We conducted a cross-sectional descriptive study in order to estimate the costs to two public referral hospital facilities for treating six type of post-abortion complications, including incomplete abortion, hemorrhage, shock, infection/sepsis, cervix or vagina laceration, and uterus perforation, and to ascertain the cost saving to these health facilities of the provision of safe abortion care services in 2010.
The two public referral hospital facilities in Ouagadougou were purposely chosen for this study. The hospital facilities included a tertiary teaching hospital and a secondary level hospital with surgical capacity. They were selected to reflect postabortion services that are routinely available, and to have a sufficient demand for such services by women with abortions. Additionally, because this study intended to make a rapid assessment of the costs incurred in treating abortion complications, these health facilities offered the best alternatives in terms of completeness of data, accessibility, and expertise in order to compute sensible estimates.
Data sources and collection
We collected the costs data pertaining to 2010 in April 2011. In each hospital, we reviewed the manual vacuum aspiration ward registers in order to assess both the number of complications from induced abortion treated and the throughput of patients treated in each health facility in 2010. All the cases were analyzed, and classified into (1) incomplete abortions or into (2) abortion with hemorrhage, (3) shock, (4) infection/sepsis, (5) cervix or vagina laceration and (6) uterus perforation, using clinical definitions. Additionally, in each hospital facility, a gynaecologist (head of the maternity ward) or a midwife (chief of the manual vacuum aspiration ward) was interviewed in order to confirm case distribution. We also conducted face-to-face interviews with up to four key administrative personnel, including a human resources director, a financial and administrative director or the person responsible for finances, a principal accountant, and a pharmacist or person responsible for the pharmaceutical store. These face-to-face interviews were intended to collect the recurrent costs of running each hospital facility.
We used two structured questionnaires for data collection. The first questionnaire collected data on units of drugs and medical supplies used for treating each type of abortion complication (See Additional file 1). In addition, a list of prices of drugs and medical supplies used for treating cases was obtained from hospital pharmacists or from the responsible for the pharmaceutical store in each hospital. The second questionnaire gathered information on the recurrent costs of running a hospital, on the wages of health personnel and non-medical staff and on the estimated time spent in treating each type of abortion complications (See Additional file 2).
Because the perspective we adopted was the one of the facility, costs that were analyzed in this study were those paid out of the hospitals’ own budgets. Therefore, staff costs of medical and non-medical personnel whose salaries were paid by the Government were not analyzed. Similarly, capital costs such as buildings or core equipment were also excluded from the analysis as they were not acquired over hospital budgets. All the cost figures were converted from Burkina Faso CFA to US dollars, using the 2010 average yearly CFA to US dollars conversion rate . In order to obtain constant dollars, we deflated the estimates using the inflation factor of the US dollar, estimated at 3.2 % .
Average treatment cost
The average treatment cost of any abortion complication was obtained by adding up the estimated indirect cost, using the step-down approach, to the obtained direct cost, using the bottom-up approach.
The step-down costing approach aimed at allocating all costs for running a hospital to departments providing the final output  – i.e. to the maternity ward, and to patients in this ward. Treating patients in hospitals requires a combination of outputs from departments that are directly and indirectly producing care. Though they provide valuable services, departments such as kitchen, laundry, etc., are not directly involved in patient care. The costs for running these departments were therefore allocated to patient departments. Similarly, overheads costs, which are also necessary for allowing hospitals to function, were also allocated to each patient, using an allocation model. The hospital recurrent costs were allocated to maternity departments using allocation criteria reflecting actual resource use.
The step-down costing was complemented by bottom-up costing . The aim of this approach was to capture direct treatment costs, such as drugs, medical supplies, and staff costs, which were incurred by each hospital facility in treating the complications of abortion.
