Understanding the financial burden of incomplete abortion: An analysis of the out-of-pocket expenditure on postabortion care in eight public-sector health care facilities in Dakar, Senegal.

Timely access to treatment is essential for women when they experience abortion complications. Out-of-pocket (OOP) expenditure is a known barrier to health care access. In 2018, we assessed the financial burden of accessing postabortion care (PAC) borne by women in Dakar, Senegal, where studies estimate that half of poor women with complications obtain PAC. We interviewed 729 women following discharge from PAC. Women reported expenditures on transportation, admission, treatment, family planning, hospitalisation, complementary tests, prescriptions, other medicines and materials. We compare women's OOP on PAC by expenditure category, type of treatment and facility type, and use multiple generalised linear regression analysis to explain variation in overall OOP and forecast it under alternate scenarios. The average OOP was USD $93.84. At health centres it was $65.47 and at hospitals it was $120.47. The average cost of PAC using dilation and curettage was $112.37, manual vacuum aspiration was $99.84, and misoprostol $61.80. Overall OOP on PAC amounts, on average, to 15% of the average monthly salary for women living in Dakar. Strategies that emphasise timely access to misoprostol for treating complications in primary care settings will address the contribution of OOP costs to Senegal's appreciable unmet need for PAC among the poor.

Prophylactic antibiotics for preventing genital tract infection in women undergoing surgical procedures for incomplete abortion: a systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: Findings about the effect of prophylactic antibiotics in preventing genital tract infection (GTI) associated with surgical procedures used for incomplete abortions are conflicting. Some reported a decrease in infection associated with the use of antibiotic prophylaxis, whereas others found no significant reduction in GTI. OBJECTIVE: To synthesise systematically the evidence on the effect of prophylactic antibiotics compared with placebo in women undergoing surgical procedures for incomplete abortion. SEARCH STRATEGY: In February 2020, PubMed, Embase and Cochrane Central for Register of Controlled Trials were searched for relevant published randomised controlled trials. SELECTION CRITERIA: Randomised controlled trials reporting GTI following surgical procedures for incomplete abortion and comparing antibiotic prophylaxis with placebo. DATA COLLECTION AND ANALYSIS: Meta-analysis using inverse variance heterogeneity model included subgroup and sensitivity analyses determined a priori were conducted. The quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). MAIN RESULTS: A total of 16 178 women who participated in 24 eligible randomised controlled trials published between 1975 and 2019 were included. Pooled estimates showed the risk of GTI following surgical procedures after incomplete abortion was significantly lower among those who had prophylactic antibiotics (relative risk [RR] = 0.72; 95% CI 0.58-0.90; I2  = 49%). There was no significant effect of antibiotics in women in low- and middle-income countries (three studies, 3579 participants, RR = 0.90; 95% CI 0.50-1.62; I2  = 63%), but it was clinically and statistically significant among women high-income countries (21 studies, 12 599 participants, RR = 0.67; 95% CI 0.53-0.84; I2  = 44%), with a strong level of evidence as assessed by GRADE. CONCLUSION: This study provides evidence that antibiotic prophylaxis is beneficial in reducing post-abortion GTI among women undergoing surgical procedures for incomplete abortion. More studies are needed from low- and middle-income countries. TWEETABLE ABSTRACT: Prophylactic antibiotics after incomplete abortion are effective in reducing GTI. More studies are needed from low- and middle-income countries.

Mifepristone Combination Therapy Compared With Misoprostol Monotherapy for the Management of Miscarriage: A Cost-Effectiveness Analysis.

