Understanding the financial burden of incomplete abortion: An analysis of the out-of-pocket expenditure on postabortion care in eight public-sector health care facilities in Dakar, Senegal

In 2018, a study assessed the out-of-pocket expenditure on postabortion care (PAC) borne by women in Dakar, Senegal. The study found that women reported expenditures on transportation, admission, treatment, family planning, hospitalisation, complementary tests, prescriptions, other medicines, and materials. The average out-of-pocket expenditure on PAC was USD $93.84, with higher costs reported at hospitals ($120.47) compared to health centres ($65.47). The study also examined the costs associated with different treatment procedures. The average cost of PAC using dilation and curettage was $112.37, manual vacuum aspiration was $99.84, and misoprostol was $61.80. These costs are significant, with the average out-of-pocket expenditure on PAC amounting to 15% of the average monthly salary for women living in Dakar. The study highlights the need for strategies that emphasize timely access to misoprostol for treating complications in primary care settings to address the contribution of out-of-pocket costs to Senegal's appreciable unmet need for PAC among the poor. In sub-Saharan Africa, an estimated 8.2 million induced abortions occurred each year from 2010 to 2014, representing approximately 15% of all pregnancies in the region. The region has the highest abortion case-fatality rate of any world region, approximately 185 deaths per 100,000 abortions, for a total of 15,000 preventable deaths per year. Postabortion care saves women from the fatal consequences of abortion complications and promotes access to contraceptive methods for women who wish to use them after receiving emergency care. In Senegal, the abortion law is both restrictive and unclear, with the country's criminal code completely prohibiting the practice, while the code of medical ethics permits pregnancy termination to save a pregnant woman's life. The Ministry of Health (MOH) of Senegal introduced PAC to the country in 1997, and subsequent research has emphasized the use of provider and self-administration of misoprostol for treatment of abortion complications. The MOH has since called for the availability of both surgical aspiration and misoprostol for PAC provision at all levels of care throughout the Senegalese health system. Despite these successes, data from the previous decade raise concerns. Between one-quarter and one-third of pregnancies in the country are unintended, and, on average, Senegalese women give birth to between one and two more children than they desire. In 2018-19, only 17.9% of women in Senegal were using modern contraception. The incidence of induced abortion and consequences of unsafe abortion in Senegal are significant, with 24% of all unintended pregnancies in the country ending in abortions, 60% in unplanned births, and 16% in miscarriages. A salient barrier to timely attainment of PAC are costs, yet health systems often lack data that can guide efforts to ameliorate economic barriers to access. A Nigerian study of the direct costs of unsafe abortion estimated that nearly three-quarters of costs were shouldered by the woman and/or her household. A study from Uganda estimated high direct costs for abortion-related care at US$62 per abortion, and a study from Burkina Faso found that, excluding costs incurred prior to hospitalisation, the cost women incur on treatment for complications of induced abortion was considerably higher than spontaneous abortion. The study presented in this article provides evidence on the costs borne by women who sought routine PAC services for the treatment of incomplete abortion in Dakar, Senegal. The study compares clients' expenditures on PAC obtained at hospitals with those incurred at lower levels of the health care system, as well as costs incurred on different treatment procedures. The study also examines the drivers of out-of-pocket expenditure and illuminates opportunities to reduce economic barriers to PAC.