The cost of postabortion care and legal abortion in Colombia.

CONTEXT: Although Colombia partially liberalized its abortion law in 2006, many abortions continue to occur outside the law and result in complications. Assessing the costs to the health care system of safe, legal abortions and of treating complications of unsafe, illegal abortions has important policy implications. METHODS: The Post-Abortion Care Costing Methodology was used to produce estimates of direct and indirect costs of postabortion care and direct costs of legal abortions in Colombia. Data on estimated costs were obtained through structured interviews with key informants at a randomly selected sample of facilities that provide abortion-related care, including 25 public and private secondary and tertiary facilities and five primary-level private facilities that provide specialized reproductive health services. RESULTS: The median direct cost of treating a woman with abortion complications ranged from $44 to $141 (in U.S. dollars), representing an annual direct cost to the health system of about $14 million. A legal abortion at a secondary or tertiary facility was costly (medians, $213 and $189, respectively), in part because of the use of dilation and curettage, as well as because of administrative barriers. At specialized facilities, where manual vacuum aspiration and medication abortion are used, the median cost of provision was much lower ($45). CONCLUSIONS: Provision of postabortion care and legal abortion services at higher-level facilities results in unnecessarily high health care costs. These costs can be reduced significantly by providing services in a timely fashion at primary-level facilities and by using safe, noninvasive and less costly abortion methods. International Perspectives on Sexual and Reproductive Health, 2013, 39(3):114-123, doi:10.1363/3977413 Induced abortion is legally restricted and highly stigmatized in most Latin American countries, including Colombia, where the procedure was prohibited prior to 2006. However, on May 10, 2006, the Constitutional Court of Colombia issued a ruling that lifted the ban on all abortions, allowing the procedure under three limited circumstances. Abortion is permitted when a physician certifies that the life or health of the pregnant woman is threatened, when a physician certifies that the fetus has an abnormality incompatible with life, or when a pregnancy results from rape or incest that has been duly reported to the authorities. (1) Soon after the liberalization of the abortion law, the Colombian Ministry of Health and Social Protection released guidelines for the provision of legal abortion services, (2) adapted from the World Health Organization (WHO) guidelines recommended for health systems worldwide. (3) In October 2009, however, the Council of State (one of the four entities of the judicial branch) challenged the Ministry of Health and Social Protection's authority to regulate abortion; it suspended the use of the guidelines (4) and, in 2013, annulled them completely. As a consequence, although health facilities are still required to provide legal abortions, there are no official government guidelines on the recommended methods of care. * In addition, women seeking a legal abortion frequently encounter significant administrative and legal barriers. Delays are common, providers often ask for unnecessary documents or additional permission from the judicial system before proceeding, and some institutions refuse to provide legal abortions entirely (which is not permitted under the law). (5) Because of these barriers, as well as the restrictive nature of the abortion law, many women put their lives and health at risk by resorting to unsafe abortion. According to the most recent estimate, about 99% of abortions in Colombia are performed outside the law. (6) These abortions are more likely than legal abortions to be carried out in unsafe conditions by untrained providers, and to lead to both immediate complications and long-lasting health consequences. …