OBJECTIVE: To assess whether mifepristone pretreatment adversely affects the cost of medical management of miscarriage. METHODS: Decision tree analyses were constructed, and Monte Carlo simulations were run comparing costs of combination therapy (mifepristone and misoprostol) with monotherapy (misoprostol alone) for medical management of miscarriage in multiple scenarios weighing clinical practice, patient income, and surgical evacuation modalities for failed medical management. Rates of completed medical evacuation for each were obtained from a recent randomized controlled trial. RESULTS: In every scenario, combination therapy offered a significant cost advantage over monotherapy. Using a Monte Carlo analysis, cost differences favoring combination therapy ranged from 6.3% to 19.5% in patients making federal minimum wage. The cost savings associated with combination therapy were greatest in scenarios using a staged approach to misoprostol administration and in scenarios using in-operating room dilation and curettage as the only modality for uterine evacuation, a savings of $190.20 (99% CI 189.35-191.07) and $217.85 (99% CI 217.19-218.50) per patient in a low-income wage group, respectively. A smaller difference was seen in scenarios using in-office manual vacuum aspiration to complete medical management failures. As patients' wages increased, the difference in cost between combination therapy and monotherapy increased. CONCLUSION: Mifepristone combined with misoprostol is, overall, more cost effective than monotherapy, and therefore cost should not be a deterrent to its adoption in the management of miscarriage.

Availability, accessibility and utilization of post-abortion care in Sub-Saharan Africa: A systematic review.

At the 1994 ICPD, sub-Saharan African (SSA) states pledged, inter alia, to guarantee quality post-abortion care (PAC) services. We synthesized existing research on PAC services provision, utilization and access in SSA since the 1994 ICPD. Generally, evidence on PAC is only available in a few countries in the sub-region. The available evidence however suggests that PAC constitutes a significant financial burden on public health systems in SSA; that accessibility, utilization and availability of PAC services have expanded during the period; and that worrying inequities characterize PAC services. Manual and electrical vacuum aspiration and medication abortion drugs are increasingly common PAC methods in SSA, but poor-quality treatment methods persist in many contexts. Complex socio-economic, infrastructural, cultural and political factors mediate the availability, accessibility and utilization of PAC services in SSA. Interventions that have been implemented to improve different aspects of PAC in the sub-region have had variable levels of success. Underexplored themes in the existing literature include the individual and household level costs of PAC; the quality of PAC services; the provision of non-abortion reproductive health services in the context of PAC; and health care provider-community partnerships.

Mifepristone and misoprostol versus misoprostol alone for uterine evacuation after early pregnancy failure: study protocol for a randomized double blinded placebo-controlled comparison (Triple M Trial).

BACKGROUND: Early pregnancy failure (EPF) is a common complication of pregnancy. If women do not abort spontaneously, they will undergo medical or surgical treatment in order to remove the products of conception from the uterus. Curettage, although highly effective, is associated with a risk of complications; medical treatment with misoprostol is a safe and less expensive alternative. Unfortunately, after 1 week of expectant management in case of EPF, medical treatment with misoprostol has a complete evacuation rate of approximately 50%. Misoprostol treatment results may be improved by pre-treatment with mifepristone; its effectiveness has already been proven for other indications of pregnancy termination. This study will test the hypothesis that, in EPF, the sequential combination of mifepristone with misoprostol is superior to the use of misoprostol alone in terms of complete evacuation (primary outcome), patient satisfaction, complications, side effects and costs (secondary outcomes). METHODS: The trial will be performed multi-centred, prospectively, two-armed, randomised, double-blinded and placebo-controlled. Women with confirmed EPF by ultrasonography (6-14 weeks), managed expectantly for at least 1 week, can be included and randomised to pre-treatment with oral mifepristone (600 mg) or oral placebo (identical in appearance). Randomisation will take place after receiving written consent to participate. In both arms pre-treatment will be followed by oral misoprostol, which will start 36-48 h later consisting of two doses 400 µg (4 hrs apart), repeated after 24 h if no tissue is lost. Four hundred sixty-four women will be randomised in a 1:1 ratio, stratified by centre. Ultrasonography 2 weeks after treatment will determine short term treatment effect. When the gestational sac is expulsed, expectant management is advised until 6 weeks after treatment when the definitive primary endpoint, complete or incomplete evacuation, will be determined. A sonographic endometrial thickness < 15 mm using only the allocated therapy by randomisation is considered as successful treatment. Secondary outcome measures (patient satisfaction, complications, side effects and costs) will be registered using a case report form, patient diary and validated questionnaires (Short Form 36, EuroQol-VAS, Client Satisfaction Questionnaire, iMTA Productivity Cost Questionnaire). DISCUSSION: This trial will answer the question if, in case of EPF, after at least 1 week of expectant management, sequential treatment with mifepristone and misoprostol is more effective than misoprostol alone to achieve complete evacuation of the products of conception. TRIAL REGISTRATION: Clinicaltrials.gov (d.d. 02-07-2017): NCT03212352. Trialregister.nl (d.d. 03-07-2017): NTR6550. EudraCT number (d.d. 07-08-2017): 2017-002694-19. File number Commisie Mensgebonden Onderzoek (d.d. 07-08-2017): NL 62449.091.17.

