costs and consequences of induced abortion in zambia
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This short presentation was made at the Zambia Medical Association 2014 Annual General Meeting. It was given by one of the members of the project team, Dr Bellington Vwalika who is Head of the Obstetrics & Gynaecology Department at the University Teaching Hospital, Lusaka. It's a short (10 minute) summary of the pregnancy termination law in Zambia and the headline findings from our study of the costs and consequences of unsafe abortion for women, their households and others and for the Zambian health system.TRANSCRIPT
Costs and consequences of unsafe and safe induced abortion
in ZambiaDr Bellington Vwalika
Department of Obstetrics and Gynaecology University Teaching Hospital, Lusaka
Zambia Medical Association AGM8-9 August 2014, Livingstone
Aim of the research
To investigate:
1) why public sector investment in safe abortion services in Zambia is not fully utilised, and
2) what the costs of unsafe abortion are for women, their households and the Zambian health system
Two headline findings
1) Costs of safe abortion and post-abortion care for the Zambian health system
2) Key features shaping women’s pathways to either a safe or unsafe abortion
The Termination of Pregnancy Act, 1972TOP permitted if continuance of the pregnancy would involve
1. risk to the life of the pregnant woman; or2. risk of injury to the physical or mental health of the pregnant woman;
or 3. risk of injury to the physical or mental health of any existing children
of the pregnant woman;greater than if the pregnancy were terminated;
4. a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
In determining this risk account may be taken of the pregnant woman's actual or reasonably foreseeable environment or of her age
Opinions of single registered medical practitioners sufficient if the termination is immediately necessary to save the life or to prevent grave permanent injury to the physical or mental health of the pregnant woman
• Comparative research design: women receiving ToP at UTH vs. women receiving PAC at UTH after ToP elsewhere
• Interviews with ToP/PAC patients (n=112) elicited qualitative (women’s TOP experiences) and quantitative (associated economic costs) data at same time
• Key informant interviews (n=18) to collect information on treatment protocols and costs
• Review of medical case records women receiving SA and PAC (n=71) to validate the treatment protocols
• Review of facility aggregate records (logbooks) to estimate the number of women receiving treatment for abortions at UTH
Research design and data
MA MVA Incomplete abortion Sepsis ShockSafe induced abortions (SA) Post abortion care (PAC)
$0
$20
$40
$60
$80
$100
$120
$140
$160
$180
Blood transfusion Drugs and materials Lab tests & diagnostics Personnel
Hospitalisation
Facility-level costs per service
Facility-level and national-level annual costs for SA and PAC after unsafe abortion
Costs ($) Facility-level Safe induced abortion (N=222)
MA 5,898 MVA 1,772 Incomplete abortion 856 Total cost of SA 8,525 Average cost per SA 38.29
PAC post-induced unsafe abortion (N=2123) Incomplete abortion 70,410 Sepsis 37,544 Shock 1,857 Total cost for PAC post-induced unsafe abortion 109,811 Average cost per PAC post-induced unsafe abortion 51.72
National-level a Cost of SA (N=6,015 to 18,044) 230,280 – 690,840 Cost of PAC post-induced unsafe abortion (N= 45,471 to 11,368) 588,005 – 2,351,966 Cost savings b 152,774 – 611,046
a Due to absence of nationally available data, these calculations are based on numbers obtained from other studies and therefore presented as a range of costs as shown in Box 2
b Cost savings if all women who require PAC for induced unsafe abortion were to receive an induced SA
Cost of unsafe abortion to health system
• The Zambian health system would save $13.43 per case (i.e. $152,774 to $611,046 per year) if each woman treated for a complication of unsafe abortion had instead accessed these services for SA
• The Zambian health system spends between $588,005 and $2.4 million per year on PAC due to unsafe induced abortions
Key features shaping trajectories
1. The influence of advice
2. Perceptions of risk
3. Delays in care seeking and receipt
4. The economic costs
All influence trajectory
- Direction- Complexity - Timing
• Advice sought and received, or did not seek, played significant role in shaping their trajectories– Women who had safe abortion tended to know someone
who told them how and where to get an abortion– Women who had multiple attempts/PAC did not have
someone in their network to tell them
• Respondents reported that they and those they confided in considered risks of various ToP methods– Some women who had safe abortion did so because they
thought the alternatives were too risky– Some women who attempted abortion elsewhere chose
methods based on risks. However for some respondents the risks of harm were outweighed by the desperation for ToP
Key features shaping trajectories
• Delays in care seeking common among women who did not go straight to UTH for a SA– Lengthier delays linked to denial of pregnancy or non-
disclosure of ToP attempts to clinicians associated with stigma of unplanned pregnancy and induced abortion
– Women in this group tended to be younger
• Financial costs of seeking a ToP influence the timing and complexity of trajectories– For poorer women, knowledge of how to navigate the public
sector health system made care affordable but also added an additional step in their trajectory to the hospital
– Some women’s need to find money to make unregulated payments to doctors significantly delayed their ToP
Key features shaping trajectories
Policy implications• Cheaper to provide ToP than PAC• Women need more information about about
how and where to get safe ToP• Ultimately costs for women and health system
would be reduced further if unintended pregnancies were reduced through the uptake of family planning
Authors and fundersDr Ernestina Coast Principal Investigator)[email protected]
Dr Bellington Vwalika (Co-Investigator)University Teaching Hospital [email protected]
Dr Divya Parmar (Co-Investigator)[email protected]
Dr Susan F Murray (Co-Investigator)King's College [email protected]
Dr Tiziana Leone (Co-Investigator)[email protected]
Ms Taza Mwense (Research assistant)University of [email protected]
Dr Ellie Hukin(Researcher)[email protected]
Dr Bornwell Sikateyo (Researcher)University of [email protected]
Dr Emily Freeman (Researcher)[email protected]
Funded by UK Economic and Social Research Council (ESRC) and Department for International Development (DFID)