metadata: authors: 0: author: Johnson, Brooke R.
1: author: Benson, Janie
2: author: Bradley, Janet
count: Mexico,Kenya,Ecuador
docna: 0: docna: Costs of alternative treatments for
            incomplete abortion
docty: Policy Research Working Paper
subtopic: Health Care Services Industry,Public Sector Management and Reform,Health Service Management and Delivery
teratopic: Gender
abstracts: cdata!: Unsafely performed abortion is one of
            the five leading causes of maternal deaths worldwide. Many
            women who have undergone unsafe abortions enter the
            healthcare system to seek help for the resulting
            complications, including incomplete abortion. This human and
            financial cost of this health problem is tremendous,
            especially in the developing world. This study examined the
            potential for reducing costs to healthcare systems by
            changing the standard method of treatment for incomplete
            abortion. Vacuum aspiration (VA) has been shown to be safer
            than dilation and curettage (D&C) for uterine
            evacuation; the World Health Organization includes VA as an
            essential service at the first referral level. The technique
            most commonly used for treating first-trimester incomplete
            abortion in developing countries, however, is D&C. This
            study examined the hypothesis that use of manual vacuum
            aspiration (MVA) - a variation of VA - would be less costly
            than D&C and thus advantageous to healthcare systems
            with limited resources. The purpose of the study was to
            identify and, where possible, to explain the factors that
            contributed to cost differences between MVA and D&C for
            treatment of first-trimester incomplete abortion. To achieve
            this objective, researchers observed patient management and
            documented resource use at hospital sites in Ecuador, Kenya,
            and Mexico. In most cases, treatment with MVA required a
            shorter patient stay and fewer hospital resources than
            D&C, as the two techniques were practiced at the various
            study sites. The policy decision to adopt MVA, supported by
            procurement of instruments and incorporation of training in
            its use, is the chief prerequisite for achieving these
            improvements. But the full advantages of MVA are realized
            only if it is introduced in conjunction with certain changes
            in patient-management practices, such as offering outpatient
            treatment of incomplete abortion. Further, decentralizing
            MVA services can maximize the benefits of the technique,
            facilitating (hospitals' and) healthcare systems'
            efforts to decrease the cost of delivery service and improve
            the quality of care.
geo_reg_key: 119228,517191
repnme: repnme: Costs of alternative treatments for
            incomplete abortion
display_title: Costs of alternative treatments for
            incomplete abortion
listing_relative_url: /research/1993/01/699167/costs-alternative-treatments-incomplete-abortion
topicv3: Human Resources m1326304 1211,Sexual Reproductive, Maternal and Child
            Health m1327262 639,Health m1504661 3480,Gynecology m1504683 3610,Surgery m1504689 3616
publishtoextweb_dt: 2010-07-01T00:00:00Z
historic_topic: Gender
origu: Pop & Human Resources Department
no_of_pages: 41
model_extractions: <!-- Start of picture text --> Policy Research|<br><!-- End of picture text -->

<!-- Start of picture text --> Population, Health, and Nutfitbon|<br><!-- End of picture text -->

**WPS 1072**

- This paper a product of the Population and Human Resources Department -is part of a larger effort in the department to improve the status of women's health. Copies of the paper are available free from the World Bank, 1818 H Street NW, Washington, DC 20433. Please contact Otilia Nadora, room S6-665, extension 31091 (January 1993, 31 pages).

Unsafely performed abortion is one of the five leading causes of maternal deaths worldwide. Many women who have undergone unsafe abortions enter the healthcare system to seek help for the resulting complications, including incomplete abortion. The human and financial cost of this health problem is tremendous, especiall) in the developing world.

This study examined the potential for reducing costs to healthcare systems by changing the standard method of treatment for incomplete abortion. Vacuum aspiration (VA) has been shown to be safer than dilation and curettage (D&C) fcr uterine evacuation; the World Health Organization includes VA as an essential service at the first referral level.

The technique most commonly used for treating first-trimester incomplete qbortion in developing countries, however, is D&C. This study examined the hypothesis that use of manual vacuum aspiration (MVA) - a variation of VA - would be less costly than D&C and thus advantageous to healthcare systems with limited resources.

contributed to cost differences between MVA and D&C for treatment of first-trimester incomplete abortion. To achieve this objective, researchers observed patient management and documented resource use at hospital sites in Ecuador, Kenya, and Mexico.

In most cases, treatment with MVA required a shorter patient stay and fewer hospital resources than D&C, as the two techniques were practiced at the various study sites. The policy decision to adopt MVA, supported by procurement of instruments and incorporation of training in its use, is the chief prerequisite for achieving these improvements.

But the full advantages of MVA are realized only if it is introduced in conjunction with certain changes in patient-management practices, such as offering outpatient treatment of incomplete abortion.

Further, decentralizing MVA services can maximize the benefits of the technique, facilitating (hospitals' and) healthcare systems' efforts to decrease the cost of delivery service and improve the quality of care.

The purpose of the study was to identify and, where possible, to explain the factors that

**ThePoyResearchWorking Producedby Policy Research athe mdingsoftworkounderwayintheBank.Anobjeciveof th sries is to get these findings out quickldy, even if presentations are less than fully polished. The fmdings, interpretations.** and **conclusions in these papers do not necessarily represent of ficial Bank policy.**

**Produced by the Policy Research Di.ssemination Center**
# Costs **of Alternative Treatments for Incomplete Abortion**

Brooke R. Johnson, Janie Benson, Janet Bradley, Aurora Rabago Ordofiez, Catia Zambrano, Leonard Okoko, Leticia Vazquez Chavez, Paulina Quiroz, and Khama Rogo Brooke **R.** Johnson and Janie Benson are Research Associate and Director of Research and Evaluation, respectively, for IPAS, Carrboro, North Carolina, USA. **Janet Bradley** is IPAS' Regional Representative, based in Nairobi, Kenya, and **Catia Zambrano** is In-Country Representative for IPAS, based in Quito, Ecuador. **Aurora Rabago Ordofiez** is the Subdirector of Reproductive Health Services for the Division of Reproductive Health and Family Planning of the Mexican Social Security System (IMSS). **Leonard Okoko** is Registrar at the Deparunent of Obstetrics and Gynecology at Kenyatta National Hospital, Nairobi. **Leticia Vhzquez Chavez** is the Personnel Director for the Division of Reproductive and Maternal and Child Health of the IMSS. Paulina Quiroz was a social worker with the Hospital Gfneco-Obstetricia in Quito and is now an independent consultant. **Khama** Rogo is a senior lecturer in the Departnent of Obstetrics and Gynecology at the University of Nairobi.
Table of Contents

|Introduction...................................<br>I|
|---|
|Background<br>..................................<br>1|
|Purpose of the Study ...................................<br>2|
|Methods.....................................<br>3|
|Study Sites and Sample ..................<br>...................<br>3|
|Data Colection and Analysis .....................................<br>_5_|
|Results...................................<br>7|
|Duradon of Hospitd Stay ...............<br>....................<br>7|
|Kenya .............................<br>7|
|Mexico ................................<br>8|
|Ecuador ......................................<br>9|
|Cst of Treating Patients for Incomplete Aborion ............<br>..............<br>9|
|Kenya .............................<br>9|
|Mexico ...................................<br>11|
|Ecuador .............................<br>13|
|Tzendsin Duration of Stay and Resource Utization .<br>.......................<br>15|
|Discussion...................................<br>16|

