A comparative study of cost of care and duration of management for first-trimester abortion with manual vacuum aspiration (MVA) and sharp curettage.

OBJECTIVE: This study compared the hospital charges, duration of in-hospital procedures, clinical course and complications between manual vacuum aspiration (MVA) and sharp curettage. MATERIALS AND METHODS: A prospective observational study was conducted during the May 2007-April 2008 period in Songklanagarind Hospital, Thailand. Forty cases of pregnancy ≤9 weeks of gestation, with conditions of an incomplete abortion, a blighted ovum or missed abortion were treated with either MVA or sharp curettage. Both groups were compared in terms of demographic and obstetric data, hospitalization cost, clinical course and complications. RESULTS: The obstetric data of both groups showed that the median parity was two, with a median gestation age of 8 weeks. The median total hospital expenditure was 54.67 USD for patients using the MVA technique and 153.97 USD for the sharp curettage group (p < 0.01). The median duration of in-hospital care in the MVA group was significantly less than that of the sharp curettage group, 4 versus 20 h, respectively (p < 0.01). 90 % of patients in the MVA group had only one visit compared with 72.5 % in the sharp curettage group (p = 0.04). No complications needing further curettage or treatment in either group were noted. CONCLUSION: The use of MVA in the management of a first-trimester abortion is practical, safe, cheap and time-saving.

Medical versus surgical abortion methods for pregnancy in China: a cost-minimization analysis.

BACKGROUND: Both medical and surgical abortions are popular in developing countries. However, the monetary costs of these two methods have not been compared. METHODS: 430 women seeking abortions were recruited in 2008. Either a medical or surgical method was used for the abortion. We adopted the perspective of a third-party payer. Cost-minimization analysis was used based on all charges for the overall procedures in an out-patient clinic in Guangzhou, China. RESULTS: 219 subjects (51%) chose a medical method (mifepristone and misoprostol), whereas 211 subjects (49%) chose a surgical method. The efficacy in the surgical group was significantly higher than in the medical group (100 vs. 90%, p < 0.001). Surgical abortion incurred much more costs than medical abortion on average after initial treatment. When the subsequent costs were accumulated within the 2-week follow-up, the mean total cost in the medical group increased significantly due to failure of abortion and persistent bleeding. Patients undergoing medical abortion eventually incurred equivalent expenses compared to patients undergoing surgical abortion (p = 0.42). CONCLUSIONS: There was no difference in the mean final costs between the two abortion methods. Complications of persistent bleeding and failure to abort (requiring surgical intervention) in the medical treatment group increased the final mean total cost substantially.

Manual vacuum aspiration: a safe and cost-effective substitute of electric vacuum aspiration for the surgical management of early pregnancy loss.

OBJECTIVE: To compare the efficacy, safety and cost-effectiveness of Manual vacuum aspiration (MVA) with Electrical vacuum aspiration (EVA) in the management of first trimester pregnancy loss. METHODS: A single-centre randomized controlled trial (RCT) was conducted at Maternal and Child Health Centre (MCHC), Unit-I, Pakistan Institute of Medical Sciences (PIMS), Islamabad from April 2007-Dec 2008. A total of 176 cases with early pregnancy loss at < 12 weeks gestation, with a diagnosis of anembryonic pregnancy, incomplete, missed or septic induced abortion and molar pregnancy were randomly allocated to either MVA or EVA in the operation theatre. RESULTS: A total of 176 women were included out of which 70 underwent EVA and 106 had MVA. Baseline characteristics were similar in the two groups except significantly higher gestational age and gestational sac diameter in MVA group. Majority of EVA were performed under general anaesthesia (95.7%) while majority of MVA were performed under paracervical block (60.3%). Complete evacuation was achieved in 89.6% with MVA vs 91.4% with EVA (p=0.691). MVA was superior in terms of significantly less blood loss (62.08 +/- 32.19 vs 75.71 +/- 35.53; p=0.008), shorter hospital stay (12.26 hours +/- 6.97 vs 19.54 hours +/- 7.95; p=0.000) and less hospital cost (Rs 1419.5 +/- 1337.620 vs Rs. 3222.5 +/- 1816.02; p=0.000). Post-operative pain assessment by visual analogue score (VAS) at 0 and 6 hours showed no significant difference (p=0.845 and p=0.157 respectively). The only complication was uterine perforation in 2 (2.4%) cases both belonging to EVA. CONCLUSION: MVA is a safe and effective alternative of conventional EVA. It is superior to EVA in terms of reduced cost and need for general anaesthesia and is thus useful at low resource setting with scarcity of electricity and general anaesthesia.

