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Medical Abortion Provided by Nurse-Midwives or Physicians in a High Resource Setting: A Cost-Effectiveness Analysis

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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. Study design: 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. Conclusion: 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.
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RESEARCH ARTICLE
Medical Abortion Provided by Nurse-
Midwives or Physicians in a High Resource
Setting: A Cost-Effectiveness Analysis
Susanne Sjöström
1
*, Helena Kopp Kallner
1,2
, Emilia Simeonova
3
, Andreas Madestam
4
,
Kristina Gemzell-Danielsson
1
1Division of Obstetrics and Gynecology, Department of Womens and Childrens Health, Karolinska
Institutet, Karolinska University Hospital, Stockholm, Sweden, 2Department of Obstetrics and Gynecology,
Department of Clinical Sciences at Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden, 3John
Hopkins University, Carey School of Business, Baltimore, Maryland, United States of America, 4Stockholm
University, Department of Economics, Stockholm Sweden
*susanne.sjostrom@ki.se
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 set-
ting 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 physi-
cians, but the cost-effectiveness of such task shifting remains to be established.
Study design
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, pro-
vision 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.
PLOS ONE | DOI:10.1371/journal.pone.0158645 June 30, 2016 1/9
a11111
OPEN ACCESS
Citation: Sjöström S, Kopp Kallner H, Simeonova E,
Madestam A, Gemzell-Danielsson K (2016) Medical
Abortion Provided by Nurse-Midwives or Physicians
in a High Resource Setting: A Cost-Effectiveness
Analysis. PLoS ONE 11(6): e0158645. doi:10.1371/
journal.pone.0158645
Editor: Sharon Cameron, NHS Lothian and
University of Edinburgh, UNITED KINGDOM
Received: March 14, 2016
Accepted: June 20, 2016
Published: June 30, 2016
Copyright: © 2016 Sjöström et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are
credited.
Data Availability Statement: All data are contained
within the paper.
Funding: This work was supported by the Swedish
Research Council, Vetenskapsrådet, http://www.vr.se/
inenglish.4.12fff4451215cbd83e4800015152.html
521-2009-2605 to KGD and the Council for Working
Life and Social Research http://www.hb.se/en/
Research/Financiers/FASSwedish-council-for-
working-life-and-social-research-/ 1404/08 to KGD.
The funders had no role in the study design, data
collection and analysis, decision to publish or
preparation of the manuscript.
Conclusion
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 womens access to safe abortion.
Introduction
Lack of trained providers is a common barrier to safe provision of abortion. Shortage of physi-
cians as well as physiciansunwillingness to provide abortion is common in rural areas, but is
also becoming an increasing problem in high resource environments and in settings where
abortion is legal [1][2]. Unsafe abortion is estimated to cause eight percent of global maternal
mortality, implying that 23000 preventable deaths occur each year [3]. Thus eliminating barri-
ers to womens access to safe abortion is an important tool to reduce maternal mortality. The
number of providers of safe abortion can be increased, by task-shifting abortion provision
from physicians to health care providers with adequate but less training [4,5]. Non-physician
providers have been shown to provide medical abortion as effectively and safely as physicians
in different settings[68]. Medical abortion using mifepristone and misoprostol is highly effec-
tive, and is recommended by the World Health Organization (WHO) [9].
Health care budgets are limited worldwide and determining the cost effectiveness of an
intervention is, together with aspects such as efficacy, safety and accessibility, important in
order to influence policy and clinical practice. One previous study from a high resource setting
using a mifepristone-misoprostol regimen found medical abortion to be less costly than surgi-
cal methods [10]. The cost-effectiveness of medical abortion performed by non-physician pro-
viders compared to provision by physicians using a mifepristone and misoprostol regimen
with WHO recommended dosages, remains to be evaluated.
The objective of our study was to conduct a cost-effectiveness analysis of medical abortion
provided by nurse-midwifes or physicians in a high resource setting where ultrasound exami-
nation and dating of pregnancy is part of the protocol.
Material and Methods
Study background
This study is based on a previously published randomized two-sided equivalence study by
Kopp Kallner et al including 1180 healthy women seeking treatment for abortion at an out-
patient clinic of a university hospital in Sweden between February 2011 and July 2012 [8]. Eligi-
ble participants willing to undergo medical abortion were randomized to the intervention
where a nurse-midwife counseled, examined, informed, and treated the woman (n = 597), or
the standard treatment, in which counselling and physical examination was provided by a phy-
sician, and a nurse-midwife gave additional information and medication (n = 583). Contracep-
tive counselling and prescription was provided by the allocated care-giver. All women were
treated with mifepristone 200mg orally at the clinic on day one, and misoprostol 800mcg vagi-
nally at home or in the clinic 2448 hours after the mifepristone administration. Follow up was
provided by a nurse-midwife not participating in the study approximately three weeks after the
mifepristone administration using a low sensitivity urinary human chorionic gonadotropin (u-
hCG) test (cut-off 500 IU/ml). Outcome measures in the parent study were efficacy defined as
Cost-Effectiveness of Medical Abortion Provided by Nurse-Midwives
PLOS ONE | DOI:10.1371/journal.pone.0158645 June 30, 2016 2/9
Competing Interests: The authors have declared
that no competing interests exist.
complete abortion without need for surgical intervention, safety defined as no complication,
and acceptability defined as preferred provider, should the woman have an abortion in the
future. Complication was defined as the need for causal treatment at an unscheduled visit
within 6 weeks after the abortion. Efficacy and safety were assessed using electronic patient rec-
ords and self-administered questionnaires that were also used for measuring acceptability. The
duration of the patientsinitial visit to the clinic, as well as the allocated providers need for a
second opinion from a doctor, was recorded in the study protocol. Statistical calculations were
made using SPSS 20 (IBM Corporation, Somers, NY, USA) except the generalized estimating
equation performed with SAS 9.3 (SAS Institute, Gary, NC, USA).
Details of ethical approval
Permission was granted by the National Board of Health and Welfare and by the Ethical
Review Board of Stockholm (permission number 2010/1828-31/3, 23 December 2010) to allow
midwifes to independently provide medical TOP, according to the study protocol. After
approval by the regional ethics committee at Karolinska Institutet all applications were publicly
available. The study was registered with Clinicaltrials.gov NCT01612923.
Cost-effectiveness analysis
The main goal of the present study is to examine the cost-effectiveness of the standard versus
the intervention treatment for medical abortion using direct costs. The secondary aims are to
evaluate indirect costs, the costs of the subsequent patients waiting time and the cost of com-
plications. Direct costs were calculated for the womans first visit to the clinic where she was
treated according to the standard or intervention arms. Treatment on day 2 (2448 hours after
mifepristone) and follow-up did not differ between groups. We calculated the incremental cost
effectiveness ratio (ICER) to determine the cost for achieving a complete abortion without sur-
gical intervention when adopting the intervention as compared to the standard treatment. The
ICER considers changes in effectiveness as well as cost of treatment and was established using
the formula: [Cost of InterventionCost of Standard treatment]/ [Effectiveness Intervention
Effectiveness of Standard treatment] where Intervention is nurse-midwife provision of medical
abortion, and the Standard treatment is abortion provision by physicians. The Effectiveness is
the difference in numbers of complete abortions without surgical intervention between the
groups, which was measured as 1.6 fewer abortions requiring vacuum aspiration for comple-
tion per 100 patients in the Intervention group in the parent study. It is important to conduct a
cost-effectiveness analysis even though the effectiveness of the Intervention treatment has
already been established. The costs of the two treatments could still be significantly different. If
the Intervention treatment is substantially more expensive than the Standard treatment, the
difference in efficacy might not be enough to justify its wide-spread adoption.
