Exploring the costs and economic consequences of unsafe abortion in Mexico City before legalisation

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ctive Health Matters.ts reserved.atters 2009;17(33):120–132$ – see front matter080 (09 ) 33432-1 www.rhmjournal.org.uk

Exploring the costs and economic consequences ofunsafe abortion in Mexico City before legalisation

Carol Levin,a Daniel Grossman,b Karla Berdichevsky,c Claudia Diaz,c

Belkis Aracena,d Sandra G Garcia,e Lorelei Goodyearf

0

a Senior Health Economist, Program for Appropriate Technology in Health (PATH), Seattle WA, USA.E-mail: [email protected]

b Senior Associate, Ibis Reproductive Health, Oakland CA, USAc Research Coordinator (at the time of the study), Population Council Mexico Office, Mexico City, Mexicod Researcher, Department of Health Economics and Policy, National Institute of Public Health,Cuernavaca, Mexico

e Director, Population Council Mexico Office, Mexico City, Mexicof Senior Program Officer, PATH, Seattle WA, USA

Abstract: An assessment of abortion outcomes and costs to the health care system in Mexico Citywas conducted in 2005 at a mix of public and private facilities prior to the legalisation of abortion.Data were obtained from hospital staff, administrative records and patients. Direct cost estimatesincluded personnel, drugs, disposable supplies, and medical equipment for inducing abortion ortreating incomplete abortions and other complications. Indirect patient costs for travel, childcareand lost wages were also estimated. The average cost per abortion with dilatation and curettage wasUS $143. For manual vacuum aspiration it was US $111 in three public hospitals and US $53 at aprivate clinic. The average cost of medical abortion with misoprostol alone was US $79. The averagecost of treating severe abortion complications at the public hospitals ranged from US $601 to overUS $2,100. Increasing access to manual vacuum aspiration and early abortion with misoprostolcould reduce government costs by 62%, with potential savings of up to US $1.6 million per year.Reducing complications by improving access to safe services in outpatient settings would furtherreduce the costs of abortion care, with significant benefits both to Mexico's health care system andwomen seeking abortion. Additional research is needed to explore whether cost savings have beenrealised post-legalisation. ©2009 Reproductive Health Matters. All rights reserved.

Keywords: health care costs, out-of-pocket health expenditure, abortion methods, unsafe abortion,abortion law and policy, Mexico

NTIL 2007, when first trimester abortionwas legalised in Mexico City, abortion waslegally restricted in Mexico. Even for legal

indications, such as pregnancy resulting fromrape or when the pregnancy threatened thewoman's life, abortion services were rarely avail-able because few states had established mecha-nisms by which women could seek care. In 2002in Mexico City, the process to obtain a legal abor-tion following rape involved six steps at four dif-

ferent locations, and could take three monthsor longer.1

Illegal abortion services were much moreaccessible than legal services, even if a womanmight qualify for a legal abortion. Illegal abor-tion services by private providers are widelyavailable in Mexico, especially in urban areas,and range from safe to unsafe. Poor womenand women from rural areas suffer the conse-quences of unsafe abortion disproportionately.2

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Increasingly, women are using misoprostolobtained either from a provider or directly froma pharmacy or other drug seller in order toinduce an abortion.3–5 This is happening notonly in Mexico but all over Latin America.While efforts to improve access to safe abor-

tion services in Mexico have been limited untilrecently, post-abortion care programmes usingmanual vacuum aspiration (MVA) to treat abortioncomplications have been extensively promoted.6

Some data suggest that, at least for first tri-mester abortion, illegal services in Latin Amer-ica may be safer than they were in the past. Thishas been documented in Brazil, where, as miso-prostol use increased, a corresponding reductionin abortion-related complications was observed.7

A recent review of death certificates in two dis-tricts in Mexico found no deaths that were sus-pected to be related to first trimester abortionprocedures.8 Another study on the incidenceof abortion in Mexico found that the severityof abortion-related complications decreasedbetween 1990 and 2006.9

Although data exist on abortion-related mor-bidity and mortality, there has been relativelylittle research on the economic impact of unsafeabortion. In the area of post-abortion care,research in Brazil demonstrated the cost savingsof introducing MVA in settings where dilatationand curettage (D&C) was the norm, especiallywhen MVA is performed on an outpatient basisunder local anaesthesia.7 Similarly, a recentstudy from Nigeria found that out-of-pocketcosts were higher for women who developedserious complications after an abortion outsideof the hospital compared to those who had lesssevere or no complications.10 Yet this studyalso reported that charges for D&C were onlyslightly higher than those for MVA,8 eventhough outpatient MVA should be less costlythan inpatient D&C.6

