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.
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Costs and consequences of induced abortion in Zambia
- 1. Costs and consequences of unsafe and safe induced abortion in Zambia Dr Bellington Vwalika Department of Obstetrics and Gynaecology University Teaching Hospital, Lusaka Zambia Medical Association AGM 8-9 August 2014, Livingstone
- 2. 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
- 3. 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
- 4. The Termination of Pregnancy Act, 1972 TOP permitted if continuance of the pregnancy would involve 1. risk to the life of the pregnant woman; or 2. 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
- 5. • 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
- 6. $0 $20 $40 $60 $80 $100 $120 $140 $160 $180 MA MVA Incomplete abortion Sepsis Shock Safe induced abortions (SA) Post abortion care (PAC) Blood transfusion Drugs and materials Lab tests & diagnostics Personnel Hospitalisation Facility-level costs per service
- 7. Facility-level and national-level annual costs for SA and PAC after unsafe abortion Costs ($) 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
- 8. 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
- 9. 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
- 10. • 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
- 11. • 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
- 12. 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
- 13. Authors and funders Dr Ernestina Coast Principal Investigator) LSE e.coast@lse.ac.uk Dr Bellington Vwalika (Co-Investigator) University Teaching Hospital vwalikab@gmail.com Dr Divya Parmar (Co-Investigator) LSE d.parmar1@lse.ac.uk Dr Susan F Murray (Co-Investigator) King's College London susan_fairley.murray@kcl.ac.uk Dr Tiziana Leone (Co-Investigator) LSE t.leone@lse.ac.uk Ms Taza Mwense (Research assistant) University of Zambia tazamw@yahoo.com Dr Ellie Hukin (Researcher) LSE efhukin@gmail.com Dr Bornwell Sikateyo (Researcher) University of Zambia bsikateyo@yahoo.com Dr Emily Freeman (Researcher) LSE e.freeman@lse.ac.uk Funded by UK Economic and Social Research Council (ESRC) and Department for International Development (DFID)
Editor's Notes
- Things to quickly mention: The project is a collaboration between researchers at the London School of Economics, University of Zambia, UTH and Kings’ College London and is jointly funded by the UK Economic and Social Research Council and the UK Department for International Development. The aim of the project was to investigate why public sector investment in safe abortion services in Zambia is not fully used: why is mortality from unsafe abortion so high and what are the costs of unsafe abortion for women, their households and the Zambian health system.
- Two sets of analysis and headline findings to briefly present today: Uses quantitative data collected from patients and hospital records to estimate financial costs of safe abortion and post-abortion care for the Zambian health system. Uses qualitative data collected from patients to look at the key features shaping women’s pathways to a safe abortion or unsafe abortion
- Good idea to re-cap on Zambia’s abortion law as there is some evidence from the study that not all health practitioners are not fully aware of it (– or at least that they capitalise on women not knowing it). I looked through your excellent presentation on global abortion laws – perhaps the notes from slide 9 would be useful here: “even in countries where the laws allows for abortion under certain circumstances; it does not necessarily translate into service provision, leaving women’s access to safe legal TOP services greatly limited. Zambia is a good example. The problem is compounded by lack of political will to change the law or commitment to allocate resources for quality service provision. “
- Extra design and data details you might want to mention: Facility-based recruitment attempted to include severe morbidities Refusal rate for interviews with women was 13% Details about the analysis method: Qualitative data analysed using Framework analysis method to facilitate within and across case explanatory analysis Estimate the treatment costs and annual costs of providing SA and PAC services at UTH and project these costs to generate indicative cost estimates for the Zambian public health system by using an adaptation of the WHO Mother-Baby Package Costing Spreadsheet.
- These four features shaped: The direct of a woman’s trajectory – that is, whether she had a safe abortion in a hospital or clinic (e.g. UTH or Marie Stopes) or whether she sought a less-safe abortion or attempted an abortion (e.g. with overdose, inserting objects, herbs) The complexity of a woman’s trajectory – that is, whether she goes straight to the hospital or had a few attempts at terminating her pregnancy and/or consulted a number of providers first The timing of the trajectory – how long the delays was before identifying pregnancy, making decision, seeking help.
- Advice sought and received, or did not seek, played significant role in shaping their trajectories. Respondents’ relationships with significant others influenced who was told about their pregnancy, the decision to terminate it, how and where it was terminated and whether PAC at hospital was sought, and when Women who had safe abortion tended to know someone who told them how and where to get an abortion Women who had multiple attempts before attending UTH for SA or 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 . Government providers (clinics and hospitals) were widely trusted and considered safe. Some women who had safe abortion did so because they thought the alternatives were too risky Some women who attempted abortion elsewhere chose them based on risks. However for some respondents the risks of harm were outweighed by the desire for a ToP.
- Delays in care seeking common among women who did not go straight to UTH for a SA. Some delays connected to the healthcare system – long queues, forgotten appointments and economic costs (official and informal) but lengthier delays appear to be linked to denial of pregnancy, or non-disclosure of ToP attempts to clinicians associated with stigma of unplanned pregnancy and induced abortion. Women who had multiple attempts and long delays before attending UTH tended to be younger women, denied their pregnancy for longer and did not disclose their pregnancy in order to get help. Financial costs of seeking a ToP influence the timing and complexity of trajectories The hospital served a large area and finding money for transport was a first hurdle. Study not able to capture women who could not overcome it. Economic “incentive” to access district clinics first: a referral from a satellite health centre reduces registration fee at a hospital from K80 to K10. 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. For some women need to find money to make an additional extortion payment to a doctor significantly delayed their ToP.