title: The costs of accessing abortion in South Africa: women's costs associated with second-trimester abortion services in Western Cape Province.
abstract: OBJECTIVE
  To assess women's costs of accessing second-trimester labor induction and dilation and evacuation (D&E) services at four public hospitals in Western Cape Province, South Africa.
  
  
  METHODS
  From April to August 2010, in interviews immediately after completion of their abortion, we asked women about specific direct and indirect costs incurred. We collected information on recurring costs (i.e., per visit) and one-time expenditures and calculated total costs.
  
  
  RESULTS
  In total, 194 patients participated (136 D&E; 58 induction). Their median age was 26; 37.6% reported being employed or doing paid work. Most (73.2%) women visited two different facilities, including the study facility, while seeking the procedure. Induction women reported a median of three required visits [interquartile range (IQR) 2.0-3.0] to the study facility, while D&E women reported two required visits [IQR 1.0-2.0]. Twenty-seven percent of women missed work due to the procedure, and few (4.6%) paid for childcare. At each visit, almost all women (180, 92.8%) paid for transportation costs and reported additional one-time costs (177, 91.2%) such as sanitary supplies or doctor's fees. The total median cost incurred per woman was $21.23 [IQR 11.94-44.68]. Roughly half (49.0%) received help with these costs.
  
  
  CONCLUSIONS
  Although technically offered freely or low cost in the public sector, women accessing second-trimester abortion lost income and incurred costs for transport, fees, supplies and childcare. Their total costs could be reduced by minimizing the number of required visits to facilities and freely offering supplies such as sanitary pads and pregnancy tests.
  
  
  CONCLUSIONS
  Limited access to second-trimester, safe abortion services in South Africa may result in some women incurring unnecessary costs. Women make multiple visits in attempting to obtain an abortion, often because of facility or health systems requirements, and incur costs for lost income, child care, transport, fees and supplies.
authors.affiliation: Ibis Reproductive Health, Johannesburg, South Africa; Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. Electronic address: naomi.lince.deroche@gmail.com.
authors.forename: Naomi
authors.initials: N
authors.lastname: Lince-Deroche
authors.affiliation: Women's Health Research Unit, School of Public Health, University of Cape Town, Cape Town, South Africa.
authors.forename: Deborah
authors.initials: D
authors.lastname: Constant
authors.affiliation: Women's Health Research Unit, School of Public Health, University of Cape Town, Cape Town, South Africa.
authors.forename: Jane
authors.initials: J
authors.lastname: Harries
authors.affiliation: Ibis Reproductive Health, Cambridge, MA, USA.
authors.forename: Kelly
authors.initials: K
authors.lastname: Blanchard
authors.affiliation: Health Economics Unit, School of Public Health, University of Cape Town, Cape Town, South Africa.
authors.forename: Edina
authors.initials: E
authors.lastname: Sinanovic
authors.affiliation: Ibis Reproductive Health, San Francisco, CA, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Grossman
mesh_terms: D000028:Abortion, Induced / Q000191:economics*; D000328:Adult; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D011247:Pregnancy; D011262:Pregnancy Trimester, Second; D013019:South Africa; D055815:Young Adult
keywords: Dilation and evacuation; Economic; Labor induction; Termination of pregnancy