The aim of this study was to estimate thecosts incurred by the health care system asso-ciated with the treatment of incomplete abortionand other abortion complications due to unsafeabortion in Mexico City prior to reform of theabortion law. This includes the costs of surgi-cal abortion (MVA and D&C) and medical abor-tion (MA) for incomplete abortion, as well astreatment of haemorrhage, sepsis, uterine perfo-ration, cervical trauma and shock. More specifi-cally, we compared the costs of treating incomplete

abortion and other abortion complications inthree hospitals in the public health system (as aproxy for costs associated with unsafe abortion)with the costs of performing safe abortions ille-gally in a private clinic.

MethodologyStudy sitesThe study was conducted between January andJuly 2005 in Mexico City. Cost and abortionoutcome data were collected from a conveniencesample of three public hospitals and one privateclinic, representative of facilities providing abor-tion services to women. Hospital MX1, part ofthe Federal District Ministry of Health, wasselected because it is one of two public hospitalsin Mexico City that had implemented abortionservices for the limited number of legal indica-tions at the time of the study. Hospital MX2 is alarge tertiary hospital within the Mexican SocialSecurity System that serves non-governmentalemployees with low to moderate income levels.Hospital MX3 is a tertiary public hospital servinga low-income population without access to socialsecurity services and is part of the national Min-istry of Health.In all three public hospitals, women were

generally seeking treatment for incompleteabortion; they reported to the emergency roomand were then transferred to the gynaecologyward. Even though hospital MX1 was authorisedto perform legal abortion for limited indications,very few legal abortions were performed. BothD&C and MVA were used in the gynaecologyoperating room. Most women attending thethree hospitals did not require an overnightstay. They recuperated in a separate room onthe gynaecology ward for 2–8 hours before leav-ing. The exception was in hospital MX3, wherewomen having a D&C stayed for 24 hours. Allthree hospitals reported very few cases of severepost-abortion complications (other than incom-plete abortion). However, women who did pres-ent with such complications were hospitalised.Clinic MX4 is a private clinic that provided

comprehensive reproductive health care forwomen, including safe but illegal induced abor-tions using MVA or MA. For women havingMVA, in the first visit the doctor consultedwith the patient and evaluated her for sexuallytransmitted infections. In the second visit, she

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received counselling, had the MVA and recuper-ated. A follow-up visit was scheduled two weekslater. Women who received misoprostol on thesecond visit took it at home and had a follow-up visit on the fifth day after taking the medica-tion, to confirm completion of the abortion byultrasound, with an additional follow-up visittwo weeks later. Women over 14 weeks gestationwere referred elsewhere.Table 1 summarises the characteristics of the

study facilities. All three abortion methods wereused across the four facilities, but to differingdegrees. In the public hospitals, 82–97% ofcases of treatment of incomplete abortion andthe rare legal abortions were done using D&C;MVA was used less frequently. Medical man-agement of incomplete abortion using miso-prostol was not practised in these facilities.In the private facility, MVA was the only sur-gical technique, used in approximately 95% ofcases, and in the remaining 5%, MA with miso-prostol alone was used. In all study facilities,treatment was provided by at least one phy-sician with a nurse present. Where D&C was

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performed, general anaesthesia was adminis-tered by an anaesthetist. In the three public hos-pitals, local anaesthesia was used with MVA,also administered by an anaesthetist. In the pri-vate clinic, only local anaesthesia was used andwas administered by the physician performingthe procedure.

Data collection and analysisThe cost estimates presented in this analysisrepresent the opportunity cost of all resourcesused in the treatment of incomplete abortionand other complications from the health systemperspective. Cost data were collected using aningredients-based costing methodology basedon guidelines recommended by the WorldHealth Organization.11 The ingredients approachworks from the specific abortion procedures(D&C, MVA and MA) and treatment protocolsfor septic shock, hypovolemic shock, infectionand uterine laceration, and lists the variousinputs required. Inputs here included type of per-sonnel, drugs, consumable supplies, and medicalinstruments and equipment (hospital, surgical