Drug and medical supplies costs
The units and types of drugs and medical supplies, including gloves for examination, gauze compresses, cotton, cotton swab, suture silk, urine collecting bags, seringes with needles, used in the treatment of each type of abortion complication were gathered through a review of selected medical files. To ensure that the information collected accurately reflected hospital practice, the data were further discussed with the gynaecologist, the person responsible for the maternity ward, or with the midwife responsible for the manual vacuum aspiration ward. Additionally, a list of the prices of the drugs and medical supplies used in treating the cases was obtained from the hospital pharmacist or from the person responsible for the pharmaceutical store in each hospital. For every complication of interest, the total cost of each drug or medical supply used in treating the case was obtained by multiplying the units of each input by the cost at which it was acquired. Total expenditure on drugs and supplies necessary for treating a single case of each abortion complication was then obtained by computing the sum total of the costs spent for each drug or supply used in such a case.
In each hospital facility, a list of the medical and non-medical staff working in the department of gynaecology and obstetrics whose salaries were paid directly out of the hospital budget was established by interviewing the human resources director. The gross wage of each staff member was also obtained by interviewing the human resources director. In order to estimate the average time spent by each staff member for treating each individual case of abortion complication, the head of the maternity ward and the midwife responsible for the manual vacuum aspiration ward were interviewed. The estimated cost for each staff member was obtained by multiplying the time spent in treating each type of complication by the corresponding gross wage per minute for that staff category. The total staff cost incurred in treating each case of complication was then obtained by adding up these estimations.
Annual overheads for the year 2010 were collected from the financial statements of both health facilities. They were further discussed with the financial and administrative director in the tertiary teaching hospital, or with the person responsible for finances (or principal accountant) in the secondary level hospital, in order to identify items which were entirely paid out of the hospitals’ own finances. The overhead costs allocated to the department of gynaecology and obstetrics were calculated based on the throughput of patients in this department relative to that of the whole health facility. The estimated overhead costs attributed to the gynaecology and obstetrics department was further allocated to the maternity ward, and to each patient with an abortion. Additionally, for contractual administrative personnel working for the whole hospital, salary costs were accounted for and allocated to the maternity ward and to each case of complication treated.
Per-patient cost and estimated total cost for treating complications
The per-patient cost of treating any case of abortion complication for each hospital facility was obtained by computing the weighted average cost of all the six abortion complications we studied. For each hospital facility, the total cost of treating complications of abortion was then obtained by multiplying the number of cases treated in 2010 by the estimated per-patient cost. The estimated total cost to these two health structures was obtained by adding up the estimated costs to each hospital.
Estimated cost saving to these two public hospitals if safe abortion care services were available in 2010
To estimate the potential saving of safe abortion care services provision for the two public hospital facilities in 2010, we used additional data from a published costing study. Under a scenario that promoted the availability and accessibility of safe abortion care services, the authors estimated that safe abortion provision would only have cost USD6 . We multiplied the estimated number of complications treated in the two referral hospitals in 2010 by USD6 to obtain the total costs to these hospital facilities had women had access to safe abortion care services. Finally, we subtracted the resulting amount from the estimated total cost for treating the complications in order to ascertain the saving that would have been obtained in that year.
It is widely admitted that studies investigating abortion, particularly induced abortion, are subject to numerous limitations. Among these limitations, underreporting of cases has been acknowledged as a major source of bias which affects estimates. Underreporting may be caused by misclassification of cases, particularly induced abortions into spontaneous abortions, [27, 28] even at hospital level. This study may have been affected by misclassification of cases making it necessary to conduct a sensitivity analysis. This sensitivity analysis aimed at anticipating the lack of determinism in the parameters used to estimate the total cost of treating abortion complications. In the absence of recommendations in choosing sensitivity values for abortion costing studies, previous studies which have estimated the cost of treating abortion-related complications have used various sensitivity values [14, 16, 17]. Because of this, minimum and maximum values used to test for the sensitivity of the results were set to 25 %, lesser or greater than the central estimates . These minimum and maximum values are interpreted as the amount by which the total cost of treating the complications of abortion and the potential cost saving could be, respectively, decrease or increased given changes in cost parameters. Therefore, sensitivity tests of the estimated total cost of treating the complications of abortion were performed on all parameters, including: number of treated cases, unit cost of drugs and supplies, staff cost, and overheads. Additionally, we also tested the changes in the estimated saving if safe abortion care services were available in 2010, relative to the same parameters. All sensitivity tests were performed using a one-way sensitivity model built on Excel 2010.