title: The costs and cost effectiveness of providing first-trimester, medical and surgical safe abortion services in KwaZulu-Natal Province, South Africa.
abstract: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Ibis Reproductive Health, Johannesburg, South Africa.
authors.forename: Naomi
authors.identifier: http://orcid.org/0000-0003-3689-4205
authors.initials: N
authors.lastname: Lince-Deroche
authors.affiliation: Ipas, Chapel Hill, NC, United States of America.
authors.forename: Tamara
authors.initials: T
authors.lastname: Fetters
authors.affiliation: Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Edina
authors.initials: E
authors.lastname: Sinanovic
authors.affiliation: King Dinuzulu Hospital, Department of Obstetrics and Gynaecology, Durban, South Africa.
authors.forename: Jaymala
authors.initials: J
authors.lastname: Devjee
authors.affiliation: Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.
authors.forename: Jack
authors.initials: J
authors.lastname: Moodley
authors.affiliation: Ibis Reproductive Health, Cambridge, MA, United States.
authors.forename: Kelly
authors.initials: K
authors.lastname: Blanchard
mesh_terms: D000028:Abortion, Induced / Q000191:economics* / Q000379:methods; D003362:Cost-Benefit Analysis; D005260:Female; D006297:Health Services Accessibility; D006779:Hospitals, Public; D006801:Humans; D015735:Mifepristone / Q000191:economics* / Q000627:therapeutic use; D011247:Pregnancy; D011261:Pregnancy Trimester, First; D013019:South Africa; D016896:Treatment Outcome; D014619:Vacuum Curettage / Q000191:economics*
chemical_list: D015735:Mifepristone