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and imaging) used to induce abortion, or treatincomplete abortion or another abortion-relatedcomplication (Table 2 contains a list of typicalinputs). The quantities and prices of inputs usedwere collected based on interviews with healthcare providers at each hospital and clinic. Noobservational data or individual patient recordswere used. However, whenever possible, avisual inspection of the surgical or procedureroom was used to create an inventory of suppliesand equipment for providing abortion and treat-ment of incomplete abortion and other compli-cations. Supplementary budgetary data and

expenditure records were used to gather informa-tion on salaries and indirect facility overheadcosts. Lastly, the indirect costs of patient travel,childcare and reported lost wages were alsocollected in an effort to capture women's non-medical expenses. This study was not able tocapture the costs associated with the initial inter-ventions by women that led to incomplete abor-tion. All costs were in Mexican pesos and wereconverted to US dollars (USD) using the exchangerate of US $1=11 pesos valid in 2005.A more detailed description of how each cost

component was estimated is available from theauthors. Here we briefly describe the estimationof personnel costs, drugs and disposable supplycosts, medical instrumentation and equipment,and operational costs. Staff costs included theservice time of doctors and nurses in the directprovision of care before, during and after induc-ing an abortion, treating an incomplete abortionand/or treating a complication. Indirect timespent by other staff serving patients was alsoincluded; the percentage of indirect supportstaff time spent was estimated by hospital per-sonnel. The quantity and price of drugs forabortion services were collected from each hos-pital or clinic for analgesics, antibiotics andanaesthetics (local and general). Additionaltypes of drugs, including uterotonics, oxygenand other emergency medications used for thetreatment of abortion complications, such asseptic shock, hypovolemic shock, infectionsand repair of uterine perforation, were estimatedseparately. Cost information was obtained fromhospital pharmacies, clinic invoices, and centralstores in Mexico City or the national Ministry ofHealth, depending on the facility.Costs for laboratory tests for abortion com-

plications were obtained from hospital user feelists, showing what patients would pay. It wasconsidered too difficult to use micro-costingmethods to obtain costs for laboratory person-nel, supplies and equipment in the large publichospitals in Mexico City. The annual costs ofmedical instruments and equipment were cal-culated using reported useful years of life forcapital goods and a depreciation rate of 3% oninstruments and equipment. The total annualisedcost of medical instruments and equipment perwoman treated was estimated separately for eachtype of abortion procedure (D&C, MVA and MA)and for each type of abortion complication.

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Facility operating costs were estimated eitherfrom hospital administrative records, whereeasily available, or from published or availablehospitalisation cost estimates obtained from theMexico City or the national Ministry of Healthcentral records. Hospitalisation costs were adjustedby subtracting the share of costs attributable topersonnel, drugs and supplies used to provideabortion services to estimate a proxy for operat-ing expenses. Hospitalisation costs were adjustedto cover operating expenses only and pro-ratedfor the patient's length of stay at each hospital,depending on the service.Health workers administered a brief question-

naire to women seeking reproductive healthservices at each facility to estimate the averagetransport cost, childcare cost and lost wagesassociated with a general visit, family planningservices and abortion care. The data presentedprimarily capture their transportation andchild care costs. Most women did not reportan amount for the wages lost but did indicatethat they missed work for their hospital orclinic visit. An average of 33% of the womeninterviewed (n=75) in all the facilities said thatthey had missed all or part of a day of work toreceive treatment. It was beyond the scope ofthis project to estimate the lost wages fromwomen who did report missing a day of workbut did not specify an amount. A proxy of theaverage daily wage across all women whoreported missing work is used in this analysis,which is likely to underestimate the actual lostincome. The estimate covers all visits to receivetreatment, including follow-up visits.The total costs are presented as a total (direct

and indirect) cost per woman having an abortion,receiving post-abortion care using D&C, MVA orMA, and any additional costs for the treatment ofcomplications and required hospitalisation. Thesecosts are the sum of labour, drugs and disposablesupplies, medical instruments, equipment, oper-ating expenses and patient costs.Data on the treatment of incomplete abortions

and induced abortions were collected directlyfrom hospital records or interviews with medicalpersonnel, where available. It was more difficultto obtain information on the number of othermore severe abortion-related complications. Allthree public hospitals reported very low rates ofsevere abortion-related complications. Becauseof the difficulty in obtaining complete infor-

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mation on complication rates for the samplehospitals, the analysis uses data on complicationrates for the Mexico City and national Ministryof Health hospitals and both types of socialsecurity hospitals.12–14 Sensitivity analysis variedthe complication rate to estimate a range of plau-sible costs.In order to estimate the potential impact of

legalising safe abortion, the analysis estimatedthe total costs associated with scenarios thatassume legal access, as well as increased accessto MVA and MA services for early abortion.