i
|Implications of Study Results ..................................<br>.......<br>16|
|---|
|Comparative Costs of D&C and MVA .......<br>,,,,,,..,,........<br>16|
|Policy and Protocol Decisions Required for a Change from D&C to MVA.........<br>17|
|Purchase of MVA Instruments .......<br>,,,,........<br>17|
|Training and Procedural Adaptations ..............................<br>17|
|Patient-Management Issues .......<br>,,,,,,........<br>18|
|Location of the Evacuation Procedure .......................<br>18|
|Level of Priority Given to Incomplete Abortion Patients ..........<br>19|
|Hospital Discharge Protocols .....................<br>19|
|Decentralization......................<br>20|
|Outcomes of Policy Changes Related to the Treatment of Incomplete Abortion .....<br>20|
|Reducing Waiting Times ......................................<br>20|
|Resource Reallocation ........................................<br>21|
|Improving Accessibility of Services .<br>...............................<br>21|
|The Status of Policy Change in Kenya, Mexico and Ecuador ..................<br>21|
|Kenya.<br>................<br>21|
|Mexico<br>................<br>22|
|Ecuador ......<br>.<br>.<br>........................<br>22|
|Conclusion...............<br>23|
|Appendix 1.................................................<br>24|
|Appendix 2................................<br>....................<br>26|
|References........<br>29<br>ii|
# List of Tables

|Table 1|Characteristics of Study Hospitals by Country and<br>Procedure .....................|4|
|---|---|---|
|Table 2|Average Cost of Treating a D&C or MVA Patient in Kenya,<br>by Hospital and Cost Category .....................|10|
|Table 3|Average Cost of Treating a D&C or MVA Patient in Mexico,<br>by Hospital and Cost Category .....................|12|
|Table 4|Average Cost of Treating a D&C or MVA Patient in Ecuador,<br>by Hospital and Cost Category .....................|14|
||List of Figures|
|---|---|
|Figure 1|Average Total Patient Stay in Kenya, by Hospital and Type of Procedure ....<br>7|
|Figure 2|Average Total Patient Stay in Mexico, by Hospital and Type of Procedure...<br>8|
|Figure 3|Average Total Patient Stay in Ecuador, by Hospital and Type of Procedure.<br>. 9|
|Figure 4|Average Total Patient Cost in Kenya, by Hospital and Type of Procedure ..<br>10|
|Figure_5_|Average Total Patient Cost in Mexico, by Hospital and Type of Procedure...11|
|Figure 6|Average Total Patient Cost in Ecuador, by Hospital and Type of Procedure.<br>. 13|
|Figure 7|Trends in Duration of Stay and Resource Utilization for MVA Patients ...<br>15|
# Acknowledgments

The authors express their gratitude to the hospital administrators who pemitted us to work in their facilities, to their hospital staff and especially to the women in Kenya, Mexico and Ecuador who cooperated with field staff, allowing intrusions on their time and privacy.

We also express our appreciation to Marian .',emathy, Paul Blumenthal, Virginia Chambers, Joan Ha4y, Forrest Greenslade, Sarah Johnson, Bonnie Kay, Ann Leonard, Katie McLaurin, John Paxman, Lisette Silva, Sangeeta Tandon, Anne Tinker and Laura Yordy for their comments and assistance with the study and previous drafts of this paper; and special thanks to Merrill Wolf for help with final revisions and editing.

This study was supported by a grant to IPAS from The World Bank, Division of Population, Health, and Nutrition, whose support we gratefully acknowledge.

IPAS is an intemational nonprofit organization that addresses the global problem of unsafe abortion. IPAS' primary mission is to promote safe, respectful abortion care, defined as:

- appropriate and timely treatment for abortion complications;

- options for safe, voluntary abortion; and

comprehensive family planning counseling and services to reduce the need for abortion.

The study methods -- including sample data collection forms and instructions for data collection and analysis -- are available to hospital administrators, clinicians and policymakers. A summary of the study's major findings is available in English and Spanish as an issue of IPAS' technical bulletin series, _Advances in Abortion Care_ [1,2]. Please send inquiries to: IPAS P.O. z3ox 100 Carrboro, NC 27510 USA Tel: (919) 967-7052 Fax: (919) 929-0258 v
# **Introduction**

Faced with decreasing financial resources, healthcare systems in the developing world must cope with serving increasing numbers of clients. The delivery of abortion services, especially for treatment of abortion complications, has been particularly affecu.J by this phenomenon.

Manual vacuum aspiration is a safe, simple techl,ique for treatment of first-trimester incomplete abortion, with important potential for decentralization of service delivery. The patient-management practices facilitated by use of the technique led researchers to hypothesize that replacing dilation and curettage -- the current standard for treatment of incomplete abortion in the developing world -- with manual vacuum aspiration would result in significant decreases in hospital resource utilization.

Researchers collected data that documented the utilization of resources associated with use of manual vacuum aspiration and dilation and curettage in three countries -- Kenya, Mexico, and Ecuador. Overall, the study results supported the researchers' hypothesis, revealing reduced resource utilization with manual vacuum aspiration in most study sites. The results also highlighted the importance of adapting patient-management protocols in conjunction with introducing the technique and suggested additional benefits that can follow implementation of manual vacuum aspiration. These and other implications for changes in policy and practice relevant to the provision of abortion care are deliAeated in the remainder of this document.

## Background

Unsafe abortion is one of the five leading causes of maternal mortality worldwide. The way hospitals commonly manage the treatment of incomplete abortion, which often results from unsafe abortion, drains scarce resources in healthcare systems throughout the developing world [3-9]. Indeed, some systems spend 50% to 60% of their obstetric/gynecology (ob-gyn) budgets to treat this medical problem [10-12]. Given this high level of resource consumption, reducing the costs associated with treating incomplete abortion would be clearly advantageous.

In much of the developing world, dilation and curettage (D&C) is the most commonly used technique for treating incomplete abortion [131.1 The procedure is usually performed in a hospital setting where physicians and operating rooms are available; it often includes heavy sedation for pain control and an overnight hospital stay for patient recuperation and monitoring.

Vacuum aspiration (VA) has been shown to be safer than D&C for uterine evacuation [1418], and the World Health Organization includes VA as an essential service at the first referral level [19]. Vacuum aspiration usually requires neither heavy sedation nor an overnight hospital stay and can be performed in a treatment room or outpatient clinic rather than in an operating room. For these reasons, VA appears to be a more cost-effective technique than D&C as it is generally practiced in the developing world [5,20].

> XDilation (or dilatation) and curettage (D&C) **is used throughout this paper to include all sharp curettage procedures, even though for many incomplete abortion patients dilation has occurred prior to the actual** evacuation procedure.

**I**
Manual vacuum aspiration (MVA) is a variation of vacuum aspiration. It employs a portable, nonelectric, single- or double-valve syringe that lias been demonstrated to produce a vacuum as effective as that produced by an electric aspirator [21]. For nearly two decades, MVA has been successfully utilized in a variety of healthcare settings worldwide.

The costs and resource utilization of different methods of uterine evacuation have been neither documented nor compared basea on actual obsen ations of patients treated for incomplete abortion; however, many of the hospital resources associated with the treatment of incomplete abortion (for example, hospitalization ,ime, procedure time, blood transfusions and anesthesia) have been identifled and their costs calculated based on hospital records [5,22]. A Colombian study examined the clinical and managerial aspects of hospital treatment of incomplete abortion with vacuum aspiration (VA) and dilation and curettage (D&C) [23]. Two of the study's findings were: 1) that outpatient management using either VA or D&C resulted in decreased patient stay and 2) that the use of anesthesia was greater for D&C prima ly because of long-established pattems of practice.

