Reproductive Health Matters

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Exploring the costs and economic consequences of

unsafe abortion in Mexico City before legalisation

Carol Levin, Daniel Grossman, Karla Berdichevsky, Claudia Diaz, Belkis

Aracena, Sandra G Garcia & Lorelei Goodyear

To cite this article: Carol Levin, Daniel Grossman, Karla Berdichevsky, Claudia Diaz, Belkis
Aracena, Sandra G Garcia & Lorelei Goodyear (2009) Exploring the costs and economic
consequences of unsafe abortion in Mexico City before legalisation, Reproductive Health Matters,
17:33, 120-132, DOI: 10.1016/S0968-8080(09)33432-1

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© 2009 Reproductive Health Matters

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Exploring the costs and economic consequences of

unsafe abortion in Mexico City before legalisation
Carol Levin,a Daniel Grossman,b Karla Berdichevsky,c Claudia Diaz,c
Belkis Aracena,d Sandra G Garcia,e Lorelei Goodyearf
a Senior Health Economist, Program for Appropriate Technology in Health (PATH), Seattle WA, USA.
E-mail: clevin@path.org
b Senior Associate, Ibis Reproductive Health, Oakland CA, USA
c Research Coordinator (at the time of the study), Population Council Mexico Office, Mexico City, Mexico
d Researcher, Department of Health Economics and Policy, National Institute of Public Health,
Cuernavaca, Mexico
e Director, Population Council Mexico Office, Mexico City, Mexico
f Senior Program Officer, PATH, Seattle WA, USA

Abstract: An assessment of abortion outcomes and costs to the health care system in Mexico City
was conducted in 2005 at a mix of public and private facilities prior to the legalisation of abortion.
Data were obtained from hospital staff, administrative records and patients. Direct cost estimates
included personnel, drugs, disposable supplies, and medical equipment for inducing abortion or
treating incomplete abortions and other complications. Indirect patient costs for travel, childcare
and lost wages were also estimated. The average cost per abortion with dilatation and curettage was
US $143. For manual vacuum aspiration it was US $111 in three public hospitals and US $53 at a
private clinic. The average cost of medical abortion with misoprostol alone was US $79. The average
cost of treating severe abortion complications at the public hospitals ranged from US $601 to over
US $2,100. Increasing access to manual vacuum aspiration and early abortion with misoprostol
could reduce government costs by 62%, with potential savings of up to US $1.6 million per year.
Reducing complications by improving access to safe services in outpatient settings would further
reduce the costs of abortion care, with significant benefits both to Mexico's health care system and
women seeking abortion. Additional research is needed to explore whether cost savings have been
realised post-legalisation. ©2009 Reproductive Health Matters. All rights reserved.

Keywords: health care costs, out-of-pocket health expenditure, abortion methods, unsafe abortion,
abortion law and policy, Mexico

U
NTIL 2007, when first trimester abortion
was legalised in Mexico City, abortion was
legally restricted in Mexico. Even for legal
indications, such as pregnancy resulting from
rape or when the pregnancy threatened the
woman's life, abortion services were rarely avail-
able because few states had established mecha-
nisms by which women could seek care. In 2002
in Mexico City, the process to obtain a legal abor-
tion following rape involved six steps at four dif-
ferent locations, and could take three months
or longer.1
Illegal abortion services were much more
accessible than legal services, even if a woman
might qualify for a legal abortion. Illegal abor-
tion services by private providers are widely
available in Mexico, especially in urban areas,
and range from safe to unsafe. Poor women
and women from rural areas suffer the conse-
quences of unsafe abortion disproportionately.2