A model taking into account the cost of midwives and physicians (based on salaries, payroll
tax, and time spent with the patients), usage of surgery rooms, consultation time for second
opinion with a physician or senior physician, cost of the treated womens time, and training of
participating midwives was constructed. Direct costs of salaries and examination room rent
were derived from the department of Womens and Childrens Health, Karolinska University
Hospital, Stockholm, Sweden in 2011. The cost of consultations was calculated based on the
average consultation time and participating physiciansaverage salary. The Statistics Sweden
(Statistiska Centralbyrån, SCB) reportAverage income among women per age group in Stock-
holm County 2011was used to estimate the cost of the treated womens time. Searches in the
SCB database were conducted in February and November 2014 [11]. The costs of training the
nurse-midwifes were assessed based on the cost of a subsequently developed ultrasound course
Cost-Effectiveness of Medical Abortion Provided by Nurse-Midwives
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for midwifes providing medical abortion, including the salary costs of the participating mid-
wifes and the cost of physician supervision. The cost of complications was calculated based on
recorded unscheduled visits using the registered diagnosis and treatment according to the diag-
nostic-related group-coding system, a weighted average of costs per diagnostic related group
(DRG) (www.socialstyrelsen.se). There was no difference in costs of disposables, ultrasound, or
medication. The comparison was made per procedure. To derive a conservative estimate of the
cost of the intervention the reduced waiting time of the subsequent patient was added.
All costs were calculated in Swedish Krona (SEK) and converted to 2011 Euro (EUR) (aver-
age exchange rate 2011; 1 Euro = SEK 9.0298).
Results
The randomized-controlled equivalence trial showed that provision of medical abortion by
nurse-midwifes was superior to provision by physicians, with a risk difference for effectiveness,
complete abortion without surgical intervention, of 1.6% (95% CI; 0.23.6%, p= 0.027). This
means that for every 100 patients (procedures), the Intervention treatment resulted in 1.6
fewer follow-up surgical abortions than the Standard treatment. In per-procedure terms, this
translates into 0.016 fewer surgical interventions per treatment in the Intervention arm. The
womans initial visit to the clinic was significantly less time consuming in the intervention arm
(average 42 minutes) than the standard treatment (60 minutes) (P<0.001), which affects most
direct cost parameters. Patients allocated to the standard treatment spent, on average, the same
amount of time (30 minutes) with each provider. The direct costs of the womans first visit to
the clinic of the standard treatment was EUR 58.3 per procedure and the cost of the interven-
tion treatment was EUR 45, see Table 1.
Consultations, when the caregiver obtained a second opinion from another physician,
occurred in 4% of the cases for doctors and in 26% for nurse-midwifes (95%CI 1826%,
P<0.001). The physician providersconsultations lasted 14 minutes on average, 17% of the
consultations were ultrasound queries. Less experienced physicians consulted more often than
more senior physicians. Nurse- midwifes consultation lasted six minutes on average and 42%
the consultations were ultrasound queries, which decreased over time. Costs of the time
women spent at the clinic were assessed using the time women spent with their allocated pro-
vider and the average income among women per age group in Stockholm County, adjusted
to participating women per age group. Womens travel time was not included. The nurse-
Table 1. Direct costs of standard and intervention treatment, per procedure, 2011 EUR.
Cost item Cost Standard n = 533 Cost Intervention n = 535
Salary midwife 18 25
Salary physician 21 0
Examination room 5 4
Consultation w physicians 0.3 1
Patients time 14 10
Training of midwives 0 5
Total cost per procedure EUR 58.3 45
The direct costs are dependent on treatment time mean 60 minutes (SD18.3) in the standard care group, and
42 minutes (SD 24.1) in the intervention group(P<0.001)
Training costs are based on the total cost of training for the 2 participating midwives and include the cost of a
2-day course, salary and physician supervision of 50 ultrasounds. Total EUR 2774, 535 procedures were
performed during study
doi:10.1371/journal.pone.0158645.t001
Cost-Effectiveness of Medical Abortion Provided by Nurse-Midwives
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midwives participating in the study were highly experienced in all aspects of abortion care,
including contraceptive counselling and insertion of IUDs and implants, but had not previ-
ously performed ultrasounds. In the study setting, participating nurse-midwives were intro-
duced to the concepts of ultrasound by a senior consultant, and coupled with physicians
performing ultrasounds. No additional cost was associated with training of the physicians.
In the Intervention arm the waiting time for future abortion seeking women was reduced by
0.3 hours, which further reduces the cost of the intervention by EUR 4. This is assuming that
these women have the same age distribution and the same average income as the women
included in the study.
The overall complication rate, defined as an unscheduled visit for symptoms that lead to
further treatment was 4.1% (20/493) in the nurse-midwife group and 6.1% (29/472) in the stan-
dard care group (95%CI; -0.75%, p= 0.14). There were no significant differences in safety
parameters, and costs for complications were thus not included in the ICER calculations. In
the intervention group, 13 (2.6%) women were treated as outpatients and 6 (1.2%) admitted to
the hospital. In the standard care group, 21 women (4.4%) were treated at the outpatient clinic
and 7 patients admitted (1.5%). Secondary costs of unscheduled visits, complications and sur-
gery were derived from the hospital files for each patient. Costs of complications are shown in
Table 2.
The previous study has established that nurse-midwife provision of medical abortion to
healthy women in a high resource setting where ultrasound dating of the gestational length is
part of the protocol is more efficacious than provision by physicians. Calculation of direct and
indirect costs show that the intervention is also cheaper. Based on these findings a negative
ICER ranging from -831.25 EUR when only direct costs are considered to -17500 EUR evaluat-
ing total costs was calculated. This means that by implementing the intervention a saving in
the range of 831 to 1768.75 EUR is obtained for each avoided surgical intervention, see Table 3.
The parent study found that women in the nurse-midwife group had long-acting reversible
contraceptives (LARCs) inserted within 3 weeks of the TOP significantly more often than
women counselled by physicians (95% CI 3.215.2, P = 0.005). Calculations of direct savings
Table 2. Cost of complications 2011 EUR.
Treatment Standard (n = 533)*Intervention (n = 535)**
Outpatient 10122 (n = 21) 5306 (n = 13)
Clinic 15362 (n = 7) 14273 (n = 6)
Total 25485 19579
Per procedure 48 37
*2 missing, 1 patient had 2 complications. One of the women in the physician group was treated as an
outpatient and later admitted to the hospital.