ResultsHealth outcomesEach of the public health facilities in this studyperformed approximately 600 to 1,400 abortionsannually for the years 2004 and 2005, for a totalof 3,945 cases. The great majority (over 95%)were for treatment of incomplete abortion. Theprivate clinic providing safe but illegal abortionsperformed an average of 720 abortions per year,based on 2004 and 2005 patient visits, usingMVA and to a limited extent MA. All four facil-ities reported very low rates of serious abortion-related complications or had incomplete data.Table 3 shows the complication rates used in

the sensitivity analysis that would be expected ifabortion were legally available in all settings.According to the available data for Mexico City,of all the women who presented at hospitals fortreatment after an abortion (14,163 total cases),92.20% were treated for incomplete abortion,7.69% required treatment for infection, and0.06% required repair of a uterine perforation.12

We were unable to obtain direct information

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about blood transfusion. Hospital discharge dataindicated that 1.29% of women presenting forabortion-related care were diagnosed with hae-morrhage,12 and we estimated that 10% ofthem required a blood transfusion. We thereforeestimated that 0.13% of women presenting fortreatment after abortion required a blood trans-fusion. The complication rates listed for the“low” scenario in Table 3 are similar to thosereported in settings where abortion is safe andlegal.14,15 Estimates for the “high” complication-rate scenario are based on hospital dischargedata indicating a higher incidence of severe com-plications, taken from other states in Mexico ascompared to Mexico City. For example, in Chiapas,one of the poorest states in Mexico, the reportedincidence of uterine perforation is at least 0.16%,or more than double that of Mexico City.12

This was rounded up to 0.20% in the table.

Cost of treating incomplete abortion and/orinduced abortionFigure 1 and Table 4 present data on the averagecost of post-abortion care or inducing abortionfor the three types of abortion procedure (D&C,MVA and MA) at the four study sites in MexicoCity. Cost estimates are presented with andwithout patient costs. The total cost per patient

was highest in the two largest public hospitals(MX3 and MX2), located in the more centralparts of Mexico City and serving the largestnumber of patients. The cost of providing abor-tion was lowest in the private clinic providingsafe but illegal induced abortion, using MVAand MA. In the private clinic, the total costper patient of providing MVA, excluding patientcosts, was US $53, almost 60% of the averagecost of MVA (US $93) used to treat incompleteabortion in the three public hospitals. MVA costless than D&C. The total cost of treating anincomplete abortion with D&C ranged from US$103 to US $192 in the three hospitals. MVAwas slightly lower, ranging from US $96 to US$124. At the private clinic, the cost of providingMA was slightly more expensive than MVA, butboth methods were significantly less costlycompared to the treatment of incomplete abor-tion in the public hospitals.

Cost profilesThe variation in costs across facilities is shownin the breakdown of costs by category in Table 4.The general allocation of total costs to stafftime, drugs and supplies, and equipment wassimilar across the three public hospitals. Operat-ing expenses were the largest contributor to

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average cost per patient, followed by labourcosts, drugs and supplies, and lastly, equipment.Among the direct service-related expenses, per-sonnel time was the largest cost item across allfour facilities. In each public hospital setting,average staff costs per patient were lower forMVA compared to D&C. In the private clinic,staff costs for MVA were higher than for MA,accounting for 85% to 94% of direct inputcosts, respectively. However, drugs accountedfor 34% of total costs for the provision of med-ical abortion, due to the high cost of misoprostoltablets in Mexico. In the hospital settings, theshare of costs for drugs and supplies used forD&C and MVA was between 2% and 13%, andwas generally lower for MVA, which requiresonly local anaesthesia. The share of total costs

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for equipment was slightly higher for MVA,reflecting the need to purchase MVA cannulasand syringes.

Cost of treating abortion complicationsWe estimated the average cost per woman treatedby complication type for each public hospital,shown in Table 5. Costs of treating complica-tions were in addition to initial costs of treatingan incomplete abortion. On average, infectionwas the least costly to treat, although it wasthe most prevalent complication. Treatmentcosts on average were: septic shock (US $2,140),hypovolemic shock (including blood transfusion)(US $1,602), mild to moderate sepsis (US $601),and repair of uterine perforation (US $1,408).The Mexico City public hospital (MX1) had

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the lowest average treatment costs for shock(US $595), infections (US $596) and uterine per-foration (US $907). Average costs were highest atthe Mexico City Social Security System publichospital (MX2) for treating shock (US $3,170),infections (US $912) and uterine perforation(US $2,270). These costs included hospitalisa-tion for inpatient care, some 4–7 days for shock,2–3 days for infection, and 4–10 days for repair ofuterine perforation.