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 C Levin et al / Reproductive Health Matters 2009;17(33):120–132
Increasingly, women are using misoprostol
obtained either from a provider or directly from
a pharmacy or other drug seller in order to
induce an abortion.3–5 This is happening not
only in Mexico but all over Latin America.
While efforts to improve access to safe abor-
tion services in Mexico have been limited until
recently, post-abortion care programmes using
manual vacuum aspiration (MVA) to treat abortion
complications have been extensively promoted.6
Some data suggest that, at least for first tri-
mester abortion, illegal services in Latin Amer-
ica may be safer than they were in the past. This
has been documented in Brazil, where, as miso-
prostol use increased, a corresponding reduction
in abortion-related complications was observed.7
A recent review of death certificates in two dis-
tricts in Mexico found no deaths that were sus-
pected to be related to first trimester abortion
procedures. 8 Another study on the incidence
of abortion in Mexico found that the severity
of abortion-related complications decreased
between 1990 and 2006.9
Although data exist on abortion-related mor-
bidity and mortality, there has been relatively
little research on the economic impact of unsafe
abortion. In the area of post-abortion care,
research in Brazil demonstrated the cost savings
of introducing MVA in settings where dilatation
and curettage (D&C) was the norm, especially
when MVA is performed on an outpatient basis
under local anaesthesia.7 Similarly, a recent
study from Nigeria found that out-of-pocket
costs were higher for women who developed
serious complications after an abortion outside
of the hospital compared to those who had less
severe or no complications. 10 Yet this study
also reported that charges for D&C were only
slightly higher than those for MVA, 8 even
though outpatient MVA should be less costly
than inpatient D&C.6
The aim of this study was to estimate the
costs incurred by the health care system asso-
ciated with the treatment of incomplete abortion
and other abortion complications due to unsafe
abortion in Mexico City prior to reform of the
abortion law. This includes the costs of surgi-
cal abortion (MVA and D&C) and medical abor-
tion (MA) for incomplete abortion, as well as
treatment of haemorrhage, sepsis, uterine perfo-
ration, cervical trauma and shock. More specifi-
cally, we compared the costs of treating incomplete
abortion and other abortion complications in
three hospitals in the public health system (as a
proxy for costs associated with unsafe abortion)
with the costs of performing safe abortions ille-
gally in a private clinic.
Methodology
Study sites
The study was conducted between January and
July 2005 in Mexico City. Cost and abortion
outcome data were collected from a convenience
sample of three public hospitals and one private
clinic, representative of facilities providing abor-
tion services to women. Hospital MX1, part of
the Federal District Ministry of Health, was
selected because it is one of two public hospitals
in Mexico City that had implemented abortion
services for the limited number of legal indica-
tions at the time of the study. Hospital MX2 is a
large tertiary hospital within the Mexican Social
Security System that serves non-governmental
employees with low to moderate income levels.
Hospital MX3 is a tertiary public hospital serving
a low-income population without access to social
security services and is part of the national Min-
istry of Health.
In all three public hospitals, women were
generally seeking treatment for incomplete
abortion; they reported to the emergency room
and were then transferred to the gynaecology
ward. Even though hospital MX1 was authorised
to perform legal abortion for limited indications,
very few legal abortions were performed. Both
D&C and MVA were used in the gynaecology
operating room. Most women attending the
three hospitals did not require an overnight
stay. They recuperated in a separate room on
the gynaecology ward for 2–8 hours before leav-
ing. The exception was in hospital MX3, where
women having a D&C stayed for 24 hours. All
three hospitals reported very few cases of severe
post-abortion complications (other than incom-
plete abortion). However, women who did pres-
ent with such complications were hospitalised.
Clinic MX4 is a private clinic that provided
comprehensive reproductive health care for
women, including safe but illegal induced abor-
tions using MVA or MA. For women having
MVA, in the first visit the doctor consulted
with the patient and evaluated her for sexually
transmitted infections. In the second visit, she
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 C Levin et al / Reproductive Health Matters 2009;17(33):120–132
received counselling, had the MVA and recuper-
ated. A follow-up visit was scheduled two weeks
later. Women who received misoprostol on the
second visit took it at home and had a follow-
up visit on the fifth day after taking the medica-
tion, to confirm completion of the abortion by
ultrasound, with an additional follow-up visit
two weeks later. Women over 14 weeks gestation
were referred elsewhere.
Table 1 summarises the characteristics of the
study facilities. All three abortion methods were
used across the four facilities, but to differing
degrees. In the public hospitals, 82–97% of
cases of treatment of incomplete abortion and
the rare legal abortions were done using D&C;
MVA was used less frequently. Medical man-
agement of incomplete abortion using miso-
prostol was not practised in these facilities.
In the private facility, MVA was the only sur-
gical technique, used in approximately 95% of
cases, and in the remaining 5%, MA with miso-
prostol alone was used. In all study facilities,
treatment was provided by at least one phy-
sician with a nurse present. Where D&C was
122
performed, general anaesthesia was adminis-
tered by an anaesthetist. In the three public hos-
pitals, local anaesthesia was used with MVA,
also administered by an anaesthetist. In the pri-
vate clinic, only local anaesthesia was used and
was administered by the physician performing
the procedure.
Data collection and analysis
The cost estimates presented in this analysis
represent the opportunity cost of all resources
used in the treatment of incomplete abortion
and other complications from the health system
perspective. Cost data were collected using an
ingredients-based costing methodology based
on guidelines recommended by the World
Health Organization.11 The ingredients approach
works from the specific abortion procedures
(D&C, MVA and MA) and treatment protocols
for septic shock, hypovolemic shock, infection
and uterine laceration, and lists the various
