Economic Impact of Unsafe Abortion-Related Morbidity and Mortality

94 Pages·2008·0.3 MB·English

IDS RESEARCH REPORT59
IDS RESEARCH REPORT 59
Economic Impact of Unsafe
Abortion-Related Morbidity and
Mortality: Evidence and
Estimation Challenges
Michael Vlassoff, Jessica Shearer, Damian Walker and
Henry Lucas
December 2008
Institute ofDevelopment Studies at the University ofSussex Brighton BN1 9RE UK 1
IDS RESEARCH REPORT59
EconomicImpact ofUnsafe Abortion-Related Morbidity and Mortality: Evidence and Estimation Challenges
Michael Vlassoff, Jessica Shearer, Damian Walkerand Henry Lucas
IDS Research Report 59
First published by the Institute ofDevelopment Studies in December2008
© Institute ofDevelopment Studies 2008
ISBN 978 1 85864 539 5
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Contents
Summary, keywords 5
Author notes 6
Preface 7
1 Introduction 9
2 Framework of analysis 9
3 Review of costing literature 11
3.1 PACinterventions 13
3.2 Data considerations 14
3.3 Severity ofcomplications 15
4 Cost to health system of unsafe abortion: global and regional estimates 16
4.1 Costing methods 16
4.1.1 Average cost percase 16
4.1.2 Mother-Baby Package costing spreadsheet 20
4.2 Global and regional cost estimates 21
4.2.1 Cost estimates using average cost percase 21
4.2.2 Cost estimates using the Mother-Baby Package costing spreadsheet 25
5 Other costs: review of evidence, methods and assumptions 29
5.1 Treating unmet need: women with serious complications from unsafe abortion 29
5.2 Treating unmet need: women with minorcomplications from unsafe abortion 33
5.3 Treating unmet need: the cost ofinfertility resulting from unsafe abortion 34
5.4 Out-of-pocket expenses 36
5.5 Otherindirect costs to individuals orhouseholds 37
5.6 Impact ofunsafe abortion on the economy 39
5.6.1 Economicimpact ofabortion-related mortality 39
5.6.2 Economicimpact ofabortion-related morbidity 40
6 Conclusions 44
Annex 1 Acronyms 47
References 89
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Figure
Figure 2.1 Framework ofanalysis forcosting unsafe abortion 10
Tables
Table 3.1 Severity ofcomplications 15
Table 4.1 Empirical studies estimating costs perpatient forabortion complications 17
Table 4.2 Average costs perpatient from 24 empirical investigations 22
Table 4.3 Global and regional estimates ofhealth-system costs ofPAC(2006 US$)
using cost perpatient averages 24
Table 4.4 Applications ofthe MBP costing spreadsheet: study characteristics 25
Table 4.5 Applications ofthe MPB costing spreadsheet: cost ofPAC(US$) 26
Table 4.6 Applications ofthe MBP costing spreadsheet: global and regional
estimates ofcost ofPAC(2006 US$) 27
Table 5.1 Estimating the cost ofPACifuntreated women with serious
complications received care 30
Table 5.2 Costs ofMBP interventions in five applications (2006 US$) 31
Table 5.3 Global and regional estimates oftreatment costs ofminorcomplications
ofunsafe abortion (2006 US$) 32
Table 5.4 Summary ofstudies ofout-of-pocket expenses ofwomen with
post-abortion complications (2006 US$) 35
Table 5.5 Economicimpact ofabortion-related mortality: changes in percapita
income 38
Table 5.6 Economicimpact ofabortion-related morbidity: estimates oflost income
(one year) 42
Annex tables
A1a Immediate complications from unsafe abortion: review ofempirical studies 48
A1b Latercomplications from unsafe abortion: review ofempirical studies 52
A2 Empirical studies on the cost ofunsafe abortion and inclusion criteria 56
A3 Treatment ofcomplications from unsafe abortions: review ofempirical studies 82
A4 PACcosting studies reporting hospitalisation 84
A5 Studies reporting blood transfusions 85
A6 Age distribution ofwomen with complications from unsafe abortion: review of
literature 86
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Summary
Unsafe abortion-related morbidity and mortality (UARMM) exacts a huge price annually in
terms ofthe lives and health ofwomen in developing countries each year. Almost
20 million unsafe abortions occurannually, virtually all in the developing world. More than
5 million ofthese result in medical complications so serious that they require hospitalisation.