Costs of unsafe vs. safe abortionTo estimate the total cost of treating incompleteabortion, including costs associated with treatingmore severe abortion complications, we used7.9% as the estimate for the 2005 baseline rateof more severe abortion complications, asso-ciated with legally restricted access. This gave atotal cost of US $2.6 million to treat all compli-cations related to unsafe abortion for one yearfor Mexico City, or an average cost per womantreated of US $186. Assuming a high rate ofcomplications from unsafe abortion, as pertainsin the poorest parts of Mexico, with 11% ofwomen experiencing more severe complications,the cost to the government of treating all abortion-related complications would reach US $2.9 millionor $209 per woman treated. In contrast, if a lowcomplication rate associated with legal abortionis assumed, the total complication rate wouldbe an estimated 1.1%, and the total cost for treat-ing abortion-related complications would be US$2 million, or an average cost per woman treatedof US $144 (see Table 6).These estimates show that modest cost sav-

ings would be achievable if efforts were madeto reduce complications associated with unsafeabortion. For instance, reducing the rate of moresevere complications from 7.9% to 1.1% by

making safe and legal abortion more broadlyavailable could save US $43 per woman treated,or over US $600,000 per year for the governmentof Mexico City. Similarly, a reduction of com-plication rates from 11% to 1.1% would lead tosavings of US $65 per woman or a total of closeto US $1 million annually.Even greater savings would be possible, how-

ever, if lower-cost methods for treating incompleteabortions were introduced, alongside increasedaccess to safe and legal abortions. We exploredthe potential savings for the government of thischange through two scenarios. Table 7 presents asummary of the differences in the cost of abor-tions for Mexico City for the situation current in2005 (baseline) and for two different scenariosthat increase access to safe, legal abortions.In Scenario 1, we assumed that 10% of all

abortion patients were still receiving treatmentfrom public hospitals using D&C at the sameaverage cost as in the current or baseline situa-tion, at US $143. In Scenarios 1 and 2, an aver-age cost of US $53 was used for providing MVAin non-hospital settings, based on the cost ofproviding services in the private clinic MX4. InScenario 2, a cost of US $79 was used for MA,also based on estimates from MX4 (see Table 4).Table 7 presents the total costs and cost sav-

ings associated with increasing access to safeand simpler methods of abortion for MexicoCity. In Scenario 1, increasing access to legaland safe abortion using primarily MVA wouldreduce costs to the government by 62%, witha potential savings of up to US $1.6 million. InScenario 2, even a modest increase in access to

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MA would provide additional cost savings ofover US $50,000. Key to these scenarios is thatthe cost of providing abortion services declinesas access increases at smaller public and privatehealth facilities, which can provide abortion careefficiently and at less cost than large hospitals.

DiscussionThis study demonstrates that unsafe abortion iscostly to the Mexican health system for anumber of reasons, both health-related and eco-nomic, and that significant cost savings perwoman can be realised through increasingaccess to safe abortion services. Complicationsafter unsafe abortion are more common in legallyrestricted settings,15,16 and treatment for them isexpensive, especially serious complications forwhich prolonged hospitalisation is required.However, at the time this study was done, prior

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to abortion law reform in Mexico City, healthfacilities were reporting many incomplete abor-tions but few other post-abortion complications.This may be because women and providers wereincreasingly using medications such as miso-prostol to induce abortion or because clandestineproviders might have begun using MVA morefrequently instead of dangerous invasive tech-niques. Widespread antibiotic prophylaxis hasalso been cited as a reason for a reduction inmorbidity and mortality associated with unsafeabortion in Latin American settings.2

Despite the apparent reduction in morbidityin recent years, the incidence of complicationsreported in the hospital discharge data is stillmuch higher than that reported in settingswhere abortion is safe and legal, and we havedemonstrated significant cost savings to thehealth system in Mexico City if complicationsare reduced even further. Even small reductions

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in the incidence of serious complications has animportant impact on cost, as well as women'shealth. Because the incidence of complicationsis higher in other parts of Mexico, savingswould also likely be higher. In addition, the pub-lished data on the incidence of abortion com-plications reflect reported cases only and likelyunderestimate the total costs and health burdenfor women seeking abortions outside the nationalhealth system.In Mexico City, at the time these data were

collected, D&C was the preferred method oftreating incomplete abortion. D&C is morecostly than MVA because general anaesthesiain an inpatient setting is required. In additionto the expense, D&C is no longer recommendedby the World Health Organization unless MVAis not available because D&C has a higher com-plication rate.16,17 In two of the three publichospitals we studied, when MVA was provided,women were often made to stay in a recoveryarea as long as women who underwent D&C,even though MVA was provided with localanaesthesia. In hospital MX3, where the averagerecovery time was shorter after MVA, the costswere significantly less than for D&C. Our datasuggest that treatment of incomplete abortioncould be provided through a less costly modelthat relies on MVA under local anaesthesia inan outpatient setting, combined with a shorterrecovery period.Our findings regarding cost differences between

