Each year, an estimated 19 million unsafe abortions occur in the developing world, and around 66,500 women die from abortion-related causes.1 In developing countries, an estimated five million women are treated annually for complications from unsafe abortion;2 the cost of treating such complications burdens health care systems in these countries, where 97% of all unsafe abortions occur.1 This treatment diverts scarce health resources and, as we will demonstrate, is more costly than the alternatives of safe abortion and contraceptive services. Therefore, quantifying the economic costs of unsafe abortion is critical for informing public policy.
FRAMEWORK FOR ANALYSIS
Unsafe abortion generates unnecessary costs to society on a variety of levels. A proportion of women who have unsafe abortions will experience complications; some of these women will seek care within the formal health care system, while many will seek care elsewhere or not at all (Figure 1). Where women obtain care determines who bears the direct medical costs.* In public facilities, costs may be shared between households and the government if fees are charged. The process of seeking care will also incur direct nonmedical costs, such as transport costs, which can be significant.3,4
Women suffering from complications face three possible outcomes: survival with no long-term consequences, survival with long-term consequences or death. Each outcome generates indirect costs in the form of lost productivity, which will be borne by the households affected and, more broadly, by society. In economies with large pools of unemployed workers, these costs may be more easily offset at the societal level. That is, to the extent that unemployed persons take over the productive work not done by women who have suffered abortion complications, little or no net loss of productivity may be experienced by society. Indeed, even at the household level, some short-term productivity loss can be made up by the individuals themselves or by friends and family. However, long-term productivity losses cannot be offset at an individual or household level in the same way they can be at the societal level. Moreover, all coping strategies impose costs of one sort or another. Finally, children in households experiencing long-term maternal disability or a maternal death may also suffer in terms of their future health and education attainment,5 which has further economic implications for the household and society.
While we recognize the multidimensional nature and range of potential economic impacts, we focus on estimating one component—the cost of unsafe abortion to the health care system (the lower shaded cell in Figure 1). Household costs are excluded from this analysis, not because they are unimportant, but because of the lack of empirical data. Productivity losses and intergenerational costs are also excluded because of the paucity of empirical studies, as well as the lack of consensus among economists regarding how to value such losses.6
METHODS AND DATA
The evidence base on the cost of unsafe abortion is limited, and regional economic impacts are currently unknown. This analysis addresses existing data constraints by using two different approaches: estimating the average cost of postabortion care per patient based on available literature, and using results from studies that applied the World Health Organization (WHO) Mother-Baby Package costing model. We refer to the first approach as "top down" because it uses empirically derived overall treatment costs per patient, while we refer to the second as "bottom up" because it uses cost estimates of each specific component (e.g., supplies, drugs and labor) needed for treatment of each type of abortion complication to calculate the overall cost.† When multiplied by estimates of the number of women hospitalized for serious medical complications of induced abortion, the two approaches provide a range of estimates of the direct cost of unsafe abortion to health care systems in Africa and Latin America. (We are not aware of any relevant cost data for Asia.) To reiterate, these cost estimates do not include certain costs borne by households—for example, direct medical costs such as the purchase of drugs or other supplies, the cost of the unsafe abortion procedure, direct nonmedical costs such as transport to facilities, or the costs of lost productivity due to ill health or disability.
The first approach was based on the average cost of postabortion care as calculated from available empirical studies. Using validated search terms for economic evaluations,7,8 namely, "economics" or "cost" and "abortion" or "postabortion care," we conducted a systematic literature review of the Medline, Embase, Econlit and Popline databases. Of the studies yielded by this review, only those published between 1985 and 2007 that described data collected in low- or middle-income countries were selected. We searched the Web sites of relevant organizations—including the Population Council, Guttmacher Institute, United Nations, WHO, Pathfinder and Ipas—for project reports, and contacted staff at these organizations for further information. We manually searched relevant journals' tables of contents, as well as conference proceedings related to maternal, sexual and reproductive health.