The Unit and Scale-Up Cost of Postabortion Care in Tanzania.

INTRODUCTION: Based on research conducted in 2017, we estimated the cost to the Tanzanian health care system of providing postabortion care (PAC). PAC is an integrated service package that addresses the curative and preventive needs of women experiencing complications from abortion. PAC services include treating complications of miscarriage and incomplete abortion, providing voluntary family planning counseling and services, and engaging the community to reduce future unintended pregnancies and repeat abortions. METHODS: Thirty-one public and private health facilities, representing 3 levels of health care, were selected for data collection from key care providers and administrators in 3 regions. We gathered data on the direct costs of PAC startup (i.e., training and capital costs), as well as the recurrent costs of medicines, supplies, hospitalization, and personnel, and the indirect costs of PAC provision. We also gathered data to estimate PAC clients' out-of-pocket expenses. Estimates of the average cost per client (i.e., unit cost) were calculated for treatment of routine and severe abortion complications, treatment at different levels of health care, postabortion contraception, and various available treatment methods. RESULTS: We found that the unit cost of PAC training per provider was US$163.43. The total unit cost was $72.91. The unit recurrent cost of treating routine complications, which included 81% of the cases in our sample, was $36.23. The cost of treating incomplete abortion through manual vacuum aspiration was $22.63, while the cost of treatment with misoprostol was $18.74. The average cost of providing voluntary postabortion family planning was $11.56. We estimated an average client out-of-pocket expenditure on PAC of $22.96. CONCLUSION: We applied our unit cost estimates to those on PAC utilization and provision and unmet need for PAC that were derived from research conducted in Tanzania in 2013-2016, and we estimated an annual national cost of PAC of $4,170,476. We estimated the cost of providing PAC for all women who have abortion complications, including those who do not access PAC, at $10,426,299. Investing more resources in voluntary family planning and PAC treatment of routine complications at the primary level would likely reduce health system costs.

Cost-effectiveness of curettage vs. expectant management in women with an incomplete evacuation after misoprostol treatment for first-trimester miscarriage: a randomized controlled trial and cohort study.

INTRODUCTION: Curettage is more effective than expectant management in women with suspected incomplete evacuation after misoprostol treatment for first-trimester miscarriage. The cost-effectiveness of curettage vs. expectant management in this group is unknown. MATERIAL AND METHODS: From June 2012 until July 2014 we conducted a randomized controlled trial and parallel cohort study in the Netherlands, comparing curettage with expectant management in women with an incomplete evacuation of the uterus after misoprostol treatment for first-trimester miscarriage. Successful treatment was defined as a sonographic finding of an empty uterus 6 weeks after study entry, or an uneventful course. Cost-effectiveness and cost-utility analyses were performed. We included costs of healthcare utilization, informal care and lost productivity. Cost-effectiveness planes and cost-effectiveness acceptability curves were estimated using bootstrapping. RESULTS: We included 256 women from 27 hospitals; 95 curettage and 161 expectant management. Treatment was successful in 96% of the women treated with curettage vs. 83% of the women after expectant management (mean difference 13%, 95% confidence interval 5-20). Mean costs were significantly higher in the curettage group (mean difference €1157; 95% C confidence interval €955-1388). The incremental cost-effectiveness ratio for curettage vs. expectant management was €8586 per successfully treated woman. The cost-effectiveness acceptability curve showed that at a willingness-to-pay of €18 200/extra successfully treated women, the probability that curettage is cost-effective is 95%. CONCLUSIONS: Curettage is not cost-effective compared with expectant management in women with an incomplete evacuation of the uterus after misoprostol treatment. This indicates that curettage in this group should be restrained.