**1 missing A woman in the intervention group sought care outside of Stockholm county thus treatment
costs could not be tracked.
doi:10.1371/journal.pone.0158645.t002
Table 3. Incremental cost effectiveness ((ICER) of different measures of costs, EUR.
Item Difference in costs per case Difference in efcacy per case ICER
Direct cost per woman treated 4558.3 0.016 -831.2
Direct costs including waiting time for the consecutive patient 4158.3 0.016 -1081.2
Total direct and indirect costs 78106.3 0.016 -1768.8
doi:10.1371/journal.pone.0158645.t003
Cost-Effectiveness of Medical Abortion Provided by Nurse-Midwives
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due to this finding have not been performed within the scope of the present study but its impli-
cation is further discussed below.
Discussion
We have shown that provision of medical abortion by nurse-midwives is cost-saving and
equally effective as provision by physicians in a high resource setting. These findings are
important as the evidence can influence policy-makersdecisions, change clinical practice in
settings where health care budgets are limited, and eventually contribute to increase numbers
of abortion providers that are needed in both high and low resource settings. Previous studies
have demonstrated that task-shifting of different health care services, such as treatment of
orthopedic conditions in low income environment, is cost effective, but this is the first study
showing that task-shifting is cost effective in provision of medical abortion [12].
In our study, task shifting of medical abortion generated direct economic benefits associated
with the shorter time spent in the clinic by providers and patients and nurse-midwiveslower
salaries. Costs were also reduced due to shorter waiting time for subsequent patients and a pos-
sible lower cost for the treatment of complications. The incremental cost effectiveness was neg-
ative, which occurs when the intervention is superior in efficacy and cheaper than the standard
treatment. In addition, the costs of the intervention are expected to decrease further over time
as the cost of training nurse-midwives is disseminated on more procedures and the number of
consultations with physiciansdecline further.
Medical abortion has been shown to enhance access to safe abortion and to be cost-effective
[13]. It is preferred by women who want to avoid surgery and find the method natural and pri-
vate. Some previous studies comparing medical and surgical methods of abortion provision
and treatment of miscarriage have argued that the cost effectiveness of medical methods is
reduced due to complications and method failure[14,15]. However, complication rates of both
medical and surgical termination of pregnancy are low, and dependent on the choice of treat-
ment regimens as well as method of follow-up. Mifepristone-misoprostol regimens are more
effective than misoprostol alone and ultrasound can be difficult to interpret leading to unneces-
sary surgical interventions [16]. Our study using a mifepristone and misoprostol regimen and
a 3-week follow up shows an overall efficacy of 98.2%, which is in line with WHO guidelines.
The women in the nurse-midwife group had long-acting reversible contraceptives (LARCs,
implants and intrauterine devices and systems) inserted within 3 weeks of the abortion signifi-
cantly more often than women counseled by physicians (95% CI 3.215.2, P = 0.004). It has pre-
viously been shown that LARC use decreases numbers of repeat abortions [17]. The type of
abortion provider as well as their training in insertion and counseling has previously been shown
to be an important factor influencing womensuptakeofLARCs[18,19][20]. Approximately
90% of all mortality and morbidity related to abortion could be averted by the use of effective
contraception [21]. LARCs are more effective in preventing unintended pregnancies than oral
contraceptives and even modest increases in the uptake of LARCs in women of fertile age have
been shown to generate cost-savings for societies. A study from the United States shows that if
10% of women aged 2029 years switched from oral contraception to LARC, total costs for unin-
tended pregnancies would be reduced by USD 288 million per year[22] and a recent study from
Norway estimated cost-savings generated from a 5% increased LARC use in women 1524 years
to be 7.2 million NOK or almost 800000 Euro. Rates of unintended pregnancies in the United
States have decreased from 51% to 45% between 2008 and 2011, most likely due to increased use
of long acting reversible contraception [23]. A recent study showed that a high proportion (24%)
of women sought a repeat abortion within four years after a first abortion, fewer repeat abortions
were seen among women who started long acting contraception after the index abortion[24].
Cost-Effectiveness of Medical Abortion Provided by Nurse-Midwives
PLOS ONE | DOI:10.1371/journal.pone.0158645 June 30, 2016 6/9
Repeat abortions and unintended pregnancies that are continued soon after a first abortion, par-
ticularly among teenaged and young women, could be significantly reduced by of LARCs
Strengths and limitations
To our knowledge, this is the first study to evaluate the cost effectiveness of first trimester med-
ical abortion provided by nurse-midwifes or physicians in a high resource setting where ultra-
sound dating of gestational age is part of the protocol. The study is a straightforward analysis
of actual direct costs based on institutional prices derived from the outpatient clinic, where the
previous equivalence trial was carried out.
Possible limitations associated with the parent study include that only healthy women were
randomized and that the study was not blinded. The participating nurse-midwives were highly
experienced and motivated, which might have affected outcomes such as acceptability and
higher prescription and provision of LARCs. Neither the parent study, nor the present one pro-
vide conclusive answers on why nurse-midwives provide abortion more effectively than physi-
cians. As suggested in the parent study a possible reason women prefer nurse-midwifes may be
that abortion is not seen as a medical condition. The shorter time for the first visit in the inter-
vention arm may be associated with women seeing only one provider which reduces waiting
times at the medical office. Implementing task-shifting in abortion provision it is important to
consider that non-physician providerswillingness to participate in abortion provision vary
between individuals and settings. Two large surveys from California and India respectively
indicate that mid-level providers are willing to be trained to perform medical abortions [25,
26], on the other hand a systematic review covering health care providers attitudes toward
induced abortion in sub-Saharan Africa and South-East Asia found that nurses and midwives
disliked being involved in abortion provision[27]. Savings following implementation of the
intervention might be underestimated as we did not consider the opportunity cost due to
released physician time. Neither did we assess the gain from increasing the total number of
abortions provided. Reduced quality of life and societal costs related to delaying the procedure
for those waiting to undergo an abortion are difficult to quantify and beyond the scope the cur-
rent analysis. As patients are free to seek care at their own discretion it was not possible to trace
the costs for all unscheduled visits to clinics outside the Karolinska University Hospital which
might have occurred after the follow-up visit.
Conclusion
Provision of medical abortion by nurse-midwives is more cost effective than the standard treat-
ment, provision by physicians, in a high resource setting where ultrasound dating is part of the
protocol. This finding supports previous evidence of the efficacy and acceptability or task shift-
ing in medical abortion, and provides decision-makers and clinicians with an important tool
when assuring increased access to safe abortion services.
Acknowledgments
The authors would like to thank Alireza Tehrani, controller at Karolinska University Hospital
MK2 Division for providing direct costs and information on DRG.
Author Contributions
Conceived and designed the experiments: KGD SS HKK. Performed the experiments: SS HKK
ES AM. Analyzed the data: SS HKK ES AM. Contributed reagents/materials/analysis tools: ES
AM. Wrote the paper: SS HKK ES AM KGD.