One hundred and seventy-two studies were identified and screened, resulting in 20 studies with empirical data. Selected studies had to present original data, analyze costs from a health systems perspective and provide sufficient detail about their methods (i.e., a description of inputs and their quantity, sample size and analytic methods) to allow us to assess study quality. In these 20 studies, 72 samples with distinct cost-per-patient results were presented and analyzed.9–31
Reported costs were converted to both 2006 U.S. dollars and 2006 international dollars.‡32 Study-year costs in U.S. dollars were adjusted for inflation using U.S. gross domestic product deflators to arrive at the 2006 costs; these were then converted to 2006 local currency costs using official exchange rates and divided by the purchasing power parity conversion factor to arrive at the cost in 2006 international dollars. All historical economic data were taken from the World Bank's World Development Indicator database.33
In addition, three cost estimation methods were used to calculate a range of costs for postabortion care. Estimate 1 used the average costs of treating low-severity complications, and hence represents the lower boundary of estimates. Estimate 2 incorporated information on the incidence and cost of treatment by the severity level of complications. For this method, we combined results from two studies that measured the severity of complications using similar methods and that provided information on the percentage distribution of postabortion patients by severity in South Africa and Kenya:22 Low-severity cases represented 64% of postabortion care cases, mid-severity cases 16% and high-severity cases 21%. Using these weights and estimated costs by severity from the South African study, we calculated the average cost across all levels of severity. This approach is crude, and it extrapolates data from two Sub-Saharan African countries to the African and Latin American regions. Nonetheless, it does take into account an important cost driver—the severity pattern of postabortion care.
Finally, because most studies have underestimated the true cost of treatment by omitting hard-to-measure cost components—in particular, overhead and capital costs— Estimate 3 used data from five studies that applied the Mother-Baby Package costing model. Direct costs were estimated to be 72% of total costs, overhead costs 16% and capital costs 12%. Observed costs were therefore inflated by a factor of 1.38 (1.00/0.72). The estimated postabortion costs using this method are higher than those from the other two methods and so form the upper boundary of the cost ranges.
The second approach to estimating the cost of postabortion care was based on use of the WHO Mother-Baby Package costing spreadsheet.35 In this approach, treatment for each type of postabortion complication—incomplete abortion, sepsis, shock from blood loss, cervical and vaginal lacerations, and uterine perforations—is broken down into quantities and unit costs of drugs, materials, equipment, personnel, overhead and capital expenditures. The model has been applied in five country studies.9,10,14,15,31 These studies estimated costs for all Mother-Baby Package interventions by treatment site (i.e., health center, hospital and overall), except for the Nigerian study,10 which focused solely on costs of postabortion care. The Ghana, Bolivia and Uganda studies9,15,31 collected cost data on actual practice, and then estimated costs for WHO-recommended standard practice, which represented compliance with WHO-defined protocols for the various interventions. The Mexico study calculated costs only for standard practice.§14
Cost per Patient
The average cost of postabortion care per patient, when based on all samples from the 20 studies, was $86 (2006 US$; Table 1); costs ranged from $2 to $390 (not shown). Of the 72 samples, 46 were categorized as representing low-severity complications under the Kay-Rees severity framework.22 Many of these studies investigated operational aspects of the manual vacuum aspiration technique, and excluded patients with severe postabortion complications. The remaining 26 samples included women in all severity categories. The average cost per patient for treating low-severity complications was $72, while the average cost for samples of women with all types of complication was $111.
Because a few studies contributed many samples, thus possibly biasing the calculations, averages were recalculated by first determining within-study averages. Then simple averages of these 20 averages were obtained (one study reported two averages, one for each major region). Using this method, the overall average increased slightly to $88, while the average for low-severity samples decreased to $68 and the all-severity average declined to $109. The averages obtained from the two calculation methods were similar, and we used the within-study figures to generate the remaining Table 1 averages.
Of the 20 studies, 10 examined costs in Africa (nine in Sub-Saharan Africa) and 11 in Latin America.** Costs varied little by region, ranging from $83 in Africa to $94 in Latin America; the average for Sub-Saharan Africa was $89. Even though the cost per patient in U.S. dollars was highest in Latin America, after conversion to international dollars, the average costs in Sub-Saharan Africa and in Africa as a whole were substantially higher ($228 and $213 vs. $161). This demonstrates that in relation to patients' purchasing power, abortion complications are considerably more expensive to treat in Africa than in Latin America.
The three cost estimation methods yielded a range of cost-per-case averages. Estimate 1, representing the lower bound of treating only low-severity cases, generated an average cost of $68. Using Estimate 2—which factored in the pattern of severity of postabortion complications—the cost per case rose to $115. Finally, Estimate 3 included overhead and capital costs, and yielded averages of $114 for Africa and $130 for Latin America. Although limited data prevented more sophisticated estimates, we speculate that if severity patterns and overhead and capital costs could be simultaneously accounted for, cost estimates would be even higher.