# Purpose of the Study

The attributes of D&C and MVA described above led to the hypothesis that MVA would be less costly to healthcare systems than D&C, primarily because MVA does not involve heavy sedation, operating rooms, or overnight hospital stays, and therefore requires fewer staff and less staff time per patient. This study was a demonstration project designed to identify and, where possible, explain the factors that contribute to the cost differences between use of the two clinical procedures for treatment of first-trimester incomplete abortion. To achieve these objectives, researchers observed patient management and documented use of financial and other resources in an attempt to assess and, where appropriate, compare the type and number of resources required for each procedure. The study was implemented at selected hospital sites in Kenya, Mexico and Ecuador.

This study was designed to help researchers examine the _actual practice_ of D&C and MVA. It was not intended to produce comparative data for statistical applications; however, a limited amount of comparative analysis can enable policymakers and managers to identify trends in resource utilization and abortion-patient management. All comparisons that follow are made with the cautionary note that many clinical, administrative, economic and geographic factors vary among different hospitals and may affect resource consumption and, hence, costs.

Following a brief methods section we present the results of data collected in Kenya, Mexico and Ecuador and discuss the implications of the study's results for policy and practice within hospitals and healthcare systems with similar abortion-management protocols.

2
# **Methods**

## **Study Sites and Sample**

The study was conducted between January and August 1991 at four hospita!s in Kenya (KENI-4), five hospitals in Mexico (MEXI-5) and five hospitals in Ecuador (ECU 1-5). Table I summarizes imoortant characteristics of the study sites.<sup>2</sup> At these hospitals, uterine evacuation was perfonned by physicians -- either staff doctors or residents. With two exceptions, at any given time, the hospitals used either MVA or D&C, but not both, to treat patients for first-trimester incomplete abortion.<sup>3</sup> Field staff reported that, except for two of the Ecuadorian sites, patient caseload, staff and patientmanageryment protocols during the period of data collection were generally typical of the respective study locations.' There were slight variadons in the way data were collected and costs calculated among but not within the countries where the study was conducted.

In Kenya, D&C was done exclusively in the main operating room, and patients were admitted for an overnight stay in the gynecology ward. MVA was performed in a treatment room located in the gynecology ward, and patients recuperated for a brief time in the ward. MVA patients' overnight stays were generally attributable to administrative or personal but not medical reasons. In Mexico, both D&C and MVA were performed either in the gynecology surgical room or another evacuation room within the ob-gyn surgical unit _(tococirugla);_ all MVA and some D&C patients recovered in the ambulatory surgery area while other D&C patients were admitted to the ward for an overnight stay. In Ecuador, both D&C and MVA were performed in an evacuation room in all but Hospital ECU5 where MVA was performed in the emergency room.

Women chosen for the study were those with incomplete abortion (spontaneous or induced outside of the hospital) of less than 13 weeks uterine size, as determined by a bi-manual pelvic exam, and whose primary medical need was uterine evacuation -- that is, women with a presenting diagnosis of incomplete abortion and no _other_ major presenting complications. Women whose presenting diagnosis **was** incomplete abortion with additional complications of septicemia, intra-abdominal injury or others were not included in the study.

Patients with presenting complications in additdon to incomplete abortion were excluded from the study for two reasons. First, they do not represent the "typical" patient who presents with incomplete aborion [24-271. Second, treatment of additional complications would be the same regardless of which evacuation procedure was used; the total length of a padent's stay, and thus total resource

**' For** a more detailed descripdon of the study sites refer **to** Appendix 1.

3 **At Hospital MEXS In** Mexico, both MVA and **D&C** were utilized. At Hospital ECUI In Ecuador, where D&C is used for the vast majority of incomplete abortion cases, one provider used MVA for two cases during the data-collection period. For methodologict' asons the MVA c^.ses at Hospital **ECU1** were not included in the project results.

'Project **field** staff were told that caseloads at these two sites (ECU3 and ECU4) were low because of intermittent strikes by hospital personnel just before the data-collection period. **In** addition, widespread knowledge of a severe lack of medical supplies at Hospital ECU3 may have caused potendal patients **to** go elsewhere for treatment.

3
consumption, would be more dependent on the severity of the presenting complication(s) than the nmethod used for uterine evacuation. Thus, including these patients durIng a brief data-collection period would have biased the results in favor of the procedure with the fewest patients with _other_ complications.

Table 1. Characteristics of Study Hospitals **by** Country and Procedure

|Characteristic|Kenya (4<br>D&C|hospitals)<br>MVA|Mexico (5<br>D&C|hospitals)<br>MVA|Ecuador (<br>D&C|5 hospitals)<br>MVA|
|---|---|---|---|---|---|---|
|No. of Data<br>Colection<br>Sites|2*|4*|5**|1**|I|2***|
|No. of Cases|22|77|66|8|13|14|
|System|Ministry of<br>Health<br>(MOH)<br>I__<br>_<br>______|MOH|Mexican Social<br>Security<br>System (IMSS)|IMSS|MOH|National<br>Welfare Board<br>and MOHt<br>municipal<br>°govemmnent|
|Hospital Level<br>l__________|secondary (4)|secondary (3)<br>tertiary<br>(1)|secondary (3)<br>tertiary<br>(2)|tertiary (1)|tertiary (1)|secondary (2)|
|Location of<br>Procedure|central<br>operating<br>room|treatment<br>room in<br>gynecology<br>ward|gynecology<br>surgical roomt<br>evacuation<br>room|gynecology<br>surgical roonm<br>evacuation<br>room|evacuation<br>room|evacuadon<br>rooml<br>treatment room<br>in emergency<br>room|
|Provider|physician|physician|physician|physician|physician|physician|
|Pain Control|light sedation|none|heavy sedation|paracervical<br>block|heavy sedation|heavy<br>sedation/<br>paracervical<br>block|
|Recovery Protocl|overnight stay<br>in gynecology<br>ward|brief stay in<br>gynecology<br>ward until<br>able to leave|overnight stay,<br>or stay in<br>ambulatory<br>surgery|brief stay in<br>ambulatory<br>surgery until<br>able to leave|brief stay in<br>side room,<br>evacuadon<br>room, or<br>hallway until<br>able to leave|overnight stay<br>in ward or stay<br>in recovery<br>room; brief<br>stay in<br>emnergency<br>room until<br>able to leave|

***** KENI and KEN2 were D&C sites prior to the implementation of MVA; data were collected on D&C patients and, subsequently, on MVA patients.

**In one hospital, MEX5, data were collected for both D&C and MVA patients.

***Data collected at two hospitals (ECU3 and ECU4) were excluded due to very low caseloads.

4
# Data Collection and Analysis

Researchers used rapid-assessment data-collection techniques to identify factors that contributed to cost and to explain some of the variations in cost that occurred among different sites. Rapid-assessment procedures include qualitative, cross-sectional, limited-duration field observations and interviews of small, non-representative study populations. Such procedures usually produce quantifiable data that may suggest economic and/or behavioral trends.

Rapid-assessment methods [28] are most effective when focused on a specific, well-defined issue with a narrow range of (probable) procedural and/or behavioral variation, as is the case for treatment of first-trimester incomplete abortion in hospital settings. For the treatment of incomplete abortion, there are a limited number of intra-hospital variations in time and cost of a given procedure (e.g., MVA or D&C). Where costs vary _betueen_ the two procedures, the differences were expected to be large enough to justify use of rapid-assessmen **t** echniques. Because of the circumscribed nature of the issue under study, and because of the field staffs' familiarity with most of the study sites, a brief observation period and small sample size were considered adequate.

The research design was similar to a study that estimated clinic costs for menstrual regulation patients in Bangiadesh [29]. As in Kay and Kabir's study, project field staff attempted to identify all of the significant resources associated with abortion care. Instead of using estimates as a basis for detennining costs, however, the data-collection protocol caUed for field staff to document, where possible, actual expenditures of time and resource units by accompanying patients from the beginning to the end of their hospital stay.

