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)
Notes de l'éditeur
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.