Induced abortion.

Abortion is common. Data on abortion rates are inexact but can be used to explore trends. Globally, the estimated rate in the period 2010-2014 was 35 abortions per 1000 women (aged 15-44 years), five points less than the rate of 40 for the period 1990-1994. Abortion laws vary around the world but are generally more restrictive in developing countries. Restrictive laws do not necessarily deter women from seeking abortion but often lead to unsafe practice with significant mortality and morbidity. While a legal framework for abortion is a prerequisite for availability, many laws, which are not evidence based, restrict availability and delay access. Abortion should be available in the interests of public health and any legal framework should be as permissive as possible in order to promote access. In the absence of legal access, harm reduction strategies are needed to reduce abortion-related mortality and morbidity. Abortion can be performed surgically (in the first trimester, by manual or electric vacuum aspiration) or with medication: both are safe and effective. Cervical priming facilitates surgery and reduces the risk of incomplete abortion. Diagnosis of incomplete abortion should be made on clinical grounds, not by ultrasound. Septic abortion is a common cause of maternal death almost always following unsafe abortion and thus largely preventable. While routine follow-up after abortion is unnecessary, all women should be offered a contraceptive method immediately after the abortion. This, together with improved education and other interventions, may succeed in reducing unintended pregnancy.

Decentralizing postabortion care in Senegal with misoprostol for incomplete abortion.

OBJECTIVE: To expand access to postabortion care (PAC) services in Senegal by introducing misoprostol as a first-line treatment at the community level. METHODS: The present prospective study enrolled 481 women seeking treatment for incomplete abortion at 11 community health posts in Senegal between September 2011 and August 2012. Participants were given 400 µg of sublingual misoprostol and asked to return to the clinic 1 week later to confirm clinical status. At study completion, all women were asked to respond to a series of questions regarding their experience with this method. All care was provided by nurse midwives. RESULTS: All but three of the study women (99.4%; 474/477) had successful complete abortion after taking misoprostol. Almost all women were satisfied or very satisfied with the treatment (99.6%; 469/471), would select the method again if needed (98.9%; 465/470), and would recommend the method to a friend (99.8%; 468/469). CONCLUSION: The results provide further evidence that 400 µg of misoprostol is highly effective for first-line treatment of incomplete abortion. Furthermore, this regimen can be fully provided by nurse midwives, and can be easily and successfully introduced in community health settings where other methods of PAC may not previously have been available. Clinicaltrials.gov: NCT01939457.

Surgical versus expectant management in women with an incomplete evacuation of the uterus after treatment with misoprostol for miscarriage: the MisoREST trial.

BACKGROUND: Medical treatment with misoprostol is a non-invasive and inexpensive treatment option in first trimester miscarriage. However, about 30% of women treated with misoprostol have incomplete evacuation of the uterus. Despite being relatively asymptomatic in most cases, this finding often leads to additional surgical treatment (curettage). A comparison of effectiveness and cost-effectiveness of surgical management versus expectant management is lacking in women with incomplete miscarriage after misoprostol. METHODS/DESIGN: The proposed study is a multicentre randomized controlled trial that assesses the costs and effects of curettage versus expectant management in women with incomplete evacuation of the uterus after misoprostol treatment for first trimester miscarriage.Eligible women will be randomized, after informed consent, within 24 hours after identification of incomplete evacuation of the uterus by ultrasound scanning. Women are randomly allocated to surgical or expectant management. Curettage is performed within three days after randomization.Primary outcome is the sonographic finding of an empty uterus (maximal diameter of any contents of the uterine cavity < 10 millimeters) six weeks after study entry. Secondary outcomes are patients' quality of life, surgical outcome parameters, the type and number of re-interventions during the first three months and pregnancy rates and outcome 12 months after study entry. DISCUSSION: This trial will provide evidence for the (cost) effectiveness of surgical versus expectant management in women with incomplete evacuation of the uterus after misoprostol treatment for first trimester miscarriage. TRIAL REGISTRATION: Dutch Trial Register: NTR3110.