Field staff began the data-coUection process by interviewing hospital administrators and/or clinicians to learn about the hospitals and their management and staffing situations. This allowed field staff to become more familiar with the sites and to begin to discem the contexts within which patients were treated for incomplete abortion. Field staff also interviewed gynecologists, nurses and patients. They consulted health-system, hospital and patient records to obtain detailed information about admission and discharge procedures, caseload and case management and assessment.

Hospital costs associated with treatment of incomplete abortion -- including salaries and costs of drugs, medical instruments, miscellaneous supplies and hospitalization -- were determined by checking salary tables, drug cost lists, central operations records and health-system budgets. Al of the information (except overhead expenses) obtained from interviews and records was confirmed or modified by subsequently observing the complete treatment process abortion patients undergo from admission to discharge. A detailed account of the major cost determinants appears in Appendix 2.

To ensure that cost calculations would reflect routine variations in staffing pattems and daily caseloads, observations took place over a minimum seven-day period at each site. Data collected were limited to standard D&C procedures and MVA procedures performed with IPAS' Karnan cannulae and syringes.

The study design called for data collectors to observe at least 15 women at each site throughout their entire hospital stay for treatment of incomplete abortion. The researchers considered a sample size of 15 to represent a reasonable number of observations for one person to make during a one-week datacolection period. Also, researchers judged that 15 patient observations would be sufficient to _5_
generalize about patient management within a given site. Because of small caseloads during the weeklong observation periods, the minimum sample size of 15 patients was not achieved at every site.

At two hospitals in Kenya (KENI and KEN2), project staff collected data on D&C patients before MVA was implemented. After MVA was introduced, data were again collected on patients treated for incomplete abortion. Since time and cost data for both procedures were cotlected at the same site, most of the site variables (such as hospital level, staff efficiency and caseload) were virtuatly the same. Thus, these sites most accurately demonstrate time and cost differentials between the two techniques.

6
# Results

# **Duration of Hospital Stay**

# K1n

Figure 1 shows the average total patient stay in each of the four Kenyan hospitals.<sup>5</sup> For D&C patients, the average duration of stay ranged from 40.9 to 100.7 hours. In contrast, the average stay of MVA patients ranged from 18.8 to 23.9 hours. At the two hospitals where both D&C and MVA data were collected, differences in average total stay per patient were notable. In Hospital KENI, total stay for MVA patients was 49% shorter than for D&C patients -- 20.7 versus 40.9 hours. In Hospital KEN2, total stay was 76% shorter for MVA patients -- 23.9 versus 100.7 hours. For all sites studied **in** Kenya, the hospital with the longest average stay for patients treated with MVA (23.9 hours) was 42% shorter than the hospital with the shortest average D&C patient stay (40.9 hours).

<!-- Start of picture text --> Figure 1. Aveage Total Patlent Stay In Kenya, by Hospital and Type of Procedure<br>0l Pre-Evacuation 0 Post-Evacuation<br>120<br>100.7<br>100 10. i<br>A 80 .. -. ,t' . ), . N.t,.:<br>.5 40.9 00.2<br>E 40 . X<br>04127 23.9 19.4 18.<br>KENI KEN1 KEN2 KEN2 KEN3 KEN4<br>(n.17) (n=10) (n=5) (n=11) (n t1) (n.45)<br>D&C WA D&C MVA MVA MVA<br><!-- End of picture text --> In Kenya, the pre-evacuation period for D&C patients accounted for most of the total hospital stay. Average pre-evacuation times for D&C patients were 25.5 and 90.2 hours, representing 62% and 90% of the total hospital stay, respectively. For MVA patients, average pre-evacuation times ranged from 9.1 to 11.6 hours (45% - 56% of the total stay). Post-evacuation stay for D&C patients ranged **fron** 10.5 to 15.4 houus; for MVA patients the range was from 9.1 to 13.2 hours.

**5 For all sites, patient stay was divided into pre- and post-evacuation waiting time. "Pre-evacuadon" included elapsed time from admission through the uterine evacuatdon procedure. "Post-evacuation" included elapsed time from the completion of the evacuation procedure until discharge.**

7
# Mexico

In Mexico, the average stay for D&C patients ranged from 11.71 to 29.94 hours depending on where they recovered (i.e., ward or ambulatory surgery -- see Figure 2). By contrast, the average total duration of stay for MVA patients at Hospital MEX5 was 11.36 hours. At Hospital MEX5, where both D&C and MVA were performed, MVA patients' average hospital stay was 45% shorter (11.36 versus 20.61 hours) than the average stay of ambulatory D&C patients.

Figure **2** Average Total Patient Stay In Mexico, by Hospital and Type of Procedure <!-- Start of picture text -->
| Pre-Evacuaaon 0 Post-Evacuaton<br>20.94<br>25 23.73<br>e ~~~~~~20.76 2D.49 16 20.61<br>~2D<br>25.13<br>ro 15X is 1n,16 175 (128) 12E.861, (n.11) (n.411.71 13.18 ; 15.6 ,F 11.36<br>110 7.4<br>F<br>7.0 7.31:<br>0 - - -- - -<br>MEXI MEX2 MEX3 MEX3 MEX4 MEXS MEXS MEX5<br>Ward D&C Ambulatory Ward D&C Ambulalory AmbzJalory Ward D&C Ambulatory Ambulatory<br>D&C D&C D&C D&C MVA<br><!-- End of picture text -->

Average pre-evacuation times for D&C ranged from 3.03 to 7.9 hours, compared with 4.58 hours at the MVA site. Average post-evacuation times showed great variation: from 7.4 to 25.13 hours for D&C, and 6.78 hours for MVA. In contrast to D&C patients in Kenya, post-evacuation time was the largest component of total stay: from 62% to 85% of total stay for D&C patients in Mexico, and 60% of total stay for MVA patients.

8
<!-- Start of picture text --> Figure 3 Average Total Patient Stay In Ecuador, by Hospital and Type of Procedure<br>O Pre-Evacuation El Post-Evacuation<br>15<br>o 10 923<br>S 3.65 10.58<br>F.58 C____v_L_,___ 1.71<br>ECU1 (n=13) D&C ECU2(rl=11)MVA ECUS(n=.3) MVA<br><!-- End of picture text --> Figure 3 shows the average total patie.,t stay in each of the three Ecuadorian hospitals. At Hospital ECUI, the average total duration of stay for D&C patients was 9.23 hours. For the MVA patients at Hospital ECU2, the average total stay was 12.97 hours, and for the MVA patients at Hospital ECU5, only 1.71 hours.

At Hospital ECU1, pre-evacuation time for D&C patients was 5.58 hours, compared to 2.39 hours for MVA patients at Hospital ECU2, and 1.2 hours at Hospital ECU5, where MVA was done on an outpatient basis. Conversely, at ECU 1, women were discharged from the hospital an average of 3.65 hours after completion of the D&C procedure and 10.58 hours after the procedure at the MVA site (ECU2). Post-evacuation time at Hospital ECU5 was only 0.51 hours.

## **Cost of Treating Patients for Incomplete Abortion**

# _Kon_

Figure 4 and Table 2 show the average patient cost for D&C and MVA at four study sites in Kenya. At these sites, total cost per patient was lower for MVA than for D&C. At Hospital KENI, the average cost per MVA patient was $3.09 -- 23% less than the average patient cost of $3.99 for D&C. At Hospital KEN2, the average MVA patient cost was $5.24 -- 66% less than the average D&C patient cost of $15.25.

