The decision tree showing the consequences of induced abortion is shown in Figure 1 and the probabilities used to estimate the average costs of an induced abortion case are shown in Table 1. Women who choose to abort are first divided into those who seek care from practitioners with the training to safely terminate a pregnancy and those who go to practitioners without such training. Prada et al [²⁸]. in a study in which they interviewed health professionals, reported that the proportion of abortions induced by different providers were as follows: doctors (20%); clinical officers (17%); nurses or midwives (19%); pharmacists or dispensers in drug stores (7%); traditional healers or lay practitioners (22%); and the women themselves (15%). These estimates were used to calculate the average probability of training and abortion induction by provider assuming that doctors, clinical officers, nurses, and midwives are trained providers and dispensers, lay practitioners, traditional healers, and the women themselves are untrained providers.

Women who receive abortion procedures from the different providers are further divided into those for whom induced abortion succeeds and those for whom it fails. Induced abortion rarely fails when performed by trained practitioners, and we found no studies that estimated its incidence in Uganda or similar countries, but studies in other settings have reported frequencies of 0.01% [²⁹], 0.05% [³⁰], and 0.07% [³¹]. Although these studies were performed in high-income countries, we used the estimates because no better estimates were available. The rate of abortion failure is likely higher for certain procedures or technologies which are more likely to be performed by practitioners with less training [⁶,²⁷]. To estimate this probability, we calculated the incidence of second abortion attempts using data from an on-going cohort of women treated for induced abortion at Mbarara University Teaching Hospital in Uganda. According to these data, of the 47 women who received induced abortions from untrained providers, 8 needed a second attempt and 1 needed a third attempt. The initial, failed methods were: 1) herbs for 4 women, 2) an object inserted into the birth canal for 2 women, 3) crude surgical procedures for 2 women, and 4) over-the-counter medication for 1 woman. This distribution of procedures suggests that these abortion providers were untrained and this analysis uses the proportion of women needing a second or third attempt (17%) as the probability of induced abortion failure when procedures are performed by untrained providers. We assumed that when induced abortion by an untrained provider fails, women will try a trained practitioner before ultimately succeeding in terminating their pregnancy or failing and continuing with their pregnancy.

Women who have had successful induced abortions are divided in the model into those who develop complications and those who do not. The type of abortion provider has a direct influence on the probability of having abortion complications. A survey of health workers in Uganda estimated the proportion of induced abortion complications by provider [⁶,²⁸]. It reported rates of abortion complications as: 25% for doctors, 42% for nurses/midwives, 45% for clinical officers, 50% for pharmacists/dispensers, 66% for traditional healers/lay practitioners, and 73% when self-induced.

Women who develop complications following induced abortion were divided into those who need out-patient care and those who need hospital care. According to Prada et al [²⁸]. of the 109,926 estimated number of patients treated for post-abortion complications, 47,828 (43.5%) received hospital care and the rest received out-patient care. Those who need out-patient or hospital care were further divided into those who have access and those who do not have access to services. It has been reported that only 66.5% of those who need this care are able to access it depending on income and geographical location [²⁸].

In the model, women who need and obtain hospital treatment following abortion complications both improve and are discharged alive, or they die in hospital. The in-hospital rate of abortion related mortality ranges from 1.3% [¹⁰] to 3.3% [¹⁹] in Uganda. We assumed that those who need hospital care but are unable to access it are divided into those who die at home and those who worsen and belatedly seek hospital care--a practice which has been reported in Uganda [³²]. Because data were lacking for patients who do not access services, we assumed a doubling in the mortality rate in the community (compared to hospital mortality) at baseline. We assumed that women who do not access out-patient care resort to self-mediation--a practice common in Uganda [³³]--and subsequently get better.

In the case of abortion failure after an attempt by a trained practitioner, the woman carries the pregnancy and faces the consequences of pregnancy. These include: a) miscarriage before 13 weeks gestation, b) miscarriage between 13 and 22 weeks which usually requires treatment, or c) birth of a child which includes preterm birth as well as term live or still birth. Miscarriages at 13-22 weeks account for 2.9% of all recognized pregnancies and live births account for 84.8% [³⁴,³⁵]. The rate of still births in the East Africa region is reported to be 1.9% [³⁶]. This was added to the rate of live births to obtain the average proportion of births both live and still (86.8%). We assumed that those who miscarry between 13 and 22 weeks face health and economic consequences similar to women who suffer induced abortion. We divided women who give birth into those who give birth at home and those who give birth in health facilities. Data from Uganda suggest that 39.3% of women deliver in health facilities [¹³]. In a recent study in Ugandan healthcare facilities, of the 194,029 deliveries, there was a reported 1,302 deaths for an in-hospital mortality rate among women who deliver in hospital of 0.007% [³⁷]. We assumed that the community mortality rate was at least double that at baseline.

We estimated the average cost of each outcome in the decision tree (Figure 1). The overall average cost of induced abortion is the sum of these average costs weighted by their probability of occurrence as shown in Table 1.

The cost of induced abortion was considered to include the following cost categories: 1) direct medical costs, 2) direct non-medical costs, and 3) indirect (productivity) costs. Direct medical costs included personnel, medical supplies, drugs, radiology tests, laboratory tests, and patient out-of-pocket costs. Direct non-medical costs included recurrent expenditures (such as utility bills) and capital expenditures (such as expenditures on hospital infrastructure), patient transportation, and patient upkeep while seeking healthcare. Indirect costs included lost productivity while seeking abortions and getting treatment for complications as well as productivity losses from abortion morbidity while convalescing and premature abortion-related maternal mortality. The total healthcare cost is the sum of the direct medical and direct non-medical costs.