The economiccost ofUARMM is also enormous, burdening publichealth systems, the
households in which these women live and also the economies ofthe countries themselves.
The empirical data needed to estimate most ofthese costs are scant and in some cases,
practically non-existent, but several studies ofdirect health-system costs are available in the
literature. These data exist in two forms which allow cost estimation using two distinct
methodologies, one which uses cost-per-patient data, and one which uses a model ofideal
treatment inputs. Examining the cost ofUARMM to health systems using both ofthese
methodologies, we find that the total cost to the developing world lies between $375 and
$838 million, with a central estimate ofaround $500 million (2006 US$). Regional cost
estimates show that in relation to purchasing power, abortion complications are
considerably more expensive to treat in sub-Saharan Africa than in Latin America.
Furthermore, millions ofotherwomen with serious complications receive no treatment
from the health system. Ifthey were able to do so, an additional $375 million orso would
be expended, but this estimate rests on scant empirical data. The cost oflong-term
morbidities, mainly infertility and chronicreproductive tract infections, may cost many
billions ofdollars annually, while the losses to the economies ofdeveloping countries from
lowerproductivity caused by UARMM may be more than $400 million. Out-of-pocket
expenses to the women and theirfamilies may amount to a further$600 million. Very little
data exist to make these latterestimates, but they at least show that the total cost of
UARMM would be many times greaterthan the direct health costs, forwhich solid
evidence does exist.
Keywords: unsafe abortion; cost; morbidity; mortality; infertility; reproductive tract infection;
out-of-pocket expense; productivity
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Author notes
Michael Vlassoff is a SeniorResearch Associate at the GuttmacherInstitute, a leading
research organisation in the field ofreproductive health. This report draws on earlierwork
done fora consultation meeting on the cost ofunsafe abortion organised and hosted by
the GuttmacherInstitute and commissioned by the Hewlett Foundation which took place in
New York in June 2006. John Ross and Patricia Justino provided helpful comments on an
earlierdraft. Furthercomments are welcome to [email protected].
Jessica Shearer is a Research Associate in the Department ofInternational Health at the
Johns Hopkins Bloomberg School ofPublicHealth. She has research interests in
reproductive and maternal health, and is currently working with country level decision-
makers to assess and incorporate evidence into publichealth decisions. Following the IDS
technical meeting on UARMM, she provided inputs on the review ofthe costing literature
and assisted with analysing the reported unit costs.
Damian Walker is an Assistant Professorin the Department ofInternational Health at
Johns Hopkins Bloomberg School ofPublicHealth. He is a health economist who
specialises in evaluating the cost and cost-effectiveness ofhealth interventions in low- and
middle-income countries. He is an adjunct Scientist at the International Centre for
Diarrhoeal Disease Research, Bangladesh, visiting faculty memberat BRACJames P. Grant
School ofPublicHealth, and Honorary Lecturerat the London School ofHygiene and
Tropical Medicine. He was a memberofthe technical review panel and participated in the
IDS technical meeting on UARMM. He provided inputs on the review ofthe costing
literature and the economicmethods used in the report.
Henry Lucas is a Fellow ofthe Institute ofDevelopment Studies (IDS) at the University of
Sussex. He is a statistician who specialises in poverty analysis and survey methodologies with
particularreference to health and development. He has worked extensively in sub-Saharan
Africa and China. He was a memberofthe technical review panel and participated in the
IDS technical meeting on UARMM. He provided inputs on indirect costs and in presentation
ofthe quantitative data.
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Preface
This research report is an outcome ofwork commissioned by the Hewlett Foundation to try
to estimate the global economiccosts ofunsafe abortion related mortality and morbidity
(UARMM). It reflects a series ofconsultations and draft reports to design an acceptable and
robust methodology forestimating the costs to households, health systems and
communities ofUARMM, keeping in mind the data limitations and thin theoretical
literatures upon which such a methodology must draw. In 2006, the Hewlett Foundation
approached DrHilary Standing, Research Fellow at the Institute ofDevelopment Studies
and Directorofthe Realising Rights Research Programme Consortium, with a view to
developing the next steps in taking this work forward. A set ofreview activities was devised,
structured around a short technical meeting held at the IDS on 17 and 18 April 2007. The
workshop brought togethereconomists and otherdevelopment specialists with expertise in
economicand poverty modelling, with experts in unsafe abortion from key agencies
working in this area. This report is based on original work by the lead author, Michael
Vlassoff. Following the technical deliberations, it was agreed that a report focused on the
methodology ofUARMM would be particularly valuable to guide others wishing to
undertake similarstudies. Annex 1 provides furtherinformation on the process and findings
ofthe technical meeting.