The overall costs of postabortion care per patient using the WHO Mother-Baby Package model showed considerable variability across the five countries, from $10 to $112 (in 2006 US$) for actual practice, and from $31 to $212 for care based on WHO standards (Table 2). Costs in Latin America were substantially higher than those in Sub- Saharan Africa—$109 vs. $57 for actual practice, and $172 vs. $65 for WHO-recommended care—primarily reflecting higher Latin American salaries. Except for the Ghana study, a country's WHO standard cost was much higher than its actual cost. This may demonstrate that actual treatment regimes use fewer or lower-quality resources than recommended by the WHO treatment protocols.
Health System Costs
Based on the top-down approach, estimates of the annual health care system costs of postabortion care in Africa and Latin America combined were $187 million (Estimate 1), $319 million (Estimate 2) and $333 million (Estimate 3); the average estimate was $280 million (Table 3). The three estimates for Africa ranged from $117 million to $199 million (average, $171 million), those for Sub-Saharan Africa ranged from $80 million to $145 million (average, $120 million) and those for Latin America ranged from $70 million to $135 million (average, $108 million). Estimate 1 is the least likely scenario and was included mainly to set lower bounds for the probable cost ranges. Estimates 2 and 3, which incorporated additional empirical data and hence were more realistic, nevertheless required simplifying assumptions. For example, the pattern of severity of complications was assumed to be constant across regions, even though severity most likely varied. Only 19% of all serious abortion complications occur in Sub-Saharan Africa under our assumptions, even though around 54% of all maternal deaths from unsafe abortion occur in that region.1
Using the bottom-up approach of the Mother-Baby Package model, we calculated rough estimates of the magnitude of postabortion care costs (Table 4): The combined annual cost for Africa and Latin America was $227 million for actual practice and $320 million for WHO-recommended care (average, $274 million). The cost ranges for the two practices were $114 million to $141 million for Africa, $68 million to $76 million for Sub-Saharan Africa and $113 million to $179 million for Latin America.
To establish a range of estimates for total expenditures, we performed a simple sensitivity analysis using the lowest cost estimate (from Sub-Saharan Africa) to find the lower bound and the highest cost estimate (from Latin America) to calculate the upper bound. Actual practice estimates for Africa and Latin America combined ranged from $159 million to $302 million per year, while estimates for WHO standard care ranged from $179 million to $476 million.
The methods used in the 20 top-down studies that examined the cost of postabortion care varied considerably, and it was not always possible to determine the completeness of reporting of all cost components. Given this imprecision, we also considered cost estimates based on the WHO Mother-Baby Package model. These estimates may more accurately reflect the aggregate costs of postabortion care than the cost-per-case estimates, but because they include all components of treatment cost, they also have weaknesses. In particular, they are derived from a model of postabortion care that has been tested in only five countries. Furthermore, their costs likely reflect the higher standard of care recommended by WHO as compared with what is available and feasible in practice.
This study could not assess the cost of postabortion care in Asia or the developed world because no empirical data were available. In countries where abortion or menstrual regulation is both legal and accessible—such as Bangladesh and Vietnam, as well as some European countries—data on the cost of safe abortion services were available, but these costs were not equivalent to those of postabortion care.
If we apply our lower boundary figure of $68 per case, which assumes that all women seeking postabortion care have low-severity complications, to the annual number of cases treated in developing countries in Asia and the Pacific region (2,280,000),2 a very approximate minimum estimate of the cost of such care in this region would be $154 million per year. Adding this to the corresponding figure for Africa and Latin America ($187 million) yields a minimum annual estimate of $341 million for postabortion care in the developing world.
