Direct and opportunity costs of comprehensive abortion care for women living in humanitarian settings in the Amhara Region, Ethiopia

Abstract

BACKGROUND: Providing comprehensive abortion care (CAC), including induced abortion and post-abortion care (PAC) to manage complications, poses a financial challenge, particularly in humanitarian settings. Unsafe abortions and the costs of PAC impose a significant health and economic burden on women and society. This study aimed to assess the direct and opportunity costs of CAC for women who experienced CAC in humanitarian settings. METHODS: A stratified sampling approach was initially used to select 31 public health facilities across seven administrative zones in the conflict-affected northern Amhara region of Ethiopia. Structured surveys were administered to 1,642 women aged 13-49 years who received care for induced abortions and treatment of incomplete abortions between September 2023 and March 2024. Descriptive statistics were used to analyze direct costs associated with attempts for pregnancy termination at home, visits and stay at the health facility, needs and care after the surgical procedure, and re-visits. The opportunity costs of time for women and their caregivers were measured using gender-specific daily wages for low-skilled workers. RESULTS: The total direct cost for women undergoing all stages of CAC, including attempts for pregnancy termination, transportation, cost of food, drugs, and diagnostic tests, and additional costs for recovery and readmission, and caregiver expenses, was ETB 7,416.8 (US$134.16). Direct costs limited to the facility visit and post-procedure period were 3,273.4 (US$ 59.21). Opportunity costs were substantial, totaling ETB 2,024 ($36.61) of household income lost. Incomplete abortions (ETB 8,540.8, US$ 154.5) were costlier than induced abortions (ETB 7,282.3, US$ 131.7) and women treated in general hospitals incurred the highest total costs (ETB 11,038.0, US$ 199.7), while costs were the lowest at primary hospitals (ETB 7,635.8, US$ 138.1). CONCLUSION: Women in humanitarian settings in the Amhara Region of Ethiopia face significant financial burdens when seeking CAC, despite its availability through public services. The burden is pronounced for those receiving treatment for incomplete abortions. These findings highlight the urgent need for policy measures to reduce financial barriers and ensure equitable access to safe, affordable abortion care, especially for populations in humanitarian settings. CLINICAL TRIAL NUMBER: not applicable.