9
Figure 4. Aveage Total **PAlent** Cosd In **Kenya,** by Hosptal **and** Type of Procedure <!-- Start of picture text --> 0 Cost ot Prooduro 0 Cost of Hosptalziation<br>17.5<br>$15.25<br>15<br>12.5<br>10 10.7<br>5 - $99 $30 $5.24 $4.37<br>2.5 4,11 $QI91<br>0 O__ z2v| - 121 I w Lain~~J, .' ''2. : 6 7=f-V ~~ _F:1! 7 1117A I . . .. .._<br>KENI KEN1 KEN2 KEN2 KEN3 KEN4<br>(n.17) (n.10) (n-5) (n=11) (n-11) (n-45)<br>D&C MVA D&C MVA MVA MVA<br>'Cost In U.S. dogars. US$1 = 27.7 Kenya ShilIlings.<br><!-- End of picture text -->

Table 2. Average Cost of Treating a D&C or MVA Patient in Kenya, by Hospital and **Cost** Category

|**H_ospita**<br>and Type of<br>lrocedure|Number<br>of<br>Casew|Medical<br>instruments|Re-<br>**deriatlon**|Diposable<br>Suppiles|Drnp|Staff|SubTotal|loptalbaUn|**Tol**|
|---|---|---|---|---|---|---|---|---|---|
|KENI<br>(D&C)|17|0.00<br>(NC)|0.00<br>(NC)|0.29<br>(7%)|0.57<br>(14%)|1.40<br>(35%)|2.26<br>(57%)|1.73<br>(43%)|3.99|
|KENI<br>(MVA)|10|0.30<br>(10%)|0.14<br>(5%)|0.18<br>(6%)|0.60<br>(19%)|096<br>(31%)|2.18<br>(71%)|0.91<br>(29%)|3.09|
|KEN2<br>(D&C)|_5_|0.00<br>(NC)|0.00<br>(NC)|1.31<br>(9%)|0.65<br>(4%)|2.59<br>(17%)|4.55<br>(30%)|10.70<br>(70%)|15.25|
|KEN2<br>(MVA)|11|0.31<br>(6%)|0.16<br>(3%)|0.17<br>(3%)|0.58<br>(11%)|1.47<br>(28%)|2.69<br>_(51%)_|2.55<br>(49%)|**524**|
|KEN3<br>(MVA)|I1|0.32<br>(11%)|0.14<br>(5%)|0.29<br>(10%)|0.39<br>(13%)|0.84<br>(29%)|1.98<br>(67%)|0.96<br>(33%)|2.94|
|KEN4|45|0.31|0.08|0.23|0.58|1.56|2.76|1.61|4.37|
|(MVA)||(7%)|(2%)|(5%)|(13%)|(36%)|(63%)|(37%)||

Costs in U.S. dollars; as of May 1991. US$I - Ksh 27.7 (NC) = not calculated (%) = Percentage of average total cost by hospital 10
In all but one Kenyan hospital, the cost of hospitalization contributed the largest portion of the average total cost per patient. However, when hospitalization costs were excluded, the average cost per patient for MVA was still less than for D&C: at Hospital KENI, $2.26 for D&C and $2.18 for MVA, a 4% reduction; at Hospital KEN2, $4.55 for D&C and $2.69 for MVA, a 41% reduction; the average cost per patient, excluding hospitalization, at Hospital KEN3 was $1.98 and at Hospital KEN4, $2.76.

In most of the Kenyan hospitals, personnel costs were the second greatest contributor to average cost per patient. In Hospitals KENI and KEN2, staff costs for D&C were markedly higher than for MVA -- $1.40 versus $0.96 (31% less for MVA), and $2.59 versus $1.47 (43% less for MVA), respectively. At Hospital KEN3 staff costs were $0.84 and at Hospital KEN4 (where personnel costs are affected by higher salaries due to the increased cost of living in a large city), staff costs were $1.56 per patient.

# Mexico

The differences in average cost per patient to each hospital in Mexico are shown in Figure 5 and Table 3. For the hospitals where D&C was performed, the average cost per patient ranged from $79.23 to $235.90. At Hospital MEX5 an average of $65.73 was spent per MVA patient, making its average patient cost 17% to 72% less than the lowest and highest D&C patient costs, respectively. Within Hospital MEX5, average cost per MVA patient was 56% and 54% less than the average cost for D&C patients (ward and ambulatory surgery at MEX5, respectively).

<!-- Start of picture text --> Figure . Avrage Total Patient Codt In Mexico, by Hoaptal and Type of Procedure<br>Cl Cost of Pmoosdure 0 Cost of HospItalIzation<br>250 sf.90<br>225-<br>200<br>175 -<br>; 150 *.40.3 b $150.56 8 4326<br>-9 ~~~~~~186.74 60<br>a 125 lU0 no.30 $10 sss 1<br>0 10 83.01 $83.28 pgz 5 usa5<br>75 4.i. $79234.40 737[<br>MEXI MEX2 MEX3 MEX3 MEX4 MEX5 MEX5 MEX5<br>(n.16} (n-12) (11) (n-4) (r16) (n.3) Ward (n-6) (n.8)<br>Ward D0C Armbulto,y Ward D6C Abuialry Anbuiatoy D&C ofuiafry Anbukaboy<br>DSC D&C ObC D&C MVA<br><!-- End of picture text -->

*Cost In U.S. dolars. US$1 - 3020 **MexIcan** Pesos.

11
**Table 3. Average Cost of Treating a D&C or MVA Patient In Mexico, by Hospital and Cost**<sup>**Category**</sup>

|Hospital<br>and Type<br>of<br>Procedure|Number<br>of<br>Cases|Medical<br>Instru-<br>meats|ResteriU<br>-IZation-|Disposable<br>Supplies|Drugs|Staff|Laundry|Sub-<br>total|Hospital-<br>Izatlon|Total|
|---|---|---|---|---|---|---|---|---|---|---|
|MIEXI<br>Ward<br>(D&C)|16<br>__|.01<br>(09%)<br>_<br>_I__|4.11<br> <br>(3%)|5.95<br>(4%)<br>__<br>_<br>_I_|8.22<br>(6%)<br>I<br>_|36.18<br>(26%)<br>__|3.15<br>(29%)|57.62<br> <br>(41%)|83.01<br>(599o)|140.63|
|MEX2<br>Ambulatory<br>(D&C)|12|.04<br>_(09%)_<br>_|2.33<br> <br>(3%)<br>_|6.72<br>(8%)|5.35<br>(6%o)<br>__|36.72<br> <br>(44%)|3.33<br>(4%)|54.49<br>(65%)|28.79<br>(35%)|s3.28|
|MEX3<br>Ward<br>(D&C)|_|.01<br>(0%)<br>_<br>_<br>_|3.30<br>(1%)<br>_<br>_<br>_|5.49<br>(2%)|3.51<br>(2%)<br>I<br>_<br>_|33.92<br>(14%)<br>__|2.93<br>(1%)<br>_|49.16<br>(21%)<br>I|186.74<br>(799°)<br>__|235.90|
|MEX3<br>Ambulatory<br>(D&C__|4|.01<br>(090)<br>__|3.30<br>(4%)<br> <br>_<br>__|5.49<br>(7%)<br> <br>_|3.51<br>(4%)|33.92<br>(43%)|2.93<br>(4%)<br>_<br>_|49.16<br>(62%)|30.07<br>(38%)|79.23|
|MEX4<br>Ambulatory<br>(D&C)|15|.01<br>(0%)|1.63<br>(2%)|6.11<br>(6%)|7.58<br>(7%)<br>I|38.30<br>(36%)<br>_I_I|_-.43_<br>(3%)|56.96<br>(54%)|49.34<br>(46%)|106.30|
|MEX5<br>Ward<br>(D&C)|3|.09<br>(0%)|2.33<br>(2%)|5.39<br>(4%)|1050<br>(7%)|32.67<br>(22%)|2.75<br>(2%)|53.73<br>(369%)|96.85<br>(64%)|15O.S8|
|MEXS<br>Ambulatory<br>(D& C)|5<br>_|.09<br>(0%)<br>I__<br>_<br>_<br>_|2.33<br>(2%)<br> <br>_|5.39<br>(4%)<br>_<br>_<br>_I__|10.50<br>(7%)<br>_|32.67<br>(23%)<br>I__|2.75<br>(2%)<br> <br>_<br>_<br>_I__|53.73<br>(38%)|89.52<br>(62%)<br>_|143.25|
|boEX<br>Ambulatory<br>(M'VA)|8<br>__<br>_<br>_|.33<br>(1%)<br>_ _<br>_<br>_|.21<br>(090)<br>_<br>_<br>_<br>_|4.95<br>(8%)<br>_<br>_<br>_<br>__|4.79<br>(7%)|23.23<br>(35%)<br>_<br>_|2.51<br>(4%)<br>__<br>_<br>___|36.02<br>(55%)|29.71<br>(45%)<br>_<br>_|65.73|

