# Discussion

# Implications of Study Results

The results of this study demonstrate that use of MVA for treatment of incomplete abortion offers significant potential benefits for women, service providers and healthcare systems. A close examination of the current practice of MVA and D&C at nine sites in Kenya and Mexico showed that MVA required fewer resources than D&C for most of the cost elements studied (staff, drugs and hospitalization).

Effective adoption of MVA within a hospital or healthcare system requires decision and commitment at the policy level, followed by certain pragmatic adaptations such as developing mechanisms for procurement of medical instruments and training practitioners. The study results -- especially those from Ecuador -- also highlight the influence of patient-management practices on resource utilization, suggesting that the full benefits of MVA can be realized only if adoption of the technique is accompanied by changes in these protocols. Another policy that can contribute significantly to reducing resource consumption and improving women's health is decentralization of abortion care to lower levels of the healthcare system. While this change is not a necessary condition for use of MVA, introduction of the technique can greatly facilitate access to abortion care.

# Comparative Costs of D&C and MVA

The potential economic benefit of a shift from D&C to MVA is most clearly illustrated by the beforeand-after design of the study at KENI and KEN2. Based on the resource-use data collected during the study, KENI and KEN2 would seem to represent two hospitals at either extreme of the cost continuum.

Approximately 780 patients were treated for first-trimester incomplete abortion at Hospital KENI in 1990. If one assumes an average savings of $0.90 per patient (cost differential between MVA and D&Q), the potential resource savings to the hospital following the implementation of MVA would be approximately $702. At the other end of the resource-use continuum, Hospital KEN2 had approximately 570 patients treated for incomplete abortion in 1990. If one assumes an average savings of $10.01 per patient (cost differential between MVA and D&C), the potential resource savings to the hospital after implementing MVA would be approximately $5,706. The continuing need to treat a small percentage of severely complicated cases in the operating room using increased paincontrol measures with MVA would likely reduce these savings slightly.

The majority of public hospitals in Kenya probably fall somewhere between KENI and KEN2 in terms of resource-use efficiency and hospitalization protocols. With 50 public hospitals in Kenya, considerable monetary savings could potentially result from the widespread use of MVA.

Results from the study sites in Mexico also demonstrate the potential for reductions in cost associated with treatment of incomplete abortion. At Hospital MEX5, MVA costs were, on average, $77.52 (per patient) less than D&C costs for patients who recovered in ambulatory surgery. With approximately 600 first-trimester incomplete abortion patients annually, all other factors remaining equal, the potential resource savings would be approximately $46,512 per year.

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