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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 Women’s and Children’s 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/FAS—Swedish-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 women’s 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 physicians’unwillingness 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 women’s 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[6–8]. 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 24–48 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 patients’initial visit to the clinic, as well as the allocated provider’s 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 patient’s waiting time and the cost of com-
plications. Direct costs were calculated for the woman’s first visit to the clinic where she was
treated according to the standard or intervention arms. Treatment on day 2 (24–48 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 Intervention–Cost 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 women’s time, and training of
participating midwives was constructed. Direct costs of salaries and examination room rent
were derived from the department of Women’s and Children’s Health, Karolinska University
Hospital, Stockholm, Sweden in 2011. The cost of consultations was calculated based on the
average consultation time and participating physicians’average salary. The Statistics Sweden
(Statistiska Centralbyrån, SCB) report”Average income among women per age group in Stock-
holm County 2011”was used to estimate the cost of the treated women’s 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; 0.2–3.6%, 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
woman’s 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 woman’s 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 18–26%,
P<0.001). The physician providers’consultations 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. Women’s 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
Patient’s 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; -0.7–5%, 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 3.2–15.2, 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 efficacy per case ICER
Direct cost per woman treated 45–58.3 0.016 -831.2
Direct costs including waiting time for the consecutive patient 41–58.3 0.016 -1081.2
Total direct and indirect costs 78–106.3 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-makers’decisions, 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-midwives’lower
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 physicians’decline 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 3.2–15.2, 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 women’suptakeofLARCs[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 20–29 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 15–24 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 providers’willingness 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.
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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
PLOS ONE | DOI:10.1371/journal.pone.0158645 June 30, 2016 9/9
