs for users. The incremental cost-effectiveness ratio was calculated for the base case, as well as a deterministic and probabilistic sensitivity analysis, which we compared against a range of likely cost-effectiveness thresholds. RESULTS The incremental cost of mobile phone-based support was estimated to be an additional US $8160.49 per 1000 clients, leading to an estimated 518 couple-years of protection (CYPs) gained per 1000 clients and 99 disability-adjusted life-years (DALYs) averted. The incremental cost-effectiveness ratio was US $15.75 per additional CYP and US $82.57 per DALY averted. The model was most sensitive to personnel and mobile service costs. Assuming a range of cost-effectiveness thresholds from US $58 to US $176 for Cambodia, the probability of the intervention being cost-effective ranged from 11% to 95%. CONCLUSIONS This study demonstrates that the cost-effectiveness of the intervention delivered by mobile phone assessed in the MOTIF trial lies within the estimated range of the cost-effectiveness threshold for Cambodia. When assessing value in interventions to improve the uptake and adherence of family planning services, the use of interactive mobile phone messaging and counselling for women who have had an abortion should be considered as an option by policy makers. TRIAL REGISTRATION ClinicalTrials.gov NCT01823861; https://clinicaltrials.gov/ct2/show/NCT01823861.
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Affiliation(s)
- Jeremy Hill
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jourdan McGinn
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - John Cairns
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Caroline Free
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Chris Smith
- Graduate School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki-shi, Japan.,Department of Clinical Research, London School of Tropical Medicine, London, United Kingdom
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Baynes C, Yegon E, Kimaro G, Lusiola G, Kahwa J. The Unit and Scale-Up Cost of Postabortion Care in Tanzania. GLOBAL HEALTH, SCIENCE AND PRACTICE 2019; 7:S327-S341. [PMID: 31455628 PMCID: PMC6711630 DOI: 10.9745/ghsp-d-19-00035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 04/11/2019] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
| | | | - Godfather Kimaro
- The National Institutes of Medical Research Tanzania, Dar es Salaam, Tanzania
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Abstract
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.
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Affiliation(s)
- Ernestina Coast
- International Development, London School of Economics, London, UK
| | - Samantha R Lattof
- International Development, London School of Economics and Political Science, London, UK
| | | | - Brittany Moore
- Scientific and Technical Divison, IPAS, Chapel Hill, North Carolina, USA
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Hancart Petitet P. Abortion politics in Cambodia social history, local forms and transnational issues. Glob Public Health 2017; 13:692-701. [PMID: 28730874 DOI: 10.1080/17441692.2017.1354228] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Cambodia's current abortion rate and ratio could be among the highest in Southeast Asia. In 1997, the Cambodian parliament passed the first law regulating abortions. This law was adopted to contribute to reduce the high maternal mortality ratio, as a significant number of maternal deaths were believed to be related to complications of unsafe abortion. A decade later, the Ministry of Health had not yet established medical protocols for safe abortion access and women often continued to induce their own terminations or seek unsafe services. However, in 2009, the Cambodian authorities approved the importation and distribution of one manufactured abortion pill. In addition, manual vacuum abortions and medical abortion training programmes were implemented at the referral hospital level. How has this situation come about? What do we know about the local agencies of the transnational reproductive health policies related to safe abortion access in this country? This paper aims to analyse how history and intersections between global interventions, state policies, local moralities and individual strategies shape abortion policies, practices and technologies. Finally, our findings raise some issues for public health programming.