D&C and MVA are consistent with findings fromother studies conducted in Mexico and LatinAmerica, where the cost of providingMVA throughambulatory services was 30–70% lower than thecost of providing D&C through inpatient ser-vices.17 Also consistent with other studies inLatin America,6 our findings suggest thatimprovements in service delivery and increasedaccess to abortion services using MVA can trans-late into potential cost savings.Differences in the costs across methods alone

were less pronounced than differences in costs ofthe different methods related to where treatmentwas delivered. Excluding operating expensesacross the three public hospitals and focusingonly on the direct inputs of staff time, drugs,supplies and equipment used to provide abortionservices, personnel time was the largest cost itemacross all four facilities. The variation in costs isexplained by the choice of procedure, average

length of stay and personnel costs associatedwith the provision of care. In general, averagestaff costs per patient were lower for MVA com-pared to D&C. In the two larger hospitals (MX2and MX3), personnel costs were higher than inthe smaller secondary hospital (MX1) due toboth higher salaries and greater use of labourresources in the provision of abortion care.When the recovery times were equal, there

were only marginal differences between D&Cand MVA in the public hospitals because ofthe higher inpatient overhead costs regardlessof which method was used. However, the costof providing MVA in the outpatient clinic set-ting was 40–50% less than the cost of providingeither MVA or D&C in the hospital. The reduc-tion in cost is explained by differences in costsassociated with local anaesthesia, lower operat-ing expenses and less personnel time required forpost-operative care. Furthermore, the resourcesused to treat incomplete abortions in a large hos-pital would be better used to improve maternitycare and other critical obstetric and gynaecolo-gical care,18 while moving abortion services tosmaller facilities and/or primary care settings.In the private clinic providing safe abortion,

the cost of MA was somewhat higher thanMVA, especially when women's transportationcosts were included. This cost differential waslargely due to the additional follow-up visitthat was required with MA. A previous study ina Latin American country where abortion wasillegal documented a similar MA protocol involv-ing two follow-up visits; providers seemed par-ticularly eager to ensure that women had acomplete abortion as soon as possible,19 likelybecause of the fear that women might seekcare at a different clinic if they had prolongedbleeding or other unexpected symptoms. Onlyone follow-up visit is the norm in settings wherethe method is approved. Under a more liberalabortion law, providers are likely to feel morecomfortable following evidence-based protocolswith only two visits to provide MA,20 reducingthe associated costs. In addition, the cost of miso-prostol has risen rapidly throughout Latin Amer-ica in recent years, possibly related to the highdemand on the black market.5 With legalisationand the appearance of generic products, thislikely would fall.This study has several limitations. First, since

it focused on the costs of treating unsafe abortion

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from the perspective of the health system, wewere unable to capture the cost of women'stime waiting for treatment in the three hospitalsettings, the cost of the initial intervention thatled to an incomplete abortion, the cost of anyabortifacient medication purchased, payment toa provider who supplied pills or carried out a sur-gical or other procedure, transportation costs,childcare costs or cost of days lost from workdue to complications but prior to treatment.Second, we could not compare the costs of

abortion provision by doctors vs. mid-level pro-viders such as nurses or midwives, because inMexico only doctors are currently permitted toprovide abortion or treat incomplete abortion.A recent study in the United States examineddifferent MA service delivery models using clini-cians of varying levels and found cost differen-tials were at least partially related to providerlevel.21 Third, our sensitivity analysis did notexplore the possibility that some costs to thepatient might increase with access to safe andlegal abortion, such as increased user fees and

Doctors at the inauguration ceremony of the ReprodVelasco de Aleman, in Mexico City, where safe legal

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out-of-pocket expenses related to recommendedfollow-up visits. Future studies should attemptto estimate these differences to capture a morecomplete picture of the true costs associatedwith both safe and unsafe abortions in Mexicofor women and providers.Finally, it was beyond the scope of this study

to conduct a full economic evaluation of the costsand health outcomes (morbidity and deaths)associated with unsafe abortion in Mexico. Thiscost analysis draws on primary data from fourfacilities representative of Mexico City, alongwith secondary data on abortion complicationsfrom Mexico City only. These are not representa-tive of other parts of Mexico. A full economicanalysis could model both the costs and effec-tiveness of alternative policy options and at thesame time extend the geographic representationand the analytical horizon.After this study was completed (2005), elec-

tive abortion up to 12 weeks gestation was legal-ised in Mexico City (2007) and access to safeabortions has increased.22 It is too early to assess

uctive Health area of the Centro de Salud Beatrizabortions are now being provided, 22 May 2008