Cost-effectiveness analysis of unsafe abortion and alternative first-trimester pregnancy termination strategies in Nigeria and Ghana.

To explore the policy implications of increasing access to safe abortion in Nigeria and Ghana, we developed a computer-based decision analytic model which simulates induced abortion and its potential complications in a cohort of women, and comparatively assessed the cost-effectiveness of unsafe abortion and three first-trimester abortion modalities: hospital-based dilatation and curettage, hospital- and clinic-based manual vacuum aspiration (MVA), and medical abortion using misoprostol (MA). Assuming all modalities are equally available, clinic-based MVA is the most cost-effective option in Nigeria. If clinic-based MVA is not available, MA is the next best strategy. Conversely, in Ghana, MA is the most cost-effective strategy, followed by clinic-based MVA if MA is not available. From a real world policy perspective, increasing access to safe abortion in favor over unsafe abortion is the single most important factor in saving lives and societal costs, and is more influential than the actual choice of safe abortion modality.

Cost-effectiveness analysis of alternative first-trimester pregnancy termination strategies in Mexico City.

OBJECTIVE: To assess the comparative health and economic outcomes associated with three alternative first-trimester abortion techniques in Mexico City and to examine the policy implications of increasing access to safe abortion modalities within a restrictive setting. DESIGN: Cost-effectiveness analysis. SETTING: Mexico City. POPULATION: Reproductive-aged women with unintended pregnancy seeking first-trimester abortion. METHODS: Synthesising the best available data, a computer-based model simulates induced abortion and its potential complications and is used to assess the cost-effectiveness of alternative safe modalities for first-trimester pregnancy termination: (1) hospital-based dilatation and curettage (D&C), (2) hospital-based manual vacuum aspiration (MVA), (3) clinic-based MVA and (4) medical abortion using vaginal misoprostol. MAIN OUTCOME MEASURES: Number of complications, lifetime costs, life expectancy, quality-adjusted life expectancy. RESULTS: In comparison to the magnitude of health gains associated with all safe abortion modalities, the relative differences between strategies were more pronounced in terms of their economic costs. Assuming all options were equally available, clinic-based MVA was the least costly and most effective. Medical abortion with misoprostol provided comparable benefits to D&C, but cost substantially less. Enhanced access to safe abortion was always more influential than shifting between safe abortion modalities. CONCLUSIONS: This study demonstrates that the provision of safe abortion is cost-effective and will result in reduced complications, decreased mortality and substantial cost savings compared with unsafe abortion. In Mexico City, shifting from a practice of hospital-based D&C to clinic-based MVA and enhancing access to medical abortion will have the best chance to minimise abortion-related morbidity and mortality.

The costs and cost effectiveness of providing first-trimester, medical and surgical safe abortion services in KwaZulu-Natal Province, South Africa.

