Unsafe Abortion: The Costs to National Health Systems

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.

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  • geckogirl

    Every time I pass a car with the bumper sticker, “Choose Life — Your mother did,” I want to yell at the person driving. My mother, in fact, had two abortions before she had me. She was young, she was stupid and, even though she used birth control, she could (as she once put it) “get pregnant at the drop of a hat.”

    10 years earlier, abortion would have been illegal, which means my mother would not have taken the medical risk (she wasn’t THAT stupid) and I never would have been born. One kid was really more than she could handle anyways, and there were two of us eventually.

    When I asked her about pre-Roe abortions, she said the only people who could get safe ones were the ones that could afford to fly to a Carribbean nation where they were illegal. Everyone else had to go to black-market doctors (or people who played doctors on TV, as it were) or try and abort themselves. She was terrified someone would roll back Roe v. Wade and I would someday have to face the choice (unwanted child or early death) she barely escaped having to make.

    Banning abortion won’t stop it, any more than the previous ban did. What it will do is overload the hospitals with not-rich women (we’re talking everyone from poor to middle-class) suffering from infections, hemmorhaging and all sorts of other gyaenecological complaints. No one “dies at home” anymore — they die in hospitals, attached to thousands of dollars in equipment, with doctors and nurses working feverishly to save what remains of their life. That’s a lot more expensive than a simple D&C procedure, which only requires local anesthetic (and yes, I’ve had a D&C — no one in their right mind would choose that as a form of birth control).

    My mother was lucky enough to be able to choose life — for herself and for her children-yet-to-come. I’m lucky to have that choice, even though I haven’t yet had to exercise it; I want my daughter to be that lucky, too.

    So I’m going to choose Choice … my mother did.

  • emilyklamer

    “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.”

    I respectfully disagree with this statement. Every woman’s experience with medical abortion is different. While some women may experience no pain at all, many others experience rather intense cramping, especially 4-6 hours after the administration of misoprostol. Light cramping can last for days afterwards.

    While I certainly recognize the value and efficacy of medical abortion and am excited about its potential to save women’s lives in low-resource settings, it is very important to be clear regarding medical abortion’s effects, especially as the reproductive health community raises awareness regarding this particular abortion technology around the world.

  • sometimesamused

    I think the author is referring to the kind of pain one would feel in a situation where knitting needles, coat hangers or other sharp objects are shoved into a woman, often with no real anesthesia. I understand what you are saying about cramps, but would you consider cramps to be on the same level as the pain from a part of your body being perforated? The two are not comparible–at least not in my world.


    I am quite sure that a woman being offered the choice of a medical procedure that results in cramps for a few days versus a back-alley type procedure which could result in multiple surgeries to repair the damage (if they live) would agree with me. Cramps are not the same as pain from injury. That is what I believe the author was saying, too.

  • sometimesamused

    Basically, there was no ban for the weathy… In the pre-Roe days, wealthy women COULD get abortions in the U.S. by having a well-paid doctor to certify having a baby would threaten the mother’s life. All that was needed was a diagnosis of  “a nervous condition” to get around the “ban”.


    I too would hate for Roe v. Wade to disappear because I have a daughter. While I hope she never needs the services, I want those services to be available just in case.  What is happening on the African continent is a shame, but it could happen again here if certain people get their way. Sadly for us, those same people will still have the money to get around the law.



  • runningshoe
  • purplehope

    Health..too bad you can’t order it online from google ;)