title: Accessing medical and surgical first-trimester abortion services: women's experiences and costs from an operations research study in KwaZulu-Natal Province, South Africa.
abstract: OBJECTIVE
  To explore women's experiences accessing services and estimate costs incurred for first-trimester abortion at four public hospitals in KwaZulu-Natal Province, South Africa.
  
  
  METHODS
  Subanalysis from a prospective cohort study (2009-2011) of women aged 18-49years accessing abortion services through 12weeks' gestation. Trained study personnel conducted structured interviews with women about their reason for having an abortion, experiences accessing services and costs incurred. Women who were 9weeks' gestation or less were eligible to choose medication abortion or manual vacuum aspiration (MVA); women 10-12weeks' gestation all had MVA.
  
  
  RESULTS
  We enrolled 1167 women; 923 (79.1%) were eligible to choose their procedure. The median age was 25years; most were black African, single and unemployed. Many women reported concerns about the affordability of raising a(nother) child (58.9%) or not being ready for (more) children (43.4%) as their reason for having an abortion. In total, women incurred a median cost of US$9.99 (interquartile range 6.46-14.85) for their procedure which usually required two facility visits. Many had to pay for transportation, a pregnancy test, sanitary pads or pain medication.
  
  
  CONCLUSIONS
  Despite the availability of government assistance for children through South Africa's "child grant," the affordability of raising a child was a major concern for women. Although theoretically available free of charge in the public sector, women experienced challenges accessing abortion services and incurred costs which may have been burdensome given average local earnings. These potential barriers could be addressed by reducing the number of required visits and improving availability of pregnancy tests and supplies in public facilities.
  
  
  CONCLUSIONS
  Many women cited concerns about the affordability of having a(nother) child when requesting an abortion. Although public services are technically free or low-cost in South Africa, women incurred costs for first-trimester abortions. Women's costs could be lowered by reducing facility visits and improving availability of pregnancy tests and supplies.
authors.affiliation: Ibis Reproductive Health, Johannesburg, South Africa. Electronic address: naomi.lince.deroche@gmail.com.
authors.forename: Naomi
authors.initials: N
authors.lastname: Lince-Deroche
authors.affiliation: Ipas, Chapel Hill, NC, USA.
authors.forename: Tamara
authors.initials: T
authors.lastname: Fetters
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, Cambridge, MA, USA.
authors.forename: Kelly
authors.initials: K
authors.lastname: Blanchard
mesh_terms: D000028:Abortion, Induced / Q000191:economics* / Q000379:methods; D000029:Abortion, Legal / Q000191:economics* / Q000379:methods; D000293:Adolescent; D000328:Adult; D005260:Female; D006297:Health Services Accessibility / Q000191:economics*; D006306:Health Surveys; D006801:Humans; D008875:Middle Aged; D009874:Operations Research; D011247:Pregnancy; D011261:Pregnancy Trimester, First; D013019:South Africa; D055815:Young Adult
keywords: Access; Costs; Economic; Manual vacuum aspiration; Medication abortion; Termination of pregnancy