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Affiliation(s)
- Pascale Hancart Petitet
- a Institut de Recherche pour le Développement, UMI 233 trans VIH MI, INSERM U1175 , Université de Montpellier 1 , Montpellier , France
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Leone T, Coast E, Parmar D, Vwalika B. The individual level cost of pregnancy termination in Zambia: a comparison of safe and unsafe abortion. Health Policy Plan 2016; 31:825-33. [DOI: 10.1093/heapol/czv138] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2015] [Indexed: 11/14/2022] Open
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Lince-Deroche N, Constant D, Harries J, Blanchard K, Sinanovic E, Grossman D. The costs of accessing abortion in South Africa: women's costs associated with second-trimester abortion services in Western Cape Province. Contraception 2015; 92:339-44. [PMID: 26142621 DOI: 10.1016/j.contraception.2015.06.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 06/15/2015] [Accepted: 06/26/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess women's costs of accessing second-trimester labor induction and dilation and evacuation (D&E) services at four public hospitals in Western Cape Province, South Africa. STUDY DESIGN From April to August 2010, in interviews immediately after completion of their abortion, we asked women about specific direct and indirect costs incurred. We collected information on recurring costs (i.e., per visit) and one-time expenditures and calculated total costs. RESULTS In total, 194 patients participated (136 D&E; 58 induction). Their median age was 26; 37.6% reported being employed or doing paid work. Most (73.2%) women visited two different facilities, including the study facility, while seeking the procedure. Induction women reported a median of three required visits [interquartile range (IQR) 2.0-3.0] to the study facility, while D&E women reported two required visits [IQR 1.0-2.0]. Twenty-seven percent of women missed work due to the procedure, and few (4.6%) paid for childcare. At each visit, almost all women (180, 92.8%) paid for transportation costs and reported additional one-time costs (177, 91.2%) such as sanitary supplies or doctor's fees. The total median cost incurred per woman was $21.23 [IQR 11.94-44.68]. Roughly half (49.0%) received help with these costs. CONCLUSIONS Although technically offered freely or low cost in the public sector, women accessing second-trimester abortion lost income and incurred costs for transport, fees, supplies and childcare. Their total costs could be reduced by minimizing the number of required visits to facilities and freely offering supplies such as sanitary pads and pregnancy tests. IMPLICATIONS Limited access to second-trimester, safe abortion services in South Africa may result in some women incurring unnecessary costs. Women make multiple visits in attempting to obtain an abortion, often because of facility or health systems requirements, and incur costs for lost income, child care, transport, fees and supplies.
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Affiliation(s)
- Naomi Lince-Deroche
- Ibis Reproductive Health, Johannesburg, South Africa; Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Deborah Constant
- Women's Health Research Unit, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Jane Harries
- Women's Health Research Unit, School of Public Health, University of Cape Town, Cape Town, South Africa
| | | | - Edina Sinanovic
- Health Economics Unit, School of Public Health, University of Cape Town, Cape Town, South Africa
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Vlassoff M, Fetters T, Kumbi S, Singh S. The health system cost of postabortion care in Ethiopia. Int J Gynaecol Obstet 2013; 118 Suppl 2:S127-33. [PMID: 22920616 DOI: 10.1016/s0020-7292(12)60011-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
To address the knowledge gap that exists in costing unsafe abortion in Ethiopia, estimates were derived of the cost to the health system of providing postabortion care (PAC), based on research conducted in 2008. Fourteen public and private health facilities were selected, representing 3 levels of health care. Cost information on drugs, supplies, material, personnel time, and out-of-pocket expenses was collected using an ingredients approach. Sensitivity analysis was used to determine the most likely range of costs. The average direct cost per client, across 5 types of abortion complications, was US $36.21. The annual direct cost nationally ranged from US $6.5 to US $8.9 million. Including indirect costs and satisfying all demand increased the annual national cost to US $47 million. PAC consumes a large portion of the total expenditure in reproductive health in Ethiopia. Investing more resources in family planning programs to prevent unwanted pregnancies would be cost-beneficial to the health system.
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Abstract
Reproductive health research and policies in Cambodia focus on safe motherhood programs particularly for married women, ignoring comprehensive fertility regulation programs for unmarried migrant women of reproductive age. Maternal mortality risks arising due to unsafe abortion methods practiced by unmarried Cambodian women, across the Thai-Cambodia border, can be considered as a public health emergency. Since Thailand has restrictive abortion laws, Cambodian migrant women who have irregular migration status in Thailand experimented with unsafe abortion methods that allowed them to terminate their pregnancies surreptitiously. Unmarried migrant women choose abortion as a preferred birth control method seeking repeat “unsafe” abortions instead of preventing conception. Drawing on the data collected through surveys, in-depth interviews, and document analysis in Chup Commune (pseudonym), Phnom Penh, and Bangkok, the authors describe the public health dimensions of maternal mortality risks faced by unmarried Cambodian migrant women due to various unsafe abortion methods employed as birth control methods.
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