BACKGROUND: Despite a liberal abortion law, access to safe abortion services in South Africa is challenging for many women. Medication abortion was introduced in 2013, but its reach remains limited. We aimed to estimate the costs and cost effectiveness of providing first-trimester medication abortion and manual vacuum aspiration (MVA) services to inform planning for first-trimester service provision in South Africa and similar settings. METHODS: We obtained data on service provision and outcomes from an operations research study where medication abortion was introduced alongside existing MVA services in public hospitals in KwaZulu-Natal province. Clinical data were collected through interviews with first-trimester abortion clients and summaries completed by nurses performing the procedures. In parallel, we performed micro-costing at three of the study hospitals. Using a model built in Excel, we estimated the average cost per medical and surgical procedure and determined the cost per complete abortion performed. Results are presented in 2015 US dollars. RESULTS: A total of 1,129 women were eligible for a first trimester abortion at the three study sites. The majority (886, 78.5%) were eligible to choose their abortion procedure; 94.1% (n = 834) chose medication abortion. The total average cost per medication abortion was $63.91 (52.32-75.51). The total average cost per MVA was higher at $69.60 (52.62-86.57); though the cost ranges for the two procedures overlapped. Given average costs, the cost per complete medication abortion was lower than the cost per complete MVA despite three (0.4%) medication abortion women being hospitalized and two (0.3%) having ongoing pregnancies at study exit. Personnel costs were the largest component of the total average cost of both abortion methods. CONCLUSION: This analysis supports the scale-up of medication abortion alongside existing MVA services in South Africa. Women can be offered a choice of methods, including medication abortion with MVA as a back-up, without increasing costs.

Early abortion in Ontario: options and costs.

OBJECTIVE: Early abortions have been predominantly surgical for many years, but medical options with comparable efficacy and safety are now available. This study compares the costs of two medical options and two surgical options. METHODS: We used a clinical model to compare the costs in Ontario of four options for early abortion: medical abortion using either mifepristone or methotrexate, and surgical abortion by vacuum aspiration in either a hospital or a free-standing clinic. The cost analysis was conducted from the perspectives of society, the health care system, and the patient. RESULTS: From all perspectives, total costs were highest for hospital surgical abortion, followed by surgical abortion in a clinic. From the patient's perspective, total costs were higher for surgical abortion but direct costs (mainly for medications) were higher for medical abortion. The total cost of mifepristone and methotrexate abortion was equal if the price of mifepristone (200 mg) was $59.52. The model was robust but was sensitive to the price of mifepristone. CONCLUSION: Early medical abortion costs less than early surgical abortion from the societal and health care system perspectives but more than surgical abortion from the patient's perspective. Surgical abortion costs more in hospitals than in free-standing clinics from the societal and health care system perspectives, but the costs are the same in both settings from the patient's perspective. No method for early abortion can be identified as best, and patients should be free to choose the option they prefer.

Management strategies for abnormal early pregnancy: a cost-effectiveness analysis.

OBJECTIVE: To assess the potential effectiveness and costs of 4 commonly used strategies to manage abnormal early pregnancies (AEPs). STUDY DESIGN: A decision analysis model was constructed to compare 4 strategies to manage AEPs: (1) observation, (2) medical management, (3) manual vacuum aspiration (MVA), and (4) dilation and curettage (D&C). RESULTS: MVA was the most cost-effective strategy, at dollar 793 per cure, for a total cost of dollar 377 million per 500,000 women and a cure rate of 95%. D&C was more effective than MVA, with a cure rate of 99%, but was more expensive (dollar 2,333 per cure, for a total cost of dollar 1.2 billion). D&C cured 20,000 more patients than MVA; however, at a substantial cost of dollar 38,925 per additional cure. With other estimates at baseline, MVA remained more cost-effective than D&C until the efficacy of MVA was < 82% or the cost of D&C was < dollar 240. CONCLUSION: MVA is the most cost-effective strategy for managing AEP and would be appropriate in settings in which resources are limited. D&C remains a reasonable strategy; however, one must spend dollar 38,925 per additional cure. In the United States, MVA would save dollar 779 million per year relative to D&C.

Is pathology examination useful after early surgical abortion?