Cost-Effectiveness of Medical Abortion Provided by Nurse-Midwives
PLOS ONE | DOI:10.1371/journal.pone.0158645 June 30, 2016 7/9
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Cost-Effectiveness of Medical Abortion Provided by Nurse-Midwives
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PLOS ONE | DOI:10.1371/journal.pone.0158645 June 30, 2016 9/9
... In Nepal, medical abortion has expanded access to first-trimester abortion in rural areas, since it does not require facilities to have capacity for surgical abortion . In Sweden, a randomized-controlled equivalence trial found provision of medical abortion by nurse-midwives superior to provision by physicians: provision by nurse-midwives was more efficacious and less expensive (Sjostrom, Kopp Kallner et al. 2016). In Malawi, manual vacuum aspiration delivered cheaper (i.e. ...
... (1) The benefits of abortion differ by method (Thapa, Poudel et al. 2004, Hu, Grossman et al. 2009, Hu, Grossman et al. 2010, Cheng, Zhou et al. 2012, Pillai, Welsh et al. 2015, Sjostrom, Kopp Kallner et al. 2016, Upadhyay, Johns et al. 2017. Multiple studies compare the benefits of surgical abortion methods to medical abortion methods. ...
... Within-method benefits can be further enhanced by task shifting, service reorganization, and streamlining. In Sweden, task shifting of medical abortion from physicians to nurse-midwives produced direct economic benefits: shorter time providing care, lower salaries among nursemidwives than physicians, shorter waiting times among patients, and a potentially lower cost to treat complications (Sjostrom, Kopp Kallner et al. 2016). Reorganizing services by treating clinically eligible patients in the manual vacuum aspiration unit rather than the main operating room could free up needed hospital beds by shortening patients' stays and free up physicians and anesthesiologists for other cases (Thapa, Poudel et al. 2004). ...
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Objective: To systematically search for and synthesize the social science literature on the consequences of abortion-related care, abortion policies, and abortion stigma on economic costs, benefits, impacts, and values at the micro- (i.e., abortion seekers and their households), meso- (i.e., communities and health systems), and macro- (i.e., societies and nation states) levels. Methods: We conduct a scoping review using the PRISMA extension for Scoping Reviews (PRISMA-ScR) tool. Studies reporting on qualitative and/or quantitative data from any world region are considered. For inclusion, studies must examine one of the following economic outcomes at the micro, meso-, and/or macro-levels: costs, benefits, impacts, and/or value of abortion-related care or abortion policies. Results: Our searches yielded 19,653 unique items, of which 365 items were included in our synthesis. The economic levels are operationalized as follows: at the micro-level we examine individual decision making, at the meso-level we consider the impact on abortion services and medical systems in context, and at the macro the impact of access to abortion services on broader indicators (e.g., women’s educational attainment). At the micro-economic level, results indicate that economic costs and consequences play an important role in women’s trajectories to abortionrelated care. However, the types of costs that are studied are often unclear and tend to focus narrowly on costs to and at health facilities. Our evidence suggests that a much broader range of economic costs, impacts and values are likely to be important in a wide range of contexts. At the meso-economic level, we find that adapting to changes in laws and policies is costly for health facilities, and that financial savings can be realized while maintaining or even improving quality of abortion care services. At the macro-economic level, the evidence shows that post-abortion care services are expensive and can constitute a substantial portion of health budgets. Public sector coverage of abortion costs is sparse, and women bear most of the financial costs. Conclusions: This scoping review has uncovered a wealth of information about the economic costs, impacts, value, and benefits of abortion services and policies. The review also points to knowledge gaps, such as the ways in which women perceive the intersections between costs and quality of care, safety, and risk. Similarly, there is a dearth of methodological variation and innovation, with an abundance of studies using costing methods and regression analysis while other tools seen elsewhere in behavioral studies (such as discrete choice experiments and randomized control trials) are underexploited. This study provides a conceptual mapping of the economics of abortion in a new way, reinforcing some findings already well known while uncovering underexplored questions and methods.
... [13][14][15][16][17] Nurse-led MoC have been shown to be more cost-effective, improve collaboration between GPs and nurses in general practice, increase nurse job satisfaction and increase access for patients. 13,18 Practice nurse (PN) and GP task-sharing models have been implemented successfully in the community health setting in Australia 19 ; however, they are yet to be developed for or indeed implemented or evaluated in General Practice. 20 ...
Article
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Problem: Women in rural and regional Australia experience a number of barriers to accessing sexual and reproductive health care including lack of local services, high costs and misinformation. Setting: Nurse-led task-sharing models of care for provision of long-acting reversible contraception (LARC) and early medical abortion (EMA) are one strategy to reduce barriers and improve access to services but have yet to be developed in general practice. Key measures for improvement: Through a co-design process, we will develop a nurse-led model of care for LARC and EMA provision that can be delivered through face-to-face consultations or via telehealth in rural general practice in Australia. Strategies for change: A co-design workshop, involving consumers, health professionals (particularly General Practitioners (GPs) and Practice Nurses (PNs)), GP managers and key stakeholders will be conducted to design nurse-led models of care for LARC and EMA including implant insertion by nurses. The workshop will be informed by the 'Experience-Based Co-Design' toolkit and involves participants mapping the patient journey for service provision to inform a new model of care. Effects of change: Recommendations from the workshop will inform a nurse-led model of care for LARC and EMA provision in rural general practice. The model will provide practical guidance for the set-up and delivery of services. Lessons learnt: Nurses will work to their full scope of practice to increase accessibility of EMA and LARC in rural Australia.
... To overcome this barrier, provision of training and education tools would be beneficial. 31 It is anticipated that because of training and exposure GPs will develop more affinity with medical TOP and realise that it does not require extra time, 32 especially as GPs indicated they are already involved in counselling and providing aftercare to women with an unwanted pregnancy or miscarriage. ...
Article
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Background: The World Health Organization has indicated that GPs can safely and effectively provide mifepristone and misoprostol for medical termination of pregnancy (TOP). Dutch GPs are allowed to treat miscarriages with mifepristone and misoprostol, but few do so. Current Dutch abortion law prohibits GPs from prescribing these medications for medical TOP. Medical TOP is limited to the specialised settings of abortion clinics and hospitals. Recently, the House of Representatives debated shifting abortion to the domain of primary care, following the example of France and the Republic of Ireland. This would improve access to sexual and reproductive health care, and increase choices for women. Nevertheless, little is known about GPs' willingness to provide medical TOP and miscarriage management. Aim: To gain insight into Dutch GPs' willingness to prescribe mifepristone and misoprostol for medical TOP and miscarriages, as well as the anticipated barriers. Design and setting: Mixed-methods study among Dutch GPs. Method: A questionnaire provided quantitative data that were analysed using descriptive methods. Thematic analyses were performed on qualitative data collected through in-depth interviews. Results: The questionnaire was sent to 575 GPs; the response rate was 22.1% (n = 127). Of the responders, 84.3% (n = 107) were willing to prescribe mifepristone and misoprostol, with 58.3% (n = 74) willing to provide this medication for both medical TOP and miscarriage management. A total of 57.5% (n = 73) of participants indicated a need for training. The main barriers influencing participants' willingness to provide medical TOP and miscarriage management were lack of experience, lack of knowledge, time constraints, and a restrictive abortion law. Conclusion: Over 80.0% of responders were willing to prescribe mifepristone and misoprostol for medical TOP or miscarriages. Training, (online) education, and a revision of the abortion law are recommended.