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whether the increase in demand on the healthsystem for legal abortions in this new environ-ment will translate to savings to the publichealth system. This is because the reduction inper capita costs might be outweighed by alarger number of women seeking elective abor-tion than those seeking treatment for incompleteabortion in the past. It is clear, however, thatmany more women could have safe abortionswith the same amount of funds. We hope to con-duct a follow-up cost analysis within 3–5 yearsof the change in legislation, when servicesshould be well established, in order to furtherdocument the cost impact of improving accessto safe, legal abortion.Our data provide overwhelming support for

shifting abortion management from emergency,inpatient procedures to routine, outpatient pro-cedures in Mexico City, as well as shifting away

from D&C to MVA and MA. In 2008, the MexicoCity Ministry of Health opened the first legalabortion service at the health centre level.They have also made important strides in reduc-ing the use of D&C to induce abortion andmoving toward more widespread use of MVAand MA. It is hoped that Mexico City willserve as a model for other parts of Mexico andthat our findings will help to convince othercountries where unsafe abortion is still preva-lent that the provision of safe abortion care isnot only cost-effective but better addresses theneeds of women.

AcknowledgementsThis study was funded by an anonymous donor.A version of this paper was presented at theannual meeting of the National Abortion Federa-tion on 24 April 2006.

References

et al. El acceso al aborto legalde las mujeres embarazadas porviolación en la ciudad deMéxico. Gaceta Médica deMéxico 2003;139(1):S77–S90.

2. Alan Guttmacher Institute.Aborto clandestino: unarealidad latinoamericana.Fact sheet. New York: AllanGuttmacher Institute, 1994.

3. Espinoza H, Abuabara K,Ellertson C. Physicians'knowledge and opinionsabout medication abortion infour Latin American andCaribbean region countries.Contraception 2004;70(2):127–33.

4. Sherris J, Bingham A, BurnsMA, et al. Misoprostol use indeveloping countries: resultsfrom a multicountry study.International Journal ofGynecology and Obstetrics2005;88(1):76–81.

5. Lara D, Abuabara K, GrossmanD, et al. Pharmacy provision ofmedical abortifacients in a LatinAmerican city. Contraception2006;74(5):394–99.

6. Billings DL, Benson J.Postabortion care in Latin

America: policy and servicerecommendations from a decadeof operations research. HealthPolicy and Planning 2005;20(3):158–66.

7. Faúndes A, Santos LC,Carvalho M, et al. Post-abortioncomplications after interruptionof pregnancy with misoprostol.Advances in Contraception1996;12(1):1–9.

8. Walker D, Campero L, EspinozaH, et al. Deaths fromcomplications of unsafeabortion: misclassified secondtrimester deaths. ReproductiveHealth Matters 2004;12(24 Suppl):27–38.

9. Juarez F, Singh S, Garcia SG,et al. Estimates of inducedabortion in Mexico: what'schanged between 1990 and2006? International FamilyPlanning Perspectives 2008;34(4):158–68.

10. Henshaw SK, Adewole I, SinghS, et al. Severity and cost ofunsafe abortion complicationstreated in Nigerian hospitals.International Family PlanningPerspectives 2008;34(1):40–50.

11. World Health Organization,Department of Reproductive

Health and Research.Mother-Baby Package CostingSpreadsheet Version 1.01.Geneva: WHO, 1999.

12. Mexican Ministry of Health.Automated Hospital DischargeRecords System 2004. MexicoCity: Mexican MoH, 2005.

13. Instituto Mexicano del SeguroSocial. Hospital Release RecordsDatabase 2004. Mexico City:IMSS, 2005.

14. Instituto de Seguridad yServicios Sociales de losTrabajadores del Estado.Hospital Release Records,Mexico 2004. Mexico City:ISSSTE, 2005.

15. Berer M. National laws andunsafe abortion: the parametersof change. Reproductive HealthMatters 2004;12(24 Suppl):1–8.