OBJECTIVE: To study if the pathologist's examination of surgical abortion tissue offers more information than immediate fresh tissue examination by the surgeon. Immediate examination of the fresh tissue aspirate after surgical abortion helps reduce the risk of failed abortion and other complications. Regulations in some states also require a pathologist to analyze abortion specimens at added cost to providers. We conducted this study to evaluate the incremental clinical benefit of pathology examination after surgical abortion at less than 6 weeks' gestation. METHODS: As part of a prospective case series of women who had early surgical abortions at the Planned Parenthood League of Massachusetts during a 32-month period, we collected data on clinical outcomes and the results of postoperative tissue examinations. Using outcomes verified by in-person follow-up as the "gold standard," we calculated the validity of the tissue examinations by the surgeons and the outside pathologists. RESULTS: A total of 676 women had documented outcomes and complete tissue examination data. The sensitivity (ability of the examiner to detect an outcome other than complete abortion) was 57% (95% confidence interval [CI] 35, 76) for the surgeons' tissue inspections and 22% (95% CI 8, 44) for the pathologists' examinations. The predictive value of a positive (abnormal) tissue screen was 14% (95% CI 8, 24) and 7% (95% CI 3, 17) for the surgeons and pathologists, respectively. CONCLUSION: Routine pathology examination of the tissue aspirate after early surgical abortion confers no incremental clinical benefit. Although the surgeons' tissue inspections predicted abnormal outcomes poorly, the pathologists did no better. Our results challenge the rationale for state regulations requiring pathologic analysis of all surgical abortion specimens.

Treating incomplete abortion in El Salvador: cost savings with manual vacuum aspiration.

When manual vacuum aspiration (MVA) was introduced to treat incomplete abortion at a regional training hospital in El Salvador, this study evaluated the impact of replacing sharp curettage with MVA. Hospital cost, length of hospital stay, complication rates and postabortion contraceptive acceptance were compared in a prospective, nonrandomized, controlled study of 154 women assigned to either traditional sharp curettage services or MVA services plus contraceptive counseling. Assignment depended on availability of trained providers. Compared to sharp curettage, use of MVA and associated changes in protocol led to a significant cost savings of 13% and shorter hospital stay of 28%. Dedicated family-planning counseling resulted in a threefold higher rate of contraceptive acceptance. Although the difference in cost was significant, much higher savings could be realized if minimal postoperative stays were implemented for both procedures. Barriers to early discharge include patient expectations, physician attitudes and training and hospital systems administration.

Cost savings of manual vacuum aspiration for endometrial sampling in El Salvador.

Despite the existence of less costly and less invasive techniques to evaluate abnormal uterine bleeding, sharp curettage continues to be the most common form of endometrial sampling in the less developed world. Because manual vacuum aspiration (MVA) equipment is often associated with abortion care in countries where abortion is illegal, many practitioners have been slow to incorporate its use for other gynecological conditions. In this study, MVA was introduced in a large teaching hospital in El Salvador as an alternative for patients with abnormal uterine bleeding. Hospital cost, length of stay and complication rates were compared in a prospective, nonrandomized controlled study of 163 patients assigned to either traditional sharp curettage or MVA services. Patients were assigned to each group depending on the availability of trained providers. Methodologies for cost-savings analysis were modified to obtain more precise cost estimates. Use of MVA was associated with a significant cost savings of 11% and a hospital stay that was 27% shorter as compared to sharp curettage. Cost savings could be much higher if MVA was institutionalized as an ambulatory procedure with minimal or no preoperative evaluation and postoperative stay.

A time and cost analysis of the management of incomplete abortion with manual vacuum aspiration.

OBJECTIVES: Traditionally, management of incomplete abortion involves use of D&C or suction curettage in the operating room. Such management is costly and time-consuming. In order to potentially save time and money, we studied the use of manual vacuum aspiration curettage (MVAC) for the management of this problem. METHODS: Data on hospital charges and times (e.g. waiting time, procedure time) were obtained for all cases of incomplete abortion presenting to hospital between January 1990 and July 1992. Between January 1990 and July 1991, all cases were managed traditionally. After July 1991, all cases were managed using MVAC in either the emergency room or the labor ward. RESULTS: Compared to the use of electrical suction equipment in the operating theatre, MVAC procedures resulted in significant savings in terms of both waiting times and costs. Waiting time was reduced by 52% and procedure time was reduced from a mean of 33 min to 19 min (P < 0.01). Total hospital costs were reduced by 41% (P < 0.01). CONCLUSIONS: Use of manual vacuum aspiration curettage in the management of incomplete abortion can reduce hospital costs and save time for both patients and clinicians.