... [5][6][7][8][9][10][11] Task-shifting from physician to non-physician providers has been a promising, costeffective approach in some LMICs and HICs, increasing the pool of competent abortion providers. [12][13][14][15] Recent studies show that appropriately trained nurses and midwives can provide abortions as safely as medical practitioners. 16 As new models of abortion care emerge, it is important that the views and current practice of abortion care among these practitioners are understood, and that education is appropriately designed to incorporate contemporary knowledge around abortion care. ...
Article
Full-text available
Background: A significant barrier to the access of safe abortion is the lack of trained abortion providers. Recent studies show that with appropriate education, nurses and midwives can provide abortions as safely as medical practitioners. Aims: To examine the attitudes and practices of registered midwives (RMs) and sexual health nurses (SHNs) in Queensland toward abortion. Materials and methods: A cross-sectional mixed-methods questionnaire was distributed to RMs and SHNs from the Queensland Nursing and Midwifery Union. Data were described and analysed both quantitatively and qualitatively. Results: There was a 20% response rate (n = 624) to the survey from the overall study population. There were 53.5% who reported they would support the provision of abortion in any situation at all; 7.4% held views based on religion or conscience that would make them completely opposed to abortion. There were 92.9% who felt that education surrounding abortion should be part of the core curriculum for midwifery and/or nursing students in Australia. The qualitative responses demonstrated a variety of views and suggestions regarding the practice of abortion. Conclusions: There was a wide variation in views toward induced abortion from RMs and SHNs in Queensland. While a proportion of respondents opposed abortion in most circumstances, a significant group was in support of abortion in any situation and felt involvement in initiating and/or performing abortion would be within the scope of RMs and SHNs.
... ; https://doi.org/10.1101/2022.02.24.22270908 doi: medRxiv preprint and education tools would be beneficial (29). GPs will develop more affinity with medical TOP and recognize that it does not need to be extra time consuming (30), especially since GPs indicated they are already involved in counselling and providing after care to women with an unwanted pregnancy or miscarriage. ...
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Background The World Health Organization (WHO) indicates that General Practitioners (GPs) can effectively and safely provide mifepristone and misoprostol for medical termination of pregnancy (TOP). Dutch GPs are permitted to treat miscarriages with mifepristone and misoprostol, but in practice only guide spontaneous miscarriages. Current Dutch abortion law forbids GPs to prescribe these medications for medical TOP. Medical TOP is limited to the specialized settings of abortion clinics and hospitals. A shift to primary care is debated in the House of Representative, following the example of France and Ireland. It would improve reproductive health care and choices for women. Little is known about GPs’ willingness to provide medical TOP and miscarriage management. Aim This study aimed to gain insight into Dutch GPs’ willingness and anticipated obstacles to prescribing mifepristone and misoprostol for medical TOP and miscarriages. Design and Setting This is a mixed-method study among Dutch GPs. Method A questionnaire provided quantitative data that was analysed using descriptive methods. Thematic analyses were performed on qualitative data collected by in-depth interviews. Results The questionnaire was sent to 575 GPs, the response rate was 22.1%. Of the responders, 84.3% were willing to prescribe mifepristone and misoprostol and 58.3% were willing to provide both medical TOP and miscarriage management. 57.5% indicated a need for training. The main barriers influencing GPs’ willingness were lack of experience, knowledge, time and a restrictive abortion law. Conclusion Over 80% of the respondents were willing to prescribe mifepristone and misoprostol for medical TOP or miscarriages. Training, (online) education and a revision of the abortion law are recommended. How this fits in Medical TOP in the Netherlands can only be provided in abortion clinics and hospitals. GPs may prescribe these same medications for miscarriage management, but in practice only guide spontaneous miscarriages. To improve access to woman-centred care, it is important to allow GPs by law to provide medical TOP. Our study is the first to assess Dutch GPs’ willingness to provide mifepristone and misoprostol and aims to understand enablers and barriers that give insight into the feasibility of a shift in care. Our results illustrate the need to revise laws and to provide training and education in the similar procedure of medical TOP and miscarriage management.
... The aim of the present review was to determine the main factors influencing the number of abortions in terms of the law determined by the culture, religion, and the accessibility of professional medical care. The majority of publications focused on the global issue of abortion and the areas such as the possible methods of performing a termination, increasing its accessibility and cost-effectiveness [8,9]. We try to indicate the main directions which should be followed to improve the patients' well-being in a particular group of individuals in the countries with restrictive abortion laws where the main problem is linked to the fact that abortion cannot be performed. ...
Article
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The tendency towards the radicalization of abortion law is observed in numerous countries, including Poland. The aim of the present paper was to determine the main factors influencing the number of abortions performed worldwide and to indicate the main directions which should be followed to improve the patients’ well-being. The authors conducted their search in the PubMed of the National Library of Medicine and Google Scholar. Databases were extensively searched for all original and review articles/book chapters in English until June 2021. The main problems associated with the contemporary policy of birth regulation include no possibility of undergoing a termination because of the conscience clause invoked by the medical personnel, restrictive abortion law and lack of sexual education. Minimal changes that should be considered are: improved sex education and the availability of contraception, free access to abortion-inducing drugs with adequate information provided by qualified medical personnel in countries with a conscience clause invoked by the personnel, and the development of an international network which would facilitate undergoing a pregnancy termination abroad to provide women with access to legal abortion assisted by professional medical personnel.
... In our analysis, we noticed that by simply eliminating the post-procedure ultrasound examination we could significantly reduce costs. Moreover, replacement of the physician by an experienced nurse at follow-up was an additional element that further reduced costs [23][24][25][26]. At the family planning clinics of HUG, residents are under rotation every 6 months; thus, they do not gain sufficient experience and expertise in termination of pregnancy management, diagnosis of RPOC by ultrasound and contraceptive counselling. ...
Article
Full-text available
Aims of the study: Remote follow-up based on self-assessment plus a telephone call with a healthcare provider is a safe and reliable method for assessing the success of medical termination of pregnancy (mTOP) and can lead to an important reduction in costs. The aim of the study was to analyse its efficacy, acceptability and associated costs. Methods: This was a retrospective comparative study analysing two follow-up protocols for home-based mTOP. A total of 201 women were included: 56 for a standard in-clinic follow-up and 145 for a remote follow-up based on self-assessment with a low-sensitivity urine pregnancy test and a questionnaire. The main outcome was the total number of outpatient consultations needed for each procedure and the associated costs (according to the Swiss tariff system); acceptability and satisfaction were assessed using questionnaires. Results: Demand for home-based termination increased by 7.8% in the observation period. There was a reduction in diagnosis of retained products of conception, with a consequent decrease of follow-up consultations from 1.47 to 0.41 appointments per patient. A reduction of 38.9% in the average cost per patient (including supplementary follow-up appointments) was observed. Moreover, the remote alternative led to higher patient satisfaction (95.1% vs 55.0%) and acceptability (84.8%). The choice for long-acting reversible contraceptives was not affected by the removal of in-person consultation. Conclusion: A remote follow-up procedure is an acceptable and less costly alternative to hospital-based follow-up with a higher rate of acceptability and adherence by the studied population.
