Zambia has permitted terminations of pregnancy, under a range of conditions, since 1972. Despite this, levels of unsafe abortion are alarmingly high. Although it’s widely understood that unsafe abortion is both a cause and a consequence of poverty, there is a lack of economic evidence around the experiences of women and their households. This presentation compares the socio-economic burden of those who seek safe abortion (SA) with those who seek post-abortion care (PAC) after an unsafe procedure. We use hospital based data collected in the University Teaching Hospital in Lusaka over a period of 12 months in 2013. Information on women’s demographic and socio-economic characteristics, and direct and indirect costs incurred have been collected and triangulated using medical notes and qualitative information.

1. The economic burden of unsafe abortion for women and households in Zambia
Tiziana Leone, LSE
Ernestina Coast, LSE
Divya Parmar, City University
Bellington Vwalika, UTH Lusaka
Safe
Unsafe

2. Background
•Although abortion is legal, unsafe abortion is still high in Zambia
•Stigma and barriers to access mean that women still use illegal and unsafe clandestine providers
•Limited evidence globally on economic consequences of seeking an unsafe abortion compared to a safe abortion
•Studies often fail to account for indirect costs (e.g. loss of wages, transport, accommodation), actions taken in order to find money or for the costs for friends and family

3. Unsafe abortion…
•a large health risk for women because of inadequate skills of the providers, unsanitary environments, and hazardous techniques
•increase the rate of complications (e.g.: severe bleeding, abdominal and genital injury) or death
•can lead to further complications (e.g.: haemorrhage, sepsis, genital perforation)
•might need complex tertiary care which is only available at referral public hospitals with the capacity for surgery, blood transfusion, and intensive care

4. A relatively liberal abortion law in Zambia
•Abortion is legally permitted:
⁻To save the life of a woman
⁻To preserve physical health
⁻To preserve mental health
⁻Foetal impairment
⁻Socio-economic and welfare of existing children can be taken into account
Gestational age limits apply

5. Estimates of abortion for Zambia
Annual estimate
Total induced abortions
114,279
•Unsafe
108,264
& require post-abortion care
45,471
•Safe
6,015

6. Aims and objectives
•Estimate and compare the costs of safe abortion and post-abortion care (PAC) following an unsafe abortion for women and their households
•Analyse the impact of different pathways to termination of pregnancy on economic burdens and their determinants

7. Primary Data
•112 interviews with women
–Enough statistical power level of confidence 95% and a margin of error at 5% given a response level of 80% (87% response level achieved)
•For each woman medical records linked
•Data collected January-December 2013 for all women identified as having undergone either a safe abortion or having received PAC following an unsafe abortion in the study hospital in Lusaka and discharged Monday to Friday (08:00- 16:00 and 06:00-17:00)
•Interviews conducted privately with women following treatment and prior to discharge

8. Research instrument
•Available from: http://www.abortionresearchconsortium.org/
•Covered:
–socio-demographic background
–direct service costs (e.g.: fees per procedure or intervention)
–indirect costs (e.g.: travel, food, loss of productivity)
–resources used to pay costs (e.g.: credit, asset sale, borrowing, loss of wages)
–household assets used to calculate the wealth asset

9. Methods strengths and innovations
•Costs included all attempts and actions prior to arriving at hospital
•Medical notes used to validate individual reports of direct hospital costs
•Qualitative and quantitative data collected simultaneously

10. Methods for costing
Total patient costs =
Direct medical costs (e.g. pregnancy test costs, charges paid by women for un/safe abortion, fees)
+
Indirect nonmedical costs (e.g. childcare, travel, accommodation, informal payments)
+
Productivity losses (e.g. time away from work/loss of income for woman and people involved, including housework)
Linear regression of individual costing controlling for medical procedures (e.g. medical abortion vs manual vacuum aspiration) and socio-economic determinants

11. Pathways to study hospital in our sample
%
N=112
Safe abortion at hospital
59.8
PAC after unsafe abortion:
[Medical abortion self-initiated]
[Other method e.g.: overdose, insert foreign object]
41.2
[14.7]
[25.5]

12. Percentage of women by age and un/safe abortion
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
14-19
20-24
25-29
30-34
35+
Safe
Unsafe

13. Percentage of women by un/safe abortion and wealth
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
poorest
below average
average
above average
wealthiest
Safe
Unsafe

14. First attempt
Includes 2 ambiguous cases
No information about 3 (7%)
1 attempts third unsafe attempt
112 women
34 (89%) go to hospital
Second attempt
Government hospital
4 make a 2nd unsafe attempt
71 (63%) report going straight to hospital
11 (15%) receive referral
2 (50%) receive referral
38 attempt an unsafe abortion
4 seek an alternative unsafe method
22 (65%) receive referral
41(37%) visit different providers
What happens before arriving at hospital?

15. Breakdown of costs incurred by women (US$)
Safe abortion
Unsafe abortion + PAC
Direct pre- hospital
2.6
5.8
Indirect pre- hospital
4.7
17.7
Direct at hospital
6.5
4.9
Indirect at hospital
38.3
35.5
Total costs
52.0
64.0
•Medical abortion = $33
•PAC following a failed abortion = $88
•Average minimum monthly salary for a domestic worker is $100 Gross
•$12 is the equivalent of 3 day’s work

16. Costs for women by un/safe abortion and wealth quintile

17. Determinants of costs
Cost
Age
Parity
NS
Wealth
Procedure
PAC>ToP
Education
NS
Ward (High vs low cost)
NS
Main activity
Business owners pay more

18. What determines the costs that women incur?
•Inadequate decentralisation of ToP services
–Referrals from district clinics to tertiary hospital means further economic burden for women
•Treating the consequences of an unsafe abortion costs up to 70% more for women than a safe medical abortion
•Indirect payments account for the largest part of the burden
•Costs increase with wealth: women asked to pay more according to their visible wealth status
•More than half had to ask relatives and friends for money adding further burden on the wider household

19. Limitations
•Only one site but most of abortion care done there at the time the data were collected
•Costs accounted for up to the time of the interview but could be more costs post-hospital (transport back home included in our calculations)
•School days missed costs not included
•Costs underestimated due to the lack of data for more serious complications and those women that die

20. Future work
•This study has looked at the overall experience
–By costing directly the expenses occurred at the last leg of the journey we would miss a big chunk of burden that the whole experience is for women. Need to assess uncertainty beyond CIs (e.g.: Monte Carlo simulation/sensitivity analysis)
•More in depth study on more serious cases which might have been missed by our study and account for underrepresentation with cost unit weighting

21. More information
http://zambiatop.wordpress.com/
https://twitter.com/ZambiaToP
@ZambiaToP