Costs in U.S. dollars; as of May 1991 USSI = MN 3020 (%) = Percentage of average total cost by hospital 12
In the Mexican hospitals, hospitalization costs accounted for the largest portion of average total cost per ward patient as weLl as for the wide range of variation in cost per D&C patient (ward or ambulatory). But, as in Kenya, even when hospitalization costs were excluded, average cost per MVA patient remained lower than for D&C patients. For MVA, the cost per patient excluding hospitalization ($36.02) was 27% -- 37% less than the lowest and highest D&C patient costs ($49.16 and $57.62 respectively).

Also, as in Kenya, personnel costs were the second greatest contributor to average cost per patient, ranging from $32.67 to $38.30 per D&C patient, and $23.23 per patient at the MVA hospital. Even at Hospital MEX5, where both MVA and D&C were used, average staff costs for MVA patients were lower ($23.23 or 29% less) than for D&C patients ($32.67). Medical instrument cost per D&C patient ranged from $0.01 to $0.09; per MVA patient it was $0.33.

# Ecuado

At Hospital ECUI the average total cost per D&C patient was $3.06, compared with $4.35 and $3.66 per MVA patient at Hospitals ECU2 and ECU5, respectively (Figure 6 and Table 4). In contrast to the results from Kenya and Mexico, total patient costs in Ecuador were disproportionately affected by the expense of disposable supplies and the re-sterilization of MVA instruments, rather than staff and hospitalization. The cost of disposable supplies ranged from 25% - 58% of the total cost per patient. Re-sterilization of MVA instruments was 14% of total patient cost at ECU2 and 31% at ECU5. Staff costs ranged from 16% -- 27% of the total cost per patient and represented only a slightly smaller amount of the total cost for MVA patients than for D&C patients.

Figure **6. Average Total Patient** Cosr **hI** Ecuador, **by Hospil** and **Type of** Procedure <!-- Start of picture text --> 1 Cost of Proodure 10 Cost of Hosptalizatlon<br>5<br>$4.35<br>4 . 51 $3.66<br>|-; 3 ~$3.06 ,t.t .. w ' $.<br>2C - - _ O&C i'A ' ECW (nl11 ' MVA<br><!-- End of picture text -->

*Cost In U.S. **dollais.** US$1 -1105 Ecuadorian Sucros.

13
**Table 4. Average Cost of Treating a D&C or MVA Patient in Ecuador, by Hospital and Cost Category**

|Hosplta<br>**ad**Type<br>**of**<br>|Number<br>of<br>**cans**<br>|Medkal<br>**Instruments**|**Re-**<br>**sterllzadon**|**Itposable**<br>Supplesl|<br>**Drugs**|**staff**|SubTotal|lospltailzadc|Total|
|---|---|---|---|---|---|---|---|---|---|
|Proced|ure|__-_=|_<br>__|_._._._1_._._||||||
|ECUI<br>**(D&C)**|**13**|0.00<br>(NC)|0.00<br>(NC)|1.77<br>(58%)|0.36<br>(12%)|0.82<br>(27%)|2.95<br>(97%)|0.11<br>**(3%)**|3.06|
|ECU2<br>(MVA)|**11**|0.24<br>(6%)|0.62<br>(14%)|1.89<br>(43%)|0.41<br>(9%)|.68<br>(16%)|3.84<br>(88%)|**_*.51_**<br>(12%)|**4335**|
|ECUS|3|0.30|1.13|0.93|0.28|0.96|3.60|0.06|3.66|
|(MVA)||(8%)|(31%)|(25%)|(8%)|(26%)|(98%)|(2%)||

**Costs in** U.S. dollars; as **of** August 1991, **US$1** = **_SI._** 1105

* Indicates estimated cost

(NC) = not calculated (%) = Percentage of average total cost by hospital At Hospital ECU2 there were unusually long post-evacuation periods for MVA patients and a subsequently high hospitalization cost -- $0.51 compared to $0.11 at the D&C site (ECUI) but only $0.06 at the other MVA site (ECU5). Also, the cost of medical instnuments and sterilization (which were not accounted for at the D&C site) caused the cost of treatment to be higher at the MVA sites than at ECUI. Twenty percent of the total average patient cost at Hospital ECU2 was attnibuted to instruments and sterilization, and 39% of the average total patient cost at ECU5 was attributed to these components. Differences in cost and resource use may be explained partially by the fact that the hospitals selected for data collection in Ecuador were administered by different public sector authorities.

14
# Trends in Duration of Stay and Resource Utilization

The results of the study show that, overall, patients treated for incomplete abortion with MVA spent less time in the hospital and consumed fewer resources than similarly diagnosed patients treated with D&C.

Figure 7 shows the percentage of monetary and time resources saved (or needed) by the implementation of MVA in place of D&C for the treatment of first-trimester incomplete abortion. Grouped data must be interpreted cautiously because of differences in the duration of stay and cost associated with a given procedure at different hospitals within the same country. These differences may be due to variations in administrative level of the hospital, staff efficiency, caseload and/c patient management. However, these grouped data show similar trends in resource savings as data from the individual study sites.

Figure 7 illustrates grouped patient data from hospitals in Kenya (KEN), Mexico (MEXa -- ward patients, and MEXb -- ambulatory-surgery patients) and Ecuador (ECU).

<!-- Start of picture text --> Rgure 7. Trends In Duration of Stay and Resource Utilizatlon<br>for MVA Patients<br>(Peroentage of Resources Saved or Addiional Resources<br>% Needed for Patients Treated with MVA)<br>X Average Duration of Patient Stay Average Patient Cost<br>640%<br>4.0%-<br>KEME IEXII iIE iE KENU<br>2Do% "A ~~~~~~~~~~~~~~~~~A .A MX<br>-40<br>'Based on comparisons of mighted means aculat dforp atttreted wth O&C and MVA<br><!-- End of picture text --> 15
# 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.

16
Although resource savings are often calculated in dollars (or local currency), actual monetary savings may not be apparent because the resources "saved" are often immediately consumed by other operating expenses in a given hospital or healthcare system. However, when consumption of resources such as time, space, personnel, drugs and supplies is reduced for treatment of incomplete abortion, these resources may at least be redirected to maternity services, post-abortion family plmning, and other obgyn needs.