Article
Effective contraception can prevent unintended pregnancies, however there is an unmet need for effective contraception in Australia. Despite their being a range of contraceptive methods available, access to these remains equitable and uptake of the most effective methods is low. There is an opportunity to reduce the rate of unintended pregnancies in Australia by improving the uptake of effective contraception for those who desire this. Improving access will require increasing consumer health literacy about contraception, as well as the option of telehealth as a mode of service delivery, and stronger investment in contraceptive services through appropriate reimbursement for providers. There is also a need to test new models of care to increase access to and use of effective contraception in Australia, including nurse and midwifery-led models of contraceptive care and pharmacy involvement in contraceptive counseling.
Article
Background: Medical abortion became an alternative method of pregnancy termination following the development of prostaglandins and antiprogesterone in the 1970s and 1980s. Recently, synthesis inhibitors of oestrogen (such as letrozole) have also been used to enhance efficacy. The most widely researched drugs are prostaglandins (such as misoprostol, which has a strong uterotonic effect), mifepristone, mifepristone with prostaglandins, and letrozole with prostaglandins. More evidence is needed to identify the best dosage, regimen, and route of administration to optimise patient outcomes. This is an update of a review last published in 2011. Objectives: To compare the effectiveness and side effects of different medical methods for first trimester abortion. Search methods: We searched CENTRAL, MEDLINE, Embase, Global Health, and LILACs on 28 February 2021. We also searched Clinicaltrials.gov and the World Health Organization's (WHO) International Clinical Trials Registry Platform, and reference lists of retrieved papers. Selection criteria: We considered randomised controlled trials (RCTs) that compared different medical methods for abortion before the 12th week of gestation. The primary outcome is failure to achieve complete abortion. Secondary outcomes are mortality, surgical evacuation, ongoing pregnancy at follow-up, time until passing of conceptus, blood transfusion, side effects and women's dissatisfaction with the method. Data collection and analysis: Two review authors independently selected and evaluated studies for inclusion, and assessed the risk of bias. We processed data using Review Manager 5 software. We assessed the certainty of the evidence using the GRADE approach. Main results: We included 99 studies in the review (58 from the original review and 41 new studies). 1. Combined regimen mifepristone/prostaglandin Mifepristone dose: high-dose (600 mg) compared to low-dose (200 mg) mifepristone probably has similar effectiveness in achieving complete abortion (RR 1.07, 95% CI 0.87 to 1.33; I2 = 0%; 4 RCTs, 3494 women; moderate-certainty evidence). Prostaglandin dose: 800 µg misoprostol probably reduces abortion failure compared to 400 µg (RR 0.63, 95% CI 0.51 to 0.78; I2= 0%; 3 RCTs, 4424 women; moderate-certainty evidence). Prostaglandin timing: misoprostol administered on day one probably achieves more success on complete abortion than on day three (RR 1.94, 95% CI 1.05 to 3.58; 1489 women; 1 RCT; moderate-certainty evidence). Administration strategy: there may be no difference in failure of complete abortion with self-administration at home compared with hospital administration (RR 1.63, 95% CI 0.68 to 3.94; I2 = 84%; 2263 women; 4 RCTs; low-certainty evidence), but failure may be higher when administered by nurses in hospital compared to by doctors in hospital (RR 2.69, 95% CI 1.39 to 5.22; I2 = 66%; 3 RCTs, 3056 women; low-certainty evidence). Administration route: oral misoprostol probably leads to more failures than the vaginal route (RR 2.38, 95% CI 1.46 to 3.87; I2 = 39%; 3 RCTs, 1704 women; moderate-certainty evidence) and may be associated with more frequent side effects such as nausea (RR 1.14, 95% CI 1.03 to 1.26; I2 = 0%; 2 RCTs, 1380 women; low-certainty evidence) and diarrhoea (RR 1.80 95% CI 1.49 to 2.17; I2 = 0%; 2 RCTs, 1379 women). Compared with the vaginal route, complete abortion failure is probably lower with sublingual (RR 0.68, 95% CI 0.22 to 2.11; I2 = 59%; 2 RCTs, 3229 women; moderate-certainty evidence) and may be lower with buccal administration (RR 0.71, 95% CI 0.34 to 1.46; I2 = 0%; 2 RCTs, 479 women; low-certainty evidence), but sublingual or buccal routes may lead to more side effects. Women may experience more vomiting with sublingual compared to buccal administration (RR 1.33, 95% CI 1.01 to 1.77; low-certainty evidence). 2. Mifepristone alone versus combined regimen The efficacy of mifepristone alone in achieving complete abortion compared to combined mifepristone/prostaglandin up to 12 weeks is unclear (RR of failure 3.25, 95% CI 0.81 to 13.09; I2 = 83%; 3 RCTs, 273 women; very low-certainty evidence). 3. Prostaglandin alone versus combined regimen Nineteen studies compared prostaglandin alone to a combined regimen (prostaglandin combined with mifepristone, letrozole, estradiol valerate, tamoxifen, or methotrexate). Compared to any of the combination regimens, misoprostol alone may increase the risk for failure to achieve complete abortion (RR of failure 2.39, 95% CI 1.89 to 3.02; I2 = 64%; 18 RCTs, 3471 women; low-certainty evidence), and with more diarrhoea. 4. Prostaglandin alone (route of administration) Oral misoprostol alone may lead to more failures in complete abortion than the vaginal route (RR 3.68, 95% CI 1.56 to 8.71, 2 RCTs, 216 women; low-certainty evidence). Failure to achieve complete abortion may be slightly reduced with sublingual compared with vaginal (RR 0.69, 95% CI 0.37 to 1.28; I2 = 87%; 5 RCTs, 2705 women; low-certainty evidence) and oral administration (RR 0.58, 95% CI 0.11 to 2.99; I2 = 66%; 2 RCTs, 173 women). Failure to achieve complete abortion may be similar or slightly higher with sublingual administration compared to buccal administration (RR 1.11, 95% CI 0.71 to 1.74; 1 study, 401 women). Authors' conclusions: Safe and effective medical abortion methods are available. Combined regimens (prostaglandin combined with mifepristone, letrozole, estradiol valerate, tamoxifen, or methotrexate) may be more effective than single agents (prostaglandin alone or mifepristone alone). In the combined regimen, the dose of mifepristone can probably be lowered to 200 mg without significantly decreasing effectiveness. Vaginal misoprostol is probably more effective than oral administration, and may have fewer side effects than sublingual or buccal. Some results are limited by the small numbers of participants on which they are based. Almost all studies were conducted in settings with good access to emergency services, which may limit the generalisability of these results.
