Bsps2014 leone final
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Transcript of Bsps2014 leone final
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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
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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
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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
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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
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Estimates of abortion for Zambia
Annual estimate
Total induced abortions 114,279
• Unsafe 108,264
& require post-abortion care 45,471
• Safe 6,015
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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
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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
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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
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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
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Methods for costingTotal 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
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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]
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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
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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
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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 abortion4 seek an
alternative
unsafe method
22 (65%)
receive referral
41(37%) visit
different providers
What happens before arriving at hospital?
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Breakdown of costs incurred by
women (US$)
Safe
abortion
Unsafe
abortion +
PAC
Direct pre-
hospital2.6 5.8
Indirect pre-
hospital4.7 17.7
Direct at hospital 6.5 4.9
Indirect at
hospital38.3 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
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Costs for women by un/safe abortion
and wealth quintile
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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
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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
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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
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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
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More information
http://zambiatop.wordpress.com/
https://twitter.com/ZambiaToP
@ZambiaToP