# Policy and Protocol Decisions Required for a Change from D&C to MVA

What is needed to realize decreases in duration of stay and resource use is, foremost, the decision by policymakers (ideally at the highest level of the healthcare system) to adopt MVA for treatment of first-trimester incomplete abortion. The basic requirements for introduction of the technique are purchase of the MVA instruments and adaptations in training and certain other procedures. Changes in patient-management practices, such as moving treatment out of the operating room, are essential to achieve greatest resource savings; however, even implementing these changes incremenwlly can have positive outcomes. The policy decision to decentralize abortion care can reinforce the advantages accrued from adopting MVA, potentially leading to significant resource savings and simultaneous improvements in quality of care.

# Purchase of MVA Instruments

A major policy concem related to any change in technology is its cost. For both Kenya and Mexico the total cost savings of MVA procedures more than offset any expenditures for initial purchase or replacement of instruments and re-sterilization.

The initial cost of introducing MVA may appear significant because introduction of the technology (like any other technology) requires new expenditures, whereas most hospitals already have D&C instruments and they are less frequently replaced. Although experience has shown the syringes and cannulae to be extremely durable, given adherence to proper disinfection and re-sterilization procedures, MVA instruments must be replaced periodically. For this study, the replacement cost of MVA instruments was based on the projected use of syringes for 50 procedures and cannulae for 20 procedures. IPAS' colleagues throughout the developing world report that both MVA syringes and cannulae are actually often used safely much longer, for example, syringes are sometimes used for hundreds of procedures.

The proportion of average total patient cost attributable to MVA instruments and re-sterilization varied widely among the three countries (1% in Mexico, 9%-16% in Kenya, and 20-39% in Ecuador). This is partially explained by the fact that researchers used the same MVA instrument prices in all countries but did not compensate for differences attributable to inter-country variations in supply, drug, staff and hospitalization costs. Thus, in Mexico where wage and commodity prices are more similar to those in the United States, the proportion of cost attributable to MVA instruments is less than in Kenya and Ecuador.

# Training and Procedural Adaptations

In addition to purchasing MVA instruments (initially and for replacement), hospital administrators and clinicians should be prepared to organize didactic and practical training seminars for physicians and 17
nurses, which will require obtaining related instructional materials. Modifications in protocols for treatment will also be required. For example, healthcare providers should be trained in the use of appropriate pain-control measures since MVA usually requires different types and/or lower dosages of pain control than D&C. Incorporation of new procedures for achieving high-level disinfection or resterlization of the instruments will also be necessary.

# Patient-Management Issues

During this study, the process of data collection highlighted a number of issues associated with the way in which incomplete aborion patients were routinely managed in hospital settings. The results suggest that patient management is the primary factor that contributes to the different levels of resource utilization required for the two procedures, affecting the time patients spend in the hospital (cf. 23] as well as costs to the healthcare system. The findings from Ecuador show that technological change alone will not necessarily reduce the human and material resources required for the treatment of incomplete abortion. The maximum benefits of MVA are realized only when adoption of the technique is accompanied by changes in patient management, such as those suggested in this paper. Incremental benefits of MVA may be seen even when these changes are incorporated gradually.

Specifically, Lhie results from Ecuador show that inefficient patient-management protocols can negatively affect the time and cost data for MVA. In Ecuador, patients who were treated for incomplete abortion with MVA at two different hospitals (ECU2 and ECU5) had two very different experiences. At Hospital ECU2, patients had an average pre-evacuation wait of 2.39 hours; following the MVA procedure they remained in the hospital for an average of 10.58 hours for a total stay of almost 13 hours. Conversely at Hospital ECU5, patients waited an average of only 1.2 hours for treatment and remained in the hospital approximately 30 minutes folowing the procedure. This example suggests the importance of efficient management of the time women spend in the hospital but does not address the issue of quality of patient care which can be compromised at both ends of the time and cost continua.

Healthcare administrators should note that while many changes in patient management are not exclusive to MVA (i.e., improvements can be made in how both services are offered), many are facilitated by MVA. For example, both D&C and MVA procedures could theoretically be managed as outpatient services with similar resource expenditures. However, it is unlikely that D&C can be performed _more_ efficiently or at a _lower_ cost than MVA. D&C is a more institutionalized medical technique than MVA, and providers may be less inclined to move it from the operating-room setting where it has been traditionally practiced. MVA, on the other hand, was designed to be performed in an outpatient setting.

In this study, three interrelated management components were notable for their impact on patient flow. They were location of the evacuation procedure, the level of priority given to incomplete abortion patients and hospital discharge protocols. Following is a discussion of these factors along with suggestions about how the use of MVA combined with changes in hospital protocols and policies could improve the quality of abortion care as well as the utilization of resources.

_Location of the evacuation procedure._ In many hospitals, the operating room is a bottleneck for patient flow. This was especially true for D&C procedures in Kenya, where demands for operatingroom space and associated difficulties in scheduling resulted in long pre-evacuation waits (an average of 25.5 hours in Hospital KENI and 90.2 hours in Hospital KEN2). In Kenya, MVA was performed 18
in treatment rooms in gynecology wards; thus, scheduling the procedure did not depend on the availability of the operating room. Clearly, these practices resulted in reduced average pre-evacuation waiting time, to the benefit of both patients and hospital staff (for example, an average of 11.6 hours in Hospital KENI and 10.7 hours in KEN2 -- a decrease of 55% and 88% respectively).

Among the Mexican hospitals, pre-evacuation times did not vary markedly. This probably related to the fact that aU patients, whether treated by D&C or MVA, folowed the same administrative protocol up through the evacuation procedure in the ob-gyn surgical unit. However, the average total stay for MVA patients was much briefer than for D&C patients in MEX5 and was also less than at other D&C sites in Mexico. The shorter average stay for MVA patients in Mexico was probably attributable to differences in pain control; the use of a paracervical block instead of heavy sedation allowed women to recover more rapidly and thus leave the hospital sooner.

MVA patients at Hospital ECU5 in Ecuador required the shortest patient stay for any site in the study. This was attributable to the outpatient management of the procedure. Women remained in the emergency room from admission to discharge, and paracervical block was provided for pain control, allowing women to recuperate quickly.

Location of the procedure was a critical factor in duration of stay at aU study sites. It is likely that additional changes -- specifically, offering MVA in an outpatient setting at those sites which do not already do so -- would lead to further decreases in average patient stay and cost.

_Level of priority given to incomplete abortion patients._ In most study hospitals, unless a woman was admitted in a life-threatening condition, hospital staff gave relatively low priority to incomplete abortion cases. Patients without severe complications were often not attended immediately because of the high volume of abortion and other ob-gyn cases and the resulting demand for operating-room space. Other reasons noted by researchers for the low priority include negative attitudes among some providers toward women who sought abortion.

New patient-management protocols will not resolve all the problems that contribute to making patients treated for incomplete abortion a low priority, especially negative provider attitudes. However, they can mitigate the stresses on often overwhelmed hospital resources and staff and thus facilitate improvements in general conditions at the facility, provider attitudes and the overall quality of care patients receive.

_Hospital discharge protocols._ Discharge protocols affect the length of hospital stay and consequently the use of hospital resources. For example, D&C patients at Hospital KENI were not allowed to leave until a physician had signed the appropriate papers, which often did not occur until moming rounds the day after the procedure. This policy may have been a factor in the average post-evacuation stay for D&C patients at Hospital KENI (15.4 hours), which was longer than at any other facility in Kenya. In contrast, physicians at other hospitals in Kenya signed discharge paperwork irmmediately after the procedure, and patients were technically free to leave when they felt able.

In Mexico, except in one hospital, patients could be discharged only during a specific period each morning and afternoon. Patients at Hospital MEX3 could usually be discharged only in the morning; not coincidentally, the average post-evacuation stay for patients at MEX3 was 25 hours -- longer than at any other facility.