16. World Health Organization. Safeabortion: technical and policyguidance for health systems.Geneva: WHO, 2003.

17. Brambila C, Langer A, Garcia-Barrios C, et al. Estimating costsof postabortion services atDr. Aurelio Valdivieso GeneralHospital, Oaxaca, Mexico. In:Huntington D, Piet-Pelon NJ,editors. Postabortion Care:

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C Levin et al / Reproductive Health Matters 2009;17(33):120–132

Lessons from OperationsResearch. New York: PopulationCouncil, 1999. p.108–24.

18. Johnson BR, Benson J, BradleyJ, et al. Costs and resourceutilization for the treatment ofincomplete abortion in Kenyaand Mexico. Social Science andMedicine 1993;36:1443–53.

19. Billings DL. Misoprostol alonefor early medical abortion in aLatin American clinic setting.

RésuméEn 2005, avant la légalisation deon a évalué les résultats et le coût dsur le système sanitaire à Mexétablissements publics et privésont été obtenues auprès du personet des patientes, et dans les dossiersLes estimations directes des coûtspersonnel, les médicaments, les cet l 'équipement médical poul'avortement ou traiter les avortemeet d'autres complications. Les fradéplacement, de garde d'enfantsgain des patientes ont aussi étécoût moyen par avortement avet curetage était de $US143. Pmanuelle, il était de $US 111 danspublics et $US 53 dans une cliniqcoût moyen de l'avortement méavec du misoprostol seul était dmoyenne, le traitement des cograves de l'avortement danspublics allait de $US 601 à plusUn accès élargi à l'aspiration ml'avortement précoce au misoprostde réduire de 62% les coûts gouvavec des économies potentielleà $US 1,6 million par an. Encomplications par l'amélioration dservices ambulatoires sûrs, on dimile coût des soins de l'avortementavantages pour le système de sanles femmes souhaitant avorter. Il frecherches supplémentaires pourdes économies ont été réalisées ap

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Reproductive Health Matters2004;12(24 Suppl):57–64.

20. Clark WH, Gold M, Grossman D,et al. Can mifepristone medicalabortion be simplified? A reviewof the evidence and questionsfor future research.Contraception 2007;75(4):245–50.

21. Afable-Munsuz A, Gould H,Stewart F, et al. Providerpractice models for and costs of

l'avortement,e l'avortementico, dans des. Les donnéesnel hospitalieradministratifs.incluaient leonsommablesr provoquernts incompletsis indirects deet de perte decalculés. Le

ec dilatationar aspirationtrois hôpitauxue privée. Ledicamenteuxe $US 79. Enmplicationsles hôpitauxde $US 2100.anuelle et àol permettraiternementaux,s se chiffrantréduisant lese l'accès à desnuerait encore, avec de netsté mexicain etaut mener desdéterminer sirès l'adoption

ResumenEn 2005, antesel Distrito Fedeevaluación del ien el sistema destablecimientobtuvieron datregistros admicálculos de cosmedicamentosequipo médicoabortos incompTambién se calclas pacientes enperdidos. El costdilatación y cuaspiración manuUS $111 en tresuna clínica privainducido con mEl costo promedgraves del abovarió de US $6ampliar el accescon misoprostolgubernamentalede hasta US $1.las complicacionservicios segurdisminuirían tamdel aborto, lo cupara el sistema dmujeres que busnecesitan más inhan logrado aho

delivering medication abortion– evidence from 11 US abortioncare settings. Contraception2007;75(1):45–51.

22. Sánchez Fuentes ML, Paine J,Elliott-Buettner B. Thedecriminalisation of abortion inMexico City: how did abortionrights become a politicalpriority? Gender &Development 2008;16(2):345–60.

de la legalización del aborto enral de México, se realizó unampacto y los costos del abortoe salud del D.F., en diversosos públicos y privados. Seos de personal hospitalario,nistrativos y pacientes. Lostos directos incluían personal,, suministros desechables, ypara inducir el aborto o tratarletos y otras complicaciones.ularon los costos indirectos deviajes, cuido de niños y sueldoso promedio por cada aborto conretaje fue de US $143. Para laal endouterina (AMEU), fue dehospitales públicos y US $53 enda. El costo promedio del abortoisoprostol solo fue de US $79.io de tratar las complicacionesrto en los hospitales públicos01 a más de US $2,100. Alo a la AMEU y al aborto precoz, se podrían disminuir los costoss en un 62%, un posible ahorro6 millones al año. Al disminuires tras mejorar el acceso a losos en ámbitos ambulatorios,bién los costos de la atenciónal sería un gran beneficio tantoe salud de México como para lascan servicios de aborto. Aún sevestigaciones para explorar si serros en costos post-legalización.

de la légalisation.