title: Medical Abortion Provided by Nurse-Midwives or Physicians in a High Resource Setting: A Cost-Effectiveness Analysis.
abstract: OBJECTIVE
  The objective of the present study is to calculate the cost-effectiveness of early medical abortion performed by nurse-midwifes in comparison to physicians in a high resource setting where ultrasound dating is part of the protocol. Non-physician health care professionals have previously been shown to provide medical abortion as effectively and safely as physicians, but the cost-effectiveness of such task shifting remains to be established.
  
  
  METHODS
  A cost effectiveness analysis was conducted based on data from a previously published randomized-controlled equivalence study including 1180 healthy women randomized to the standard procedure, early medical abortion provided by physicians, or the intervention, provision by nurse-midwifes. A 1.6% risk difference for efficacy defined as complete abortion without surgical interventions in favor of midwife provision was established which means that for every 100 procedures, the intervention treatment resulted in 1.6 fewer incomplete abortions needing surgical intervention than the standard treatment. The average direct and indirect costs and the incremental cost-effectiveness ratio (ICER) were calculated. The study was conducted at a university hospital in Stockholm, Sweden.
  
  
  RESULTS
  The average direct costs per procedure were EUR 45 for the intervention compared to EUR 58.3 for the standard procedure. Both the cost and the efficacy of the intervention were superior to the standard treatment resulting in a negative ICER at EUR -831 based on direct costs and EUR -1769 considering total costs per surgical intervention avoided.
  
  
  CONCLUSIONS
  Early medical abortion provided by nurse-midwives is more cost-effective than provision by physicians. This evidence provides clinicians and decision makers with an important tool that may influence policy and clinical practice and eventually increase numbers of abortion providers and reduce one barrier to women's access to safe abortion.
authors.affiliation: Division of Obstetrics and Gynecology, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Susanne
authors.identifier: http://orcid.org/0000-0001-7869-1620
authors.initials: S
authors.lastname: Sjöström
authors.affiliation: Division of Obstetrics and Gynecology, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.|Department of Obstetrics and Gynecology, Department of Clinical Sciences at Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Helena
authors.initials: H
authors.lastname: Kopp Kallner
authors.affiliation: John Hopkins University, Carey School of Business, Baltimore, Maryland, United States of America.
authors.forename: Emilia
authors.initials: E
authors.lastname: Simeonova
authors.affiliation: Stockholm University, Department of Economics, Stockholm Sweden.
authors.forename: Andreas
authors.initials: A
authors.lastname: Madestam
authors.affiliation: Division of Obstetrics and Gynecology, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Kristina
authors.initials: K
authors.lastname: Gemzell-Danielsson
mesh_terms: D000020:Abortifacient Agents, Nonsteroidal / Q000627:therapeutic use; D000028:Abortion, Induced / Q000191:economics* / Q000379:methods*; D000328:Adult; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D016595:Misoprostol / Q000191:economics / Q000627:therapeutic use; D009721:Nurse Midwives; D017060:Patient Satisfaction; D010820:Physicians; D011247:Pregnancy; D011261:Pregnancy Trimester, First; D016387:Women's Health
chemical_list: D000020:Abortifacient Agents, Nonsteroidal; D016595:Misoprostol