19
In Ecuador, abortion patients at Hospital ECU2 were kept in the hospital for an unusually long time following the procedure (10.58 hours versus 3.65 hours at ECUI and 0.51 hours at ECU5), apparently primarily for administrative reasons. This discharge practice caused MVA patients to remain in the hospital for a longer period of time (and thus require more hospital resources) than D&C patients at Hospital ECU1.

Discharge protocols are affected by the recovery time require(i by clients who have undergone a particular procedure. As the two procedures are practiced in the developing world, MVA is usualy performed with lower levels and/or different types of pain control than D&C. As a result, less intense post-operative monitoring is usually required; physicians can often authorize discharge immediately following the procedure and patients may leave as soon as they feel able. When a longer stay is required -- regardless of the evacuation procedure used -- hospital protocols that allow patient departures more than once a day can reduce the post-evacuation stay, as was seen in Mexico.

## Decentralizaton

The policy decision to decentralize abortion care can significantlv enhance the benefits that can be derived from adoption of MVA. The decision to decentralize requires a series of policy changes so that MVA services can be offered safely and effectively at lower levels of the healthcare system. These changes include establishing mechanisms to ensure a continuous supply of commodities, training and supervising providers at these lower levels, and developing and using protocols for the management of varying degrees of abortion complications.

# Outcomes of Policy Changes Related to the Treatment of Incomplete Abortion

Changing policy to support adoption of MVA can lead to irjmerous beneficial outcomes. This study focused on documenting the resource savings associated with replacing D&C with MVA. Reduced resource consumption can have significant implications for the quality of care, both for treatment of incomplete abortion and other reproductive-health needs. Use of MVA offers the potential to improve the quality of abortion care in several important ways, including:

- decreasing the time women must wait to receive care and the time they spend recuperating from treatinent for incomplete abortion;

- allowing reallocation of staff time and resources to other needs (for example, maternity services); and

- improving the accessibility of treatment services.

_Reducing waiting times._ An important advantage for women treated with MVA is the shorter hospital stay usually required. Women can be treated sooner if they do not have to wait for an operating room to become available. Prompt treatment can decrease the risk associated with abortion complications. Women's total hospital stay is further reduced because often they can avoid an overnight stay. A shorter hospital stay has direct benefits for the woman: she can return home sooner and potentially has to pay less in patient fees and other out-of-pocket expenses.

One factor that can contribute significantly to the shorter hospital stay associated with MVA is the reduced level of pain control required. In certain circumstances, use of MVA can further enhance quality of care by allowing women to remain more involved in their care, if they are encouraged by an 20
empathetic service provider. The use of reduced pain-control measures also allows treatment to be moved out of the operating room.

_Resource reallocation._ Use of MVA can allow reallocation of resources such as time, space, personnel, drugs, and supplies to other ob-gyn and abortion-patient needs. Specifically, resource savings could be redirected to post-abortion family planning programs, maternity care, and/or other reproductive healthcare services. This would improve the facility's overall quality of care by improving its ability to meet a range of women's needs.

_Improving accessibility of services._ If implemented through a decentralized service delivery system, MVA offers the opportunity to improve the accessibility of abortion care, bnnging lifesaving services closer to women in underserved areas. Although WHO includes VA as an essential element of abortion care at the first referral level, decentralized abortion care has not yet been implemented on a wide-scale basis. In developing countries, treatment for incomplete abortion is usually delivered at secondary or tertiary level healthcare facilities, with D&C performed in the operating room. With the proper equipment and trained staff, morbidity and mortality related to unsafe abortion can be reduced by providing emergency services for many women at lower levels of the healthcare system [30].

The use of MVA in an outpatient setting shows the potential for decentralizing MVA services so that women can receive essential care even more quickly. For reasons mentioned above, the practice of MVA can be more easily decentralized to lower levels of the healthcare system than D&C. It is important to note, however, that regardless of the level of decentralization of abortion care, there will continue to be a certain smaU percentage of complicated cases that will require more complex approaches to care, including referral to higher levels of the system.

# The Status of Policy Change in Kenya, Mexico and Ecuador

The findings of this study have already contributed to policy changes underway at hospitals and/or healthcare systems in Kenya, Mexico and Ecuador and have informed discussions with Ministry of Health representatives from Zambia and Zimbabwe regarding the development of plans for sustainable MVA programs.

=ya: Incomplete abortion is a significant public health problem and a major drain on Kenya's healthcare resources. In July 1991, a workshop brought together members of the Kenyan Ministry of Health (MOH), district hospital gynecologists, faculty from Kenyatta National Hospital (KNH -- the country's tertiary-care teaching hospital) and representatives of various donor agencies. Presentations were made the findings of this study, on the safety and effectiveness of MVA, and on the expeniences of KNH and some district hospitals currently using the technique for treatment of incomplete abortion. The primary outcome of the meeting was the formation of an MOH Task Force to develop a plan for the expansion of MVA training and services to all district hospitals. Since the workshop, the Ministry has preEaed such a plan to assume responsibility for country-wide implementation of MVA training and services at the district level, in collaboration with the Department of Obstetrics and Gynaecology at KNH. In addition to being presented at the MOH workshop, the study results have been widely disseminated within the country, including to participants at the 1992 annual meeting of the Kenyan Obstetrics and Gynaecology Society.

21
Mexico: The study results from Mexico were an important factor in the decision by the Instituto Mexicano del Seguro Social (IMSS) to introduce MVA training and services in the healthcare system. The initial steps to eventual system-wide adoption of the aspiration technique for treatment of incomplete abortion include a training of trainers for medical, nursing, and social work staff from three key hospitals and the development of updated technical and administrative guidelines for abortion care. A report of the findings has also been distributed to a number of decisionmakers in the healthcare systems of Mexico.

Ecuador: The chief administrator at Hospital ECU2 -- where the study results indicated that the hospital stay for MVA patients seemed unnecessarily long -- has agreed to review the recovery protocols for these patients, recognizing that the modification of inefficient practices would reduce hospitalization costs at this facility. The study results were also presented at a May 1992 workshop on the impact of abortion on the Ecuadorian healthcare system organized by the Corporaci6n de Investigaci6n Social y en Salud (COINSOS), IPAS and Columbia University. Meeting sponsors were the Pan-American Health Organization (PAHO), the United Nations Population Fund (UNFPA) and IPAS. Participants included Ministry of Health officials, hospital staff and representatives of intemational and local organizations. Conference recommendations include replacing sharp curettage with vacuum aspiration.

22
# Conclusion

The results of this study demonstrate that a change from D&C to MVA can have positive benefits for both clients and providers of emergency abortion services and allow for more efficient use of hospitals' and healthcare systems' resources. Adoption of MVA for treatment of abortion complications was shown to reduce duration of hospital stay and consumption of resources.

Commitment at the policy level to adopt MVA must be followed by the fundamental steps of procuring instruments and initiating clinical and administrative protocols required by the new method. These include:

- training staff in use of the method;

- adopting new instrument sterilizadon procedures;

- * implementing appropriate pain-control practices.

This study also suggests that incorporation of certain patient-management practices in conjunction with the introduction of MVA is essential for realization of the full advantages of the technique. Examples of these include:

- performing procedures in a treatment and/or emergency room instead of the main operating room; and

- * nmodifying discharge protocols to eliminate needless waiting.

Furthenmore, decentralizing care to lower levels of the system can maximize the benefits of MVA by improving accessibility of **care.** A significant implication of this study is MVA's potential impact in improving the quality of care that women receive for treatment of abordon complications while also conserving scarce health-system resources.

23