Article
Approximately one in three Australian women with an unintended pregnancy will have an abortion, yet significant barriers remain to ensure the delivery of equitable and timely medical abortion services, including lack of trained providers, high out-of-pocket costs, abortion stigma, conscientious objection and large geographical distance to services. Practice nurses can be suitably trained to provide early medical abortion in general practice; however, there remain several key limitations to the implementation of nurse-led models of care. This forum article discusses these limitations, including issues concerning legislation, funding models, lack of access to medical abortion training, practice structure and systems, and makes recommendations as to how increased access to medical abortion in Australia can be achieved.
Article
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Understanding what factors influence the receipt of postabortion contraception can help improve comprehensive abortion care services. The abortion visit is an ideal time to reach women at the highest risk of unintended pregnancy with the most effective contraceptive methods. The objectives of this study were to estimate the relationship between the type of abortion provider (consultant physician, house officer, or midwife) and two separate outcomes: (1) the likelihood of adopting postabortion contraception; (2) postabortion contraceptors' likelihood of receiving a long-acting and permanent versus a short-acting contraceptive method. We used retrospective cohort data collected from 64 health facilities in three regions of Ghana. The dataset includes information on all abortion procedures conducted between 1 January 2008 and 31 December 2010 at each health facility. We used fixed effect Poisson regression to model the associations of interest. More than half (65 %) of the 29,056 abortion clients received some form of contraception. When midwives performed the abortion, women were more likely to receive postabortion contraception compared to house officers (RR: 1.18; 95 % CI: 1.13, 1.24) or physicians (RR: 1.21; 95 % CI: 1.18, 1.25), after controlling for facility-level variation and client-level factors. Compared to women seen by house officers, abortion clients seen by midwives and physicians were more likely to receive a long-acting and permanent rather than a short-acting contraceptive method (RR: 1.46; 95 % CI: 1.23, 1.73; RR: 1.58; 95 % CI: 1.37, 1.83, respectively). Younger women were less likely to receive contraception than older women irrespective of provider type and indication for the abortion (induced or PAC). When comparing consultant physicians, house officers, and midwives, the type of abortion provider is associated with whether women receive postabortion contraception and with whether abortion clients receive a long-acting and permanent or a short-acting method. New strategies are needed to ensure that women seen by physicians and house officers can access postabortion contraception and to ensure that women seen by house officers have access to long-acting and permanent contraceptive methods.
Article
Full-text available
Background: Unsafe abortions are a serious public health problem and a major human rights issue. In low-income countries, where restrictive abortion laws are common, safe abortion care is not always available to women in need. Health care providers have an important role in the provision of abortion services. However, the shortage of health care providers in low-income countries is critical and exacerbated by the unwillingness of some health care providers to provide abortion services. The aim of this study was to identify, summarise and synthesise available research addressing health care providers' perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia. Methods: A systematic literature search of three databases was conducted in November 2014, as well as a manual search of reference lists. The selection criteria included quantitative and qualitative research studies written in English, regardless of the year of publication, exploring health care providers' perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia. The quality of all articles that met the inclusion criteria was assessed. The studies were critically appraised, and thematic analysis was used to synthesise the data. Results: Thirty-six studies, published during 1977 and 2014, including data from 15 different countries, met the inclusion criteria. Nine key themes were identified as influencing the health care providers' attitudes towards induced abortions: 1) human rights, 2) gender, 3) religion, 4) access, 5) unpreparedness, 6) quality of life, 7) ambivalence 8) quality of care and 9) stigma and victimisation. Conclusions: Health care providers in sub-Saharan Africa and Southeast Asia have moral-, social- and gender-based reservations about induced abortion. These reservations influence attitudes towards induced abortions and subsequently affect the relationship between the health care provider and the pregnant woman who wishes to have an abortion. A values clarification exercise among abortion care providers is needed.
Article
Full-text available
The objective of this study was to quantify the cost burden of unintended pregnancies (UPs) in Norway, and to estimate the proportion of costs due to imperfect contraceptive adherence. Potential cost savings that could arise from increased uptake of long-acting reversible contraception (LARC) were also investigated. An economic model was constructed to estimate the total number of UPs and associated costs in women aged 15-24 years. Adherence-related UP was estimated using 'perfect use' and 'typical use' contraceptive failure rates. Potential savings from increased use of LARC were projected by comparing current costs to projected costs following a 5% increase in LARC uptake. Total costs from UP in women aged 15-24 years were estimated to be 164 million Norwegian Kroner (NOK), of which 81.7% were projected to be due to imperfect contraceptive adherence. A 5% increase in LARC uptake was estimated to generate cost savings of NOK 7.2 million in this group. The cost of UP in Norway is substantial, with a large proportion of this cost arising from imperfect contraceptive adherence. Increased LARC uptake may reduce the UP incidence and generate cost savings for both the health care payer and contraceptive user. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Article
Background The rate of unintended pregnancy in the United States increased slightly between 2001 and 2008 and is higher than that in many other industrialized countries. National trends have not been reported since 2008. Methods We calculated rates of pregnancy for the years 2008 and 2011 according to women’s and girls’ pregnancy intentions and the outcomes of those pregnancies. We obtained data on pregnancy intentions from the National Survey of Family Growth and a national survey of patients who had abortions, data on births from the National Center for Health Statistics, and data on induced abortions from a national census of abortion providers; the number of miscarriages was estimated using data from the National Survey of Family Growth. Results Less than half (45%) of pregnancies were unintended in 2011, as compared with 51% in 2008. The rate of unintended pregnancy among women and girls 15 to 44 years of age declined by 18%, from 54 per 1000 in 2008 to 45 per 1000 in 2011. Rates of unintended pregnancy among those who were below the federal poverty level or cohabiting were two to three times the national average. Across population subgroups, disparities in the rates of unintended pregnancy persisted but narrowed between 2008 and 2011; the incidence of unintended pregnancy declined by more than 25% among girls who were 15 to 17 years of age, women who were cohabiting, those whose incomes were between 100% and 199% of the federal poverty level, those who did not have a high school education, and Hispanics. The percentage of unintended pregnancies that ended in abortion remained stable during the period studied (40% in 2008 and 42% in 2011). Among women and girls 15 to 44 years of age, the rate of unintended pregnancies that ended in birth declined from 27 per 1000 in 2008 to 22 per 1000 in 2011. Conclusions After a previous period of minimal change, the rate of unintended pregnancy in the United States declined substantially between 2008 and 2011, but unintended pregnancies remained most common among women and girls who were poor and those who were cohabiting. (Funded by the Susan Thompson Buffett Foundation and the National Institutes of Health.)