The authors would like to thank Sara Seims and Tamara Fox ofthe Hewlett Foundation’s
Population Program, who funded the work from the start and maintained a very close
interest throughout the process. They would also like to thank participants at the IDS
technical review meeting fortheirmany valuable contributions to strengthening the
methodology and theirinsights into furtherareas ofcosting that could be taken up in future
studies. In particular, they would like to acknowledge the comments and suggestions made
by Susheela Singh, David Newlands, Jo Borghi, Janie Benson, Eva Weissman and Stan
Bernstein. Special thanks to Hilary Standing who not only organised the expert meeting but
also provided every organisational support forthe research report. Thanks are also due to
JenniferLeavy, Research Officerat the Institute ofDevelopment Studies, forherexcellent
rapporteuring ofthe technical meeting. Additional costs forpublishing this report were met
by the IDS Health and Social Change Programme.
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1 Introduction
Unsafe abortion-related morbidity and mortality (UARMM) impacts welfare at the individual,
household, community and national levels. Out ofan estimated 46 million induced abortions
that take place every yearin the world, around 19.8 million are unsafe abortions (WHO
2007b).1 More than 5 million ofthese abortions result in serious medical complications that
require hospital-based treatment (Singh 2006). Ofthese cases, many sufferlong-term
effects, including an estimated 1.6 million women who annually suffersecondary infertility
and a further3–5 million women experience chronicreproductive tract infections.
The cost that these figures imply is a matterofimportance forpublicpolicy. Despite this,
little research has gone into estimating UARMM costs ordeveloping an overall framework
and costing methodology to arrive at cost estimates. The objectives ofthis report are to
survey the empirical information available on costing unsafe abortion, to develop an
analytical framework forcost estimation, to describe the methodological approaches
available, given the constraints ofthe subject matter, and finally to estimate cost ranges
within the limitations ofdata on unsafe abortion.
The complications from unsafe abortion have been listed elsewhere, forinstance by
Bernstein and Rosenfield (1998) and WHO (1995). Empirical studies on abortion
complications, however, show that the list ofpossible complications is a very long one.
Annex Table A1 attempts to organise this long list into three categories: immediate
complications, latercomplications and othercomplications that are reported only
sporadically in the literature. A complete costing ofabortion-related complications would
need evidence on the prevalence ofall the complications listed in the table. When we look
at empirical costing studies below, however, we will find that in practice only a few ofthe
majorcomplications are taken into consideration.
The report is divided into foursubstantive sections. In the next section, a general framework
forthe analysis ofthe costs ofunsafe abortion is developed. In the section following this, a
review ofthe literature on the cost ofunsafe abortion is presented. This is followed by a
section on the estimation ofthe cost ofunsafe abortions to health systems in developing
countries. In this section, a discussion ofmethodological considerations is followed by a
series ofcost estimations using a variety ofmethodological approaches. The final substantive
section ofthe report examines othercosts listed in the framework forwhich empirical
evidence is less secure. A concluding section summarises the different costs estimated in the
report in the light oflimitations ofdata and necessary assumptions, pointing out priorities
forfuture research into UARMM costing.
2 Framework of analysis
Unsafe abortion generates unnecessary costs to society at a variety oflevels. Where
abortion is illegal, households will generally finance the costs ofthe abortion procedure
from theirown resources. Even where abortions are legal, many women will still have
recourse to unsafe procedures fora variety ofreasons: the stigma that society still attaches
to abortion, the desire ofthe woman to maintain a cloak ofsecrecy, orthe inadequacy of
the health system vis-à-vis abortion procedures. The 19.8 million women who undergo
unsafe abortions annually incura variety ofcosts to society, the household and the
individual. Figure 2.1 presents a framework foranalysing these costs in the form ofa
decision diagram. An unknown proportion ofwomen who have an unsafe abortion will
experience serious complications; some ofthese women will seek care within the formal
health system, while many will seek care outside ofthe formal health system ornot seek
1 The World Health Organization defines unsafe abortion as a procedure to terminate an unintended
pregnancy carried out eitherby persons lacking the necessary skills orin an environment that does not
conform to minimal medical standards orboth (WHO 2007b).
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