Clearly, more costing research is needed, particularly in Asia, where the estimated number of hospitalized postabortion patients is large. In addition, studies are needed to measure the impact of newer methods of abortion (particularly medication abortion), because these methods can reduce the severity of complications of unsafe abortion, and over time will likely reduce the numbers of women who need hospitalization.2
As illustrated in Figure 1, the health care system cost of treating serious abortion complications is only one component of the total economic impact on society of unsafe abortion. The costs of treating long-term health consequences, such as chronic pelvic infections and infertility, have hardly been studied. The indirect economic costs of unsafe abortion—those borne by households, by sectors outside the health care system and by the wider economy—are also essentially unmeasured. Studies of maternal health have shown that despite the difficulties in measuring the value of women's time in the informal sector, or the home, these costs can be significant. For instance, a study using the REDUCE model estimated that the productivity loss from a maternal death was between $850 and $1,838 per case (in 2001 U.S. dollars), and the loss related to maternal disability ranged from $83 to $628 per case.††38 A study of how improved vaccination coverage affects productivity estimated that per capita GDP increases by 0.12% for every 1,000 surviving adults, based on the findings that average wages rise by 0.18% for every 1,000 people surviving from age 15 to 60 and that labor productivity and wages account for two-thirds of national income.39More evidence of the adverse economic impact of health conditions was found in a study of malaria: The condition accounts for a reduction of 0.25–1.3 percentage points of economic growth per person per year in malaria-endemic countries, after controlling for demographic and economic factors.40 Further research is needed on how the health consequences of unsafe abortion affect women's productivity in low-income settings.
In many low-income countries, households finance a large proportion of health care costs. For example, in Sub-Saharan Africa, private expenditures represent 60% of total health care costs.33 Therefore, households are likely to bear a substantial proportion of the direct costs of both getting an abortion and treating subsequent complications. Given the controversial nature of abortion as a medical procedure, especially in settings where abortion is illegal, women may find it particularly difficult to access funds from their usual social networks. Indeed, evidence suggests that women are more likely to seek abortion care alone.41 For poor households, such expenditures may exacerbate their poverty.42 Further research into the household costs of abortion care and coping strategies for paying for care is required.
Many women who need hospital-based care for postabortion complications do not receive it (an estimated 15–25% of all women who have unsafe abortions).2 If they were to receive such care, the cost of unsafe abortion to health care systems would possibly double—and this is likely a minimum estimate of the marginal costs of addressing unmet need for postabortion care. In many settings, there is no capacity to treat these extra cases, implying that additional costs for infrastructure and training would be required. More empirical research into the extent and pattern of unmet need for such care is a priority if the overall economic impact of unsafe abortion is to be better understood.
Unsafe abortions are direct consequences of unwanted pregnancies. The costs we have been able to calculate result from the failure to prevent these pregnancies or, where legal, to terminate them safely. A recent study in Nigeria10 estimated that the cost of contraceptive services to prevent unwanted pregnancies would have been only one-fourth of that expended in treating postabortion complications. Another study21 showed that the cost of obtaining a safe abortion in Uganda was between $6 and $23, compared to the average cost of $89 that we calculated for treating a postabortion complication in Sub-Saharan Africa. Furthermore, a global study on the costs and benefits of reducing unmet need for contraception estimated that, in Sub-Saharan Africa in 2003, eliminating this unmet need would have cost about US$1 billion for additional contraceptive services, while averting 10.5 million unintended pregnancies, 3.9 million induced abortions and 23,000 abortion-related deaths.43
Empirical studies of the cost of abortion-related morbidity and mortality are scarce, and existing data are flawed. This study found that the health system costs of postabortion care in Africa and Latin America ranged from $159 million to $476 million per year, depending on the estimation method used. The average estimates from the two approaches largely coincide: $280 million using the top-down approach, and $274 million using the bottom-up approach (averaging actual and standard practice estimates).
These sums are considerable and impose an added burden on the already overstretched health resources of developing countries. A new United Nations estimate of maternal and newborn health expenditures places the cost of unsafe abortion in context:44 Obstetric complications cost health care systems in Africa and Latin America around $490 million annually.‡‡ Thus, treating the serious complications of unsafe abortion represents a financial burden equal to more than half of what is currently spent on obstetric emergencies.
A fuller understanding of the costs of postabortion care is hindered by critical data gaps. We have identified five areas in which additional research is required: the size and characteristics of the large group of women who suffer serious complications but do not receive treatment in the health care system; the economic consequences of morbidity resulting from unsafe abortion, including associated productivity losses; the costs of postabortion care in Asian and Pacific developing countries; the household expenditures for postabortion care and coping strategies for paying; and the impact of newer methods of abortion (particularly medication abortion) on the severity of complications from unsafe abortion.
This study strengthens arguments that unsafe abortion needs to be eliminated. Information on the direct health care system costs of unsafe abortion should be communicated to governments and compared with the much less costly alternatives for preventing unintended pregnancy and unsafe abortion—namely, the provision of contraceptive services and access to safe abortion where it is legal.