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.

Surgical management of early pregnancy failure: history, politics, and safe, cost-effective care.

Early pregnancy failure and induced abortion are often managed differently, even though safe uterine evacuation is the goal in both. Early pregnancy failure is commonly treated by curettage in operating room settings in anesthetized patients. Induced abortion is most commonly managed by office vacuum aspiration in awake or sedated patients. Medical evidence does not support routine operating room management of early pregnancy failure. This commentary reviews historical origins of these different care standards, explores political factors responsible for their perpetuation, and uses experience at University of Michigan to dramatize the ways in which history, politics, and biomedicine intersect to produce patient care. The University of Michigan initiated office uterine evacuations for early pregnancy failure treatment. Patients previously went to the operating room. These changes required faculty, staff, and resident education. Our efforts blurred the lines between spontaneous and induced abortion management, improved patient care and better utilized hospital resources.

Misoprostol for the treatment of early pregnancy failure.

Nearly 20% of all pregnancies end in early pregnancy failure, and surgical evacuation of retained products of conception is often used to manage this failure. Misoprostol is an inexpensive, stable analog of prostaglandin E(1), and is powerful at contracting the uterus. With intravaginal misoprostol, the peak plasma levels are lower, but the levels after 4 hours are higher, than after oral or sublingual administration. With oral misoprostol, the evacuation rates in early pregnancy varied from about 50% up to 96%. Similar variation in evacuation rates were obtained from small trials with intravaginal misoprostol. To date, only small studies have used sublingual misoprostol, and there has been no direct comparison to oral or intravaginal misoprostol. A recent large clinical trial has shown, that with intravaginal misoprostol 800 microg, an expulsion rate of 84% can be achieved by 8 days. This large trial also established that women prefer misoprostol to surgical evacuation. Two economic evaluations have shown that misoprostol treatment is less costly than surgical intervention. On the basis of recent findings, it seems likely that misoprostol treatment will become a standard or preferred treatment for early pregnancy failure.

Ultrasound assessment of the endometrium for irregular vaginal bleeding.

Irregular vaginal bleeding is a common symptom of women seeking gynecologic care. Etiologies of irregular vaginal bleeding can be classified into the following categories: pregnancy related (retained products of conception, threatened or missed abortion, or ectopic pregnancy), hormonal (disorders of ovulation, menopause, or hormonal contraceptive use), structural (polyps, myomas, or arteriovenous malformation), neoplasm (endometrial cancer), and infection (endometritis). After the history and physical examination, the initial evaluation of irregular vaginal bleeding has traditionally involved an endometrial biopsy. Transvaginal ultrasound has revolutionized the evaluation of the gynecologic ultrasound examination by providing a minimally invasive means to determine the etiology for the bleeding. Transvaginal ultrasound assessment of the endometrial cavity allows treatment to be tailored to the specific cause of irregular vaginal bleeding, thus saving women time, money, and exposure to unnecessary interventions. The purpose of this article is to give the clinician critical information regarding the capabilities of ultrasound to evaluate women with irregular vaginal bleeding.

Patient preferences, satisfaction, and resource use in office evacuation of early pregnancy failure.