In a separate classification, the costs of induced abortion were also considered to include patient/family costs and government costs. Patient/family costs included the costs of procuring abortions, out-of-pocket costs, transportation, and upkeep while procuring abortions and seeking treatment for complications, and self-medication. Government costs included the costs of treating abortion complications and pregnancy-related costs when abortions fail, but excluded the healthcare costs associated with the procurement of abortions which are illegal in Uganda and are not provided by the national healthcare system.

The societal cost estimate is the sum of all the different kinds of costs i.e. direct medical + direct non-medical + indirect/productivity costs or patient/family costs + government costs.

The cost to women of abortion services by provider were obtained from a survey of health workers (see Table 2) [²⁸].

A primary chart abstraction study was performed to estimate the resource use and costs for treatment of induced abortion complications in the hospital setting. In the study, which was performed at Mbarara Hospital in Uganda, a simple random sample of 200 charts was obtained from among the patients treated for abortion complications between January 2006 and December 2008. Data on health resource use--drugs, laboratory tests, radiological tests, blood transfusions, and disposable supplies--were abstracted and used to calculate the types and amounts of resources, which were multiplied by the unit costs obtained from the price catalogue of Uganda's Joint Medical Stores [³⁸]. Data on the unit costs of laboratory tests were obtained from a study performed in a Ugandan hospital [³⁹]. Data on the cost of radiology tests were obtained by surveying providers in Uganda's capital Kampala. Data on the cost of a single unit of transfused blood were not available for Uganda and were obtained from a study in Malawi which is similar to Uganda [⁴⁰].

The costs of healthcare personnel were based on a study in Uganda in which the personnel costs of treating abortion complications were estimated for public hospitals and missionary hospitals [²⁶]. The unit costs of pregnancy-related care were obtained from the same study and included antenatal care as well as normal and cesarean birth [²⁶]. These costs were adjusted for the proportion of women who attend at least 1 antenatal care visit which is 94% [⁴¹], the rate of cesarean birth which is 15.7% [⁴²], the prevalence of common complications like post-partum hemorrhage (0.84-19.8%) [⁴³] and eclampsia (0.53%) [⁴⁴].

The overhead and recurrent (hotel) costs of out-patient and hospital treatment of abortion complications were estimated from the World Health Organization Choosing Interventions that are Cost-Effective (WHO-CHOICE) database for Uganda [⁴⁵]. Transportation and upkeep costs for patients and caregivers were estimated using data from a prospective study of women treated for post-abortion complications at Mbarara University in Uganda. This study, which is ongoing, specifically asked women how much they spent to seek healthcare services and on upkeep while they sought services.

Productivity losses due to morbidity were estimated for both patients and caregivers using data from the prospective study by summing lost time spent in transit to hospitals (for patients and caregivers), seeking care, convalescing, and admitted to hospital (for patients and caregivers), and multiplying by wages. Wage data were obtained for formally-employed women in the same prospective study. The wage of the proportion of women who were unemployed (subsistence farmers) was valued at Uganda's gross domestic product per capita at the official exchange rate which was $474 in 2009 [²].

Productivity losses due to mortality were estimated using the human capital approach [⁴⁶] valuing lost productivity based on GDP per capita for wage and the life expectancy for Ugandan women at age 28, the average age of women receiving treatment for induced abortion complications, obtained from World Health Organization life tables for Ugandan women [⁴⁷]. Future costs were discounted at 3% per year.

The unit costs used in the analysis are summarized in Table 2.

All costs were converted into United States dollars ($US) using the Bank of Uganda official exchange rate on 1st June 2010 [⁴⁸] and were adjusted to the year 2010 using Uganda's Consumer Price Index for health [⁴⁹]. To take into account the potentially large amount of uncertainty in many of the parameter estimates, distributions were defined for each uncertain parameter estimate using the mean and the standard error estimated based on the assumption that all the ranges represented a 95% confidence interval (equal to four times the standard error) [⁵⁰]. Beta distributions were used for probabilities and normal distributions for costs. The model was run 10,000 times and on each occasion, a new set of estimates was randomly selected according to their distribution using Monte Carlo simulation. This provided an outcome distribution of the cost of an average case of induced abortion and allowed the reporting of a mean and a 95% credibility range (95% CRs) around the estimate. Univariate uncertainty analysis was also performed to determine which variables had the greatest influence on costs. The uncertainty analyses were performed using TreeAge Pro.

The average costs of induced abortion are shown in Table 3. The average societal cost per induced abortion (95% credibility range) was $177 ($140-$223). The average direct medical cost was $65 ($49-$86) and the average direct non-medical cost was $19 ($16-$23). The average indirect (productivity) cost was $92 ($57-$139). Patients incurred an average of $62 ($46-$183), 73% of the healthcare costs of induced abortion while government incurred an average of $14 ($10-$20), 17% of the healthcare costs of induced abortion.

The annual incidence of induced abortion in Uganda is 362,000 cases. Therefore the national annual expenditure on induced abortion is projected to be $23.6 million in direct medical costs, $7.0 million in direct non-medical costs, $33.5 million in indirect/productivity costs, $5.1 million in costs to the government, $22.3 million in costs to patients, and $64.2 million in societal costs.

Univariate sensitivity analysis (Figure 2) showed that the societal cost of an average induced abortion was most sensitive to the uncertainty associated with the probability of in-hospital abortion-related mortality, the probability of hospitalization for abortion complications, access to health services for abortion complications, and community abortion-related mortality.

*Equivalent to GDP per capita at the real exchange rate

^$ Costs incurred by patients to procure inputs such as drugs and gloves that may be out of stock at a health facility

SD - Standard Deviation; CR - Credibility Range