Cost-effectiveness of managing abortions: manual vacuum aspiration (MVA) compared to evacuation by curettage in Tanzania.

Cost effectiveness of managing 107 incomplete abortions by manual vacuum aspiration (MVA) is compared with management of 92 incomplete abortions by evacuation by curettage (E by C) at Muhimbili Medical Centre (September-November 1992). Pre-evacuation waiting times, duration of procedures and duration of hospital stay were less for MVA as compared to E by C. The total pre-evacuation waiting time, the durations of the procedure and hospital stay were 15.59 days (55.11%), 10.96 (46.41%) hours and 21.23 (40.53%) days less for MVA as compared to E by C. The direct costs revealed a cost differential of MVA over E by C of Tshs 776.9 (US$2.6). MVA is more cost effective than contemporary E by C and its introduction on a wider scale in our health care delivery system is recommended.

[Use of manual vacuum aspiration in reducing cost and duration of hospitalization due to incomplete abortion in an urban area of northeastern Brazil]. / Uso da aspiração manual a vácuo na redução do custo e duração de internamentos por aborto incompleto em fortaleza, CE, Brasil.

INTRODUCTION: In most developed countries vacuum aspiration has been shown to be safer and less costly than sharp curettage (SC) for uterine evacuation. In many of the developing countries, including Brazil, sharp curettage (SC) is the most commonly used technique for treating cases of incomplete abortion admitted to hospital. The procedure often involves light to heavy sedation for pain control and an overnight hospital stay for patient recuperation and monitoring. Two hypotheses are examined: the first, that the use of manual vacuum aspiration (MVA)--a variation of the vacuum aspiration, would be less costly than SC for the treatment of cases of incomplete abortion admitted to hospital; and the second, that the treatment of incomplete abortion with MVA would substantially reduce the length of hospital stay. METHODOLOGY: Thirty women with diagnosis of first trimester incomplete abortion were randomly allocated to the SC or MVA group. Rapid-assessment data collection techniques were used to identify factors that contributed to cost reduction and hospital stay. RESULTS AND CONCLUSION: The results of the study show that, overall, patients treated for incomplete abortion with MVA spent 77% less time in the hospital and consumed 41% fewer resources than similarly diagnosed patients treated with SC. Recommendations are made as to the need of certain changes in patient management. Particularly necessary is information regarding cultural perception and concepts of abortion treatment.

Manual vacuum aspirator: a safe and effective tool for decentralization of post miscarriage care.

OBJECTIVE: To compare the efficacy and safety of Manual Vacuum Aspiration (MVA) performed as outpatient versus inpatient procedure in terms of success rate, blood loss, hospital stay and procedure related complications. STUDY DESIGN: A quasi-experimental study. PLACE AND DURATION OF STUDY: Maternal and Child Health Centre (MCHC), Unit-I, Pakistan Institute of Medical Sciences (PIMS), Islamabad, from December 2009 to December 2010. METHODOLOGY: Cases with early pregnancy failure (incomplete, missed and an embryonic) at gestational age less than 12 weeks were allocated to MVA as outpatient or elective procedure performed in the operation theatre. Studied variables were noted as above. RESULTS: A total of 177 women were eligible for study, out of whom 78 underwent MVA as outpatient procedure and 99 as indoor procedure. The baseline characteristics were comparable in both groups except significantly high multipara in the indoor group. Complete evacuation was achieved in 96.1% in outpatient vs. 79.7% in indoor cases (p=0.001). Outpatient group had a shorter hospital stay (median 3 hours, IQR-1 vs. 10 hours, IQR-4; p < 0.001), though the median hospital cost was less but statistically insignificant (Rs. 800, IQR-25 vs. 735, IQR-1265; p=0.728). Blood loss was comparable in both groups (median 60 ml, IQR-20 vs. 60 ml-IQR-30; p=0.350). There were two uterine perforations noted in the inpatient group (2.02%) vs. none in outpatient setting. CONCLUSION: Outpatient based manual vacuum aspiration is a safe and effective tool for management of early pregnancy loss. A decentralized approach proved useful in reducing hospital stay.

