This is the third in a series of articles from Keeping Our Promise: Addressing Unsafe Abortion in Africa this week. The conference has brought together more than 250 health providers, advocates, policy makers and youth participants for a discussion of how to reduce the impact of unsafe abortion in Africa.
How much does unsafe abortion cost national health systems? This is exactly the question that a group of medical experts and health researchers set out to answer in 2007, using the example of the east African country Ethiopia.
Ethiopia was selected because its policymakers sought more information about the economic burden that unsafe abortion placed on the country’s health system. The Ethiopian government liberalised abortion care in 2005, allowing it in cases of incest, rape, threats to the woman’s life and health and in cases where the patient is a minor or has physical or mental disabilities.
The researchers wanted to show how much money could be saved if surgery and medication for care after unsafe abortions were not needed. This is an important consideration as such savings would free up money for other health priorities, explains Dr Haile Gebreselassie, senior research advisor at Ipas Africa and involved in the design of the cost study.
The study was presented at the “Keeping Our Promise. Addressing Unsafe Abortion in Africa” conference in Accra, Ghana, hosted by Ipas and supported by, among others, Ghana’s ministry of health.
The first step was to conduct a magnitude study. Its findings were that, in 2008, unsafe abortions that required post-abortion care numbered 53,000. Safe abortions inside facilities numbered 103,000 while abortions outside facilities that did not require post-abortion care came in at 58,000. Unsafe abortions resulting in untreated complications were still the most prevalent at 163,000.
For the second phase of the study, five categories of complications were identified: shock, sepsis, uterine evacuation, vaginal or cervical lacerations and uterine perforation. The researchers investigated which medical resources are generally used to treat each of these complications, from staff to facilities to medication.
The total direct cost per case was as follows: shock $39.70; sepsis $40.40; uterine evacuation $23.69; vaginal or cervical lacerations $114.86; and uterine perforation $153.15.
The study did not stop there. The researchers took it one step further by determining the cost of treating those women who at that time had access to health services in Ethiopia as opposed to how much it would have cost if Ethiopia’s health services were “perfect” and had universal coverage and access.
Therefore, the researchers “made a projection to include the women who die at home, outside the health system, due to unsafe abortion”, explains Gebreselassie.
The researchers arrived at the following estimates: national expenditure on post-abortion care at current level of access would have been $7,560,000 in 2008; national expenditure at universal access to care would have been $31,620,000 in 2008.
The study shows that the longer the delay in seeking treatment, the higher the cost. “No woman develops sepsis within a day. But if she waits three or four days, it is a different matter,” says Gebreselassie.
Using unhygienic instruments or inserting foreign material into the uterus can cause sepsis whether the uterus is perforated or not. Sepsis, if not treated immediately, can spread to other organs, becoming systemic. This could lead to fever and shock and cause renal shutdown and, ultimately, death.
Women who risk unsafe abortion are aware of the likelihood of infection and the extreme pain that can accompany unsafe abortion. The cervix consists of some of the most sensitive tissues in the human body. Cardiac arrest is the lethal reality that results from overdosing on chloroquine or quinine.
Still, women persist with seeking abortions because unwanted pregnancy remains a bigger problem for them, whether socially, economically or personally, Gebreselassie found in another study that was qualitative and involved interviews with 40 women. Where it is illegal, they are pushed into a corner and have no other option but to resort to unsafe abortion.
Gebreselassie points out that the experience in Ethiopia confirms that it is a myth that health facilities are overwhelmed and that the national health bill shoots up when abortion is legalised. Instead, money is saved. And, more importantly, so are lives.
Liberalising access to safe abortion results in a huge reduction in the severity of complications and, ultimately, of deaths. In Gebreselassie’s lifetime, he has noticed a dramatic change. In the mid-1980s he would come across one to two deaths due to unsafe abortion every day in the course of his work at a public health facility in Ethiopia. Nowadays it is unusual to treat a perforated uterus or come across a patient who suffered cardiac arrest due to an overdose of chloroquine. In 2008, only seven deaths were recorded in one month studied.
Gebreselassie ascribes this to the improved technology of medical abortion, a painless and simple procedure which can be done at home and requires no surgical intervention. The other essential factor is the liberalisation of the law in Ethiopia.