Association between hospital procedure volume, socioeconomic status, comorbidities, and adverse events related to surgical abortion: a nationwide population-based cohort study.

ABSTRACT

BACKGROUND: Limited evidence exists on the influence of hospital procedure volume, socioeconomic status, and comorbidities on surgical abortion outcomes. OBJECTIVE: Our study aimed to assess the association between hospital procedure volume, individual and neighborhood deprivation, comorbidities, and abortion-related adverse events. STUDY DESIGN: A nationwide population-based cohort study of all women hospitalized for surgical abortion was conducted from January 1, 2018 to December 31, 2019 in France. Annual hospital procedure volume was categorized into 4 levels based on spline function visualization very low (<80), low ([80-300]), high ([300-650]), and very high-volume (≥650) centers. The primary outcome was the occurrence of at least one surgical-related adverse event, including hemorrhage, retained products of conception, genital tract and pelvic infection, transfusion, fistulas and neighboring lesions, local hematoma, failure of abortion, and admission to an intensive care unit or death. These events were monitored during the index stay and during a subsequent hospitalization up to 90 days. The secondary outcome encompassed general adverse events not directly linked to surgery. RESULTS: Of the 112,842 hospital stays, 4951 (4.39%) had surgical-related adverse events and 256 (0.23%) had general adverse events. The multivariate analysis showed a volume-outcome relationship, with lower rates of surgical-related adverse events in very high-volume (2.25%, aOR=0.34, 95% CI [0.29-0.39], P<.001), high-volume (4.24%, aOR=0.61, 95% CI [0.55-0.69], P<.001), and low-volume (4.69%, aOR=0.81, 95% CI [0.75-0.88], P<.001) wh en compared to very low-volume centers (6.65%). Individual socioeconomic status (aOR=1.69, 95% CI [1.47-1.94], P<.001), neighborhood deprivation (aOR=1.31, 95% CI [1.22-1.39], P<.001), and comorbidities (aOR=1.79, 95% CI [1.35-2.38], P<.001) were associated with surgical-related adverse events. Conversely, the multivariate analysis of general adverse events did not reveal any volume-outcome relationship. CONCLUSION: The presence of a volume-outcome relationship underscores the need for enhanced safety standards in low-volume centers to ensure equity in women's safety during surgical abortions. However, our findings also highlight the complexity of this safety concern which involves multiple other factors including socioeconomic status and comorbidities that policymakers must consider.