Surgical abortion prior to 7 weeks of gestation.

The following guidelines reflect a collation of the evaluable medical literature about surgical abortion prior to 7 weeks of gestation. Early surgical abortion carries lower risks of morbidity and mortality than procedures performed later in gestation. Surgical abortion is safe, practicable and successful as early as 3 weeks from the start of last menses (no gestational sac visible on vaginal ultrasound) provided that (a) routine sensitive pregnancy testing verifies pregnancy, (b) the tissue aspirate is immediately examined for the presence of a gestational sac plus villi and (c) a protocol to identify ectopic pregnancy expeditiously--including calculation of readily obtained serial serum quantitative human chorionic gonadotropin titers when clinically appropriate--is in place and strictly adhered to. Manual and electric vacuum aspiration methods for early abortion demonstrate comparable efficacy, safety and acceptability. Current data are inadequate to determine if any of the following techniques substantially improve procedure success or safety: use of rigid versus flexible cannulae, light metallic curettage following uterine aspiration, uterine sounding or routine use of intraoperative ultrasound.

A cost-effectiveness analysis of surgical versus medical management of early pregnancy loss.

OBJECTIVE: To determine the cost-effectiveness of medical and surgical management of early pregnancy loss. DESIGN: Analyses of cost, effectiveness, and incremental cost-effectiveness ratios and utilities of a multicenter trial with 652 women with first-trimester pregnancy failure randomized to medical or surgical management. SETTING: Analysis of data from a multicenter trial. PATIENT(S): Secondary analysis of a multicenter trial. INTERVENTION(S): Cost-effectiveness analysis. MAIN OUTCOME MEASURE(S): Cost and effectiveness of competing treatment strategies. RESULT(S): Cost analysis of treatment demonstrates an increased cost of US$336 for 13% increased efficacy of surgical management. This analysis was sensitive to the probability of an extra office visit, the cost of the visit, and the probability of success. When the surgical arm is divided into outpatient manual vacuum aspiration (MVA) versus inpatient electric vacuum aspiration (EVA), there is an increased cost of $745 for EVA but a decreased cost of $202 for MVA compared with medical management. In general, MVA was found to be more cost-effective than medical management. For treatment of incomplete or inevitable abortion, medical management was found to be less costly and more efficacious. Utilities studies demonstrated that a patient would need to prefer surgery 14% less than medication for its treatment efficacy to be outweighed by the desire to avoid surgery. CONCLUSION(S): Surgical or medical management of early pregnancy failure can be cost effective, depending on the circumstances. Surgery is cost effective and more efficacious when performed in an outpatient setting. For incomplete or inevitable abortion, medical management is cost effective and more efficacious.

VFDs can cut costs and improve control.

Phil Giles of Becker Pumps Australia examines the use of variable frequency drives for medical suction plant, and explains the many potential benefits--both practical and economic. The paper on which this article is based was presented at the Institute of Hospital Engineering Australia's (IHEA) 60th National Conference in 2009.

Diagnostic dilation and curettage: a reappraisal.

Diagnostic dilation and curettage (D & C) is widely considered to be the method of choice for obtaining samples of endometrium for histologic examination, although the scientific basis for this assumption is elusive. Despite extensive use of D & C, the tissue yield and diagnostic accuracy of this technique have not been adequately evaluated. More is known about these features of a newer diagnostic procedure, Vabra aspiration (VA). VA also appears to be safer, less expensive, and more convenient than D & C. Until the alleged benefits of diagnostic D & C can be shown to outweigh its risks and costs (approaching one billion dollars per year in the United States alone), D & C probably should not be the primary procedure used for obtaining most samples of endometrium.