OBJECTIVE: To examine patient treatment preferences and satisfaction with an office-based procedure for early pregnancy failure and to compare resource use and cost between office and operating room management of early pregnancy failure. METHODS: This study was a prospective observational study of 165 women presenting for surgical management of early pregnancy failure. Participants completed a preoperative questionnaire addressing treatment preferences and expectations and a postoperative questionnaire measuring level of pain experienced and satisfaction with care. Resource use was determined by measuring the time patients spent at the health care facility and the actual procedure time. Cost was estimated using an institutional database. RESULTS: One hundred fifteen women from the office and 50 from the operating room were enrolled. Patients selecting outpatient management scored "privacy," "avoiding going to sleep," and "previous experience" higher than the operating room group (P < .05). Patients who perceived that their physicians preferred one procedure over the other were more likely to select that procedure (P < .001). Satisfaction was high in both groups, and underestimating the procedure's discomfort was negatively associated with satisfaction (P < .002). Costs were greater than two-fold higher in the operating room group compared with the office group (P < .01). Complications were uncommon, but hemorrhage-related complications were four times more common in the operating room group than in the office group (P < .01). CONCLUSION: Office-based surgical management of early pregnancy failure is an acceptable option for many women and offers substantial resource and cost savings. LEVEL OF EVIDENCE: II-2.

Educação para uma maternidade segura: módulos de educação em obstetrícia: manual para professores de enfermagem obstétrica

Mostra casos que demonstra como determinados fatores sociais, econômicos e culturais, combinados com atrasos na procura de cuidados médicos colocam as mães em risco de complicações, que muitas vezes conduzem a morte. O tema da história é então reforçado ao longo do módulo, sendo enfatizado o papel das parteiras na promoção de uma maternidade segura na comunidade

Abortion discourse in Bolivian hospital contexts: doctors' repertoire conflicts and the Saving Women device.

The author proposes going Beyond attitudes (Potter and Wetherell 1987) to a more nuanced assessment of doctors' discursive variations. Through an application of Gilbert and Mulkay's (1984) interpretative repertoires, she defined three voices--technical, normative and pragmatic--in which Bolivian doctors spoke of abortion. In State and social security hospital contexts, doctors hastened to express compliance with government policy and institutional norms regulating abortion and postabortion care. Technical and pragmatic considerations, however, often entered into conflict with established rules. When contradictions became apparent in their own discourse, doctors regularly drew on the Saving Women device. This accounting strategy enabled them to save face as up-to-date professionals through justifying temporary deviance from norms in terms of benefit to women treated. The author describes her development of the repertoires, their validation with different medical audiences, and doctors' critical appropriation of the model to explain their own discursive variations.

Caracterización clínico-epidemiológica de las pacientes atendidas por aborto en el Instituto Hondureño de Seguridad Social: San Pedro Sula / Clinical and epidemiological characterization of patients assisted by abortion at the Instituto Hondureño de Seguridad Social: San Pedro Sula

Objetivo. Determinar algunas características sociodemográficas, económicas y clínicas, de una muestra de pacientes atendidas por aborto en el Hospital del Instituto Hondureño de Seguridad Social de San Pedro Sula. METODOS. Se encuestaron 46 pacientes con diagnósticos de aborto incompleto en quienes se practicó legrado intrauterino. RESULTADOS. La edad promedio fue de 27 años (rango 20-40 años). La mayoría procedía de San Pedro Sula(39.1 por ciento), Choloma(19.6 por ciento) y Villanueva (17.4 por ciento),e informó trabajar como operaria de maquila (63.0 por ciento), en posición de pie (58.7 por ciento) y con un salario mensual inferior o igual a L 5,000.00 (aprox. US$270). El 58.7 por ciento informó estar practicando algún método de planificación familiar. El espacio intergenético promedio fue de 5 años (DS = 3 años), el (67.4 por ciento) respondió que el embarazo era deseado y el 54.3 por ciento, informó haber iniciado control prenatal. CONCLUSIONES. El bajo nivel de escolaridad detectado, 54.3 por ciento con educación primaria incompleta o ninguna educación formal, podría ser la causa del uso incorrecto de los métodos de planificación. La educación y cultura general de la mujer son determinantes en la salud sexual y reproductiva de ella misma y de su familia. Por lo tanto, las intevenciones educativas en grupos con estas características requieren atención especial