Article
Introduction: Despite high access to contraceptive services, 42% of the women who seek an abortion in Sweden have a history of previous abortion(s). The reasons for this high repeat abortion rate remain obscure. The objective of this study was to study the choice of contraceptive method after abortion and related odds of repeat abortions within three to four years. Material and methods: This is a retrospective cohort study based on a medical record review at three hospitals in Sweden. We included 987 women who had an abortion during 2009. We reviewed medical records from the date of the index abortion until the end of 2012 to establish the choice of contraception following the index abortion and the occurrence of repeat abortions. We calculated odds ratios (OR) with 95% confidence intervals (CI). Results: While 46% of the women chose oral contraceptives, 34% chose long-acting reversible contraceptives (LARC). LARC was chosen more commonly by women with a previous pregnancy, childbirth and/or abortion. During the follow-up period, 24% of the study population requested one or more repeat abortion(s). Choosing LARC at the time of the index abortion was associated with fewer repeat abortions compared with choosing oral contraceptives (13% versus 26%, OR 0.36; 95% CI 0.24-0.52). Sub-dermal implant was as effective as intrauterine device in preventing repeat abortions beyond three years. Conclusions Choosing LARC was associated with fewer repeat abortions over more than three years of follow-up. This article is protected by copyright. All rights reserved.
Article
Unintended pregnancy remains a serious public health challenge in the USA. We assessed the effects of an intervention to increase patients' access to long-acting reversible contraceptives (LARCs) on pregnancy rates. We did a cluster randomised trial in 40 reproductive health clinics across the USA in 2011-13. 20 clinics were randomly assigned to receive evidence-based training on providing counselling and insertion of intrauterine devices (IUDs) or progestin implants and 20 to provide standard care. Usual costs for contraception were maintained at all sites. We recruited women aged 18-25 years attending family planning or abortion care visits and not desiring pregnancy in the next 12 months. The primary outcome was selection of an IUD or implant at the clinic visit and secondary outcome was pregnancy within 12 months. We used generalised estimating equations for clustered data to measure the intervention effect on contraceptive selection, and used survival analysis to assess pregnancy rates. Of 1500 women enrolled, more at intervention than control sites reported receiving counselling on IUDs or implants (565 [71%] of 797 vs 271 [39%] of 693, odds ratio 3·8, 95% CI 2·8-5·2) and more selected LARCs during the clinic visit (224 [28%] vs 117 [17%], 1·9, 1·3-2·8). The pregnancy rate was lower in intervention group than in the control group after family planning visits (7·9 vs 15·4 per 100 person-years), but not after abortion visits (26·5 vs 22·3 per 100 person-years). We found a significant intervention effect on pregnancy rates in women attending family planning visits (hazard ratio 0·54, 95% CI 0·34-0·85). The pregnancy rate can be reduced by provision of counselling on long-term reversible contraception and access to devices during family planning counselling visits. William and Flora Hewlett Foundation. Copyright © 2015 Elsevier Ltd. All rights reserved.
Article
There is only limited evidence on whether certified and uncertified health care providers in India support reforming the Medical Termination of Pregnancy (MTP) Act to expand the abortion provider base to allow trained nurses and AYUSH physicians (who are trained in Indian systems of medicine) to provide medical abortion. To explore their views, we conducted a survey of 1,200 physicians and other health care providers in Maharashtra and Bihar states and in-depth interviews with 34 of them who had used medical abortion in their practices. Findings indicate that obstetrician-gynaecologists and other allopathic physicians were less supportive than non-physicians of nurses and AYUSH physicians providing early medical abortion. The physicians did not think that these providers would be able to assess women's eligibility for medical abortion correctly. In contrast, the majority of non-physicians found task shifting of medical abortion provision to trained nurses and AYUSH physicians acceptable, and they were confident that these providers would be able to provide medical abortion as safely and effectively as trained physicians. Assuming the reforms are passed, efforts will need to be made by government and medical professional bodies to train these new providers to undertake this role, prepare the health infrastructure to include them, and create an environment, including among physicians, that is conducive to enabling non-physicians to provide medical abortion. Copyright © 2015 Reproductive Health Matters. Published by Elsevier Ltd. All rights reserved.
Article
Study question: What proportions of women have a second abortion or continued pregnancy within 12-46 months of a first abortion? Summary answer: Estimated return rates for a second abortion were 5, 10.9 and 19.8% at 12, 24 and 46-months, respectively, and rates of continued pregnancy were 5.6, 12.9 and 24.3% at the same intervals. What is known already: Studies attempting to identify women at risk for 'repeat abortion' for intervention purposes have described a range of demographic and behavioural characteristics associated with presentation for more than one abortion, but few have taken timing of abortions into account. Study design, size, duration: Retrospective cohort study involving women presenting for a first abortion at a public hospital abortion clinic in New Zealand (2007-2010). Participants/materials, setting, methods: Electronically stored records were analysed for women discharged from a public hospital abortion clinic in New Zealand. Outcome measures were the proportion of women having a second abortion or continued pregnancy within 24 months of a first abortion, and characteristics associated with shorter time to subsequent pregnancy. Cox proportional hazards modelling was used to detect factors associated with time to a second abortion or continued pregnancy, and Kaplan-Meier survival analyses were used to estimate time to one of these two pregnancy outcomes. Main results and the role of chance: A total of 6767 women had a first abortion between 2007 and 2010. Some data were missing for 11 women so were excluded from the cohort and analyses. Return rates for a second abortion estimated from survival analyses were 5, 10.9 and 19.8% at 12, 24 and 46 months, respectively. Estimated rates of continued pregnancies were 5.6, 12.9 and 24.3% at 12, 24 and 46 months, respectively. Younger age, non-European ethnicity and greater parity were significantly associated with shorter time to a second abortion and to a subsequent continued pregnancy (P < 0.01 for all factor P-values). Hazard ratios (HR) for a second abortion were highest among those aged 16-19 years (HR 1.6, 95% confidence interval (CI) 1.3-1.9, Reference 20-24), of Pacific Island (HR 1.35, 95% CI 1.1-1.7) or Maori ethnicity (HR 1.26, 95% CI 1.1-1.5, Reference New Zealand European), and with 1 (HR 1.41, 95% CI 1.1-1.7) or 2 (HR 1.41, 95% CI 1.1-1.9, Reference nulliparous) children at the time of the first abortion. Both pregnancy outcomes were observed among 120 women (1.8%), with 60% of these women having a second abortion before the continued pregnancy. Limitations, reasons for caution: This study was limited to analysis of routinely collected clinical and demographic data for women presenting for abortion over a 4-year period. Conclusions could not be drawn about a wider range of personal and situational factors influencing pregnancy and pregnancy outcomes. Data were drawn from only one clinic but characteristics of the study sample were broadly representative of those reported nationally. Loss to follow-up for women seeking a second abortion elsewhere in the country cannot be ruled out and would serve to underestimate return rates reported here. Wider implications of the findings: To date, the most effective public health measure known to reduce abortion return rates within 24 months is the initiation of long-acting reversible contraception (LARC) at the time of an abortion. The high proportion of women seeking a second abortion <4 years after a first abortion (20%) could be significantly reduced by use of LARC, as could unintended pregnancies that are continued soon after a first abortion, particularly among teenaged and young women. Barrier-free access to a range of LARC methods should be prioritized to prevent unintended and mistimed pregnancies. Study funding/competing interests: Funded by a Lottery Health Research Grant and a University of Otago Research Grant. The authors have no competing interests. Trial registration number: Not applicable.