inputs required. Inputs here included type of per-
sonnel, drugs, consumable supplies, and medical
instruments and equipment (hospital, surgical
 C Levin et al / Reproductive Health Matters 2009;17(33):120–132
and imaging) used to induce abortion, or treat
incomplete abortion or another abortion-related
complication (Table 2 contains a list of typical
inputs). The quantities and prices of inputs used
were collected based on interviews with health
care providers at each hospital and clinic. No
observational data or individual patient records
were used. However, whenever possible, a
visual inspection of the surgical or procedure
room was used to create an inventory of supplies
and equipment for providing abortion and treat-
ment of incomplete abortion and other compli-
cations. Supplementary budgetary data and
expenditure records were used to gather informa-
tion on salaries and indirect facility overhead
costs. Lastly, the indirect costs of patient travel,
childcare and reported lost wages were also
collected in an effort to capture women's non-
medical expenses. This study was not able to
capture the costs associated with the initial inter-
ventions by women that led to incomplete abor-
tion. All costs were in Mexican pesos and were
converted to US dollars (USD) using the exchange
rate of US $1=11 pesos valid in 2005.
A more detailed description of how each cost
component was estimated is available from the
authors. Here we briefly describe the estimation
of personnel costs, drugs and disposable supply
costs, medical instrumentation and equipment,
and operational costs. Staff costs included the
service time of doctors and nurses in the direct
provision of care before, during and after induc-
ing an abortion, treating an incomplete abortion
and/or treating a complication. Indirect time
spent by other staff serving patients was also
included; the percentage of indirect support
staff time spent was estimated by hospital per-
sonnel. The quantity and price of drugs for
abortion services were collected from each hos-
pital or clinic for analgesics, antibiotics and
anaesthetics (local and general). Additional
types of drugs, including uterotonics, oxygen
and other emergency medications used for the
treatment of abortion complications, such as
septic shock, hypovolemic shock, infections
and repair of uterine perforation, were estimated
separately. Cost information was obtained from
hospital pharmacies, clinic invoices, and central
stores in Mexico City or the national Ministry of
Health, depending on the facility.
Costs for laboratory tests for abortion com-
plications were obtained from hospital user fee
lists, showing what patients would pay. It was
considered too difficult to use micro-costing
methods to obtain costs for laboratory person-
nel, supplies and equipment in the large public
hospitals in Mexico City. The annual costs of
medical instruments and equipment were cal-
culated using reported useful years of life for
capital goods and a depreciation rate of 3% on
instruments and equipment. The total annualised
cost of medical instruments and equipment per
woman treated was estimated separately for each
type of abortion procedure (D&C, MVA and MA)
and for each type of abortion complication.
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 C Levin et al / Reproductive Health Matters 2009;17(33):120–132
Facility operating costs were estimated either
from hospital administrative records, where
easily available, or from published or available
hospitalisation cost estimates obtained from the
Mexico City or the national Ministry of Health
central records. Hospitalisation costs were adjusted
by subtracting the share of costs attributable to
personnel, drugs and supplies used to provide
abortion services to estimate a proxy for operat-
ing expenses. Hospitalisation costs were adjusted
to cover operating expenses only and pro-rated
for the patient's length of stay at each hospital,
depending on the service.
Health workers administered a brief question-
naire to women seeking reproductive health
services at each facility to estimate the average
transport cost, childcare cost and lost wages
associated with a general visit, family planning
services and abortion care. The data presented
primarily capture their transportation and
child care costs. Most women did not report
an amount for the wages lost but did indicate
that they missed work for their hospital or
clinic visit. An average of 33% of the women
interviewed (n=75) in all the facilities said that
they had missed all or part of a day of work to
receive treatment. It was beyond the scope of
this project to estimate the lost wages from
women who did report missing a day of work
but did not specify an amount. A proxy of the
average daily wage across all women who
reported missing work is used in this analysis,
which is likely to underestimate the actual lost
income. The estimate covers all visits to receive
treatment, including follow-up visits.
The total costs are presented as a total (direct
and indirect) cost per woman having an abortion,
receiving post-abortion care using D&C, MVA or
MA, and any additional costs for the treatment of
complications and required hospitalisation. These
costs are the sum of labour, drugs and disposable
supplies, medical instruments, equipment, oper-
ating expenses and patient costs.
Data on the treatment of incomplete abortions
and induced abortions were collected directly
from hospital records or interviews with medical
personnel, where available. It was more difficult
to obtain information on the number of other
more severe abortion-related complications. All
three public hospitals reported very low rates of
severe abortion-related complications. Because
of the difficulty in obtaining complete infor-
124
mation on complication rates for the sample
hospitals, the analysis uses data on complication
rates for the Mexico City and national Ministry
of Health hospitals and both types of social
security hospitals.12–14 Sensitivity analysis varied
the complication rate to estimate a range of plau-
sible costs.
In order to estimate the potential impact of
legalising safe abortion, the analysis estimated
the total costs associated with scenarios that
assume legal access, as well as increased access
to MVA and MA services for early abortion.
Results
Health outcomes
Each of the public health facilities in this study
performed approximately 600 to 1,400 abortions
annually for the years 2004 and 2005, for a total
of 3,945 cases. The great majority (over 95%)
were for treatment of incomplete abortion. The
private clinic providing safe but illegal abortions
performed an average of 720 abortions per year,
based on 2004 and 2005 patient visits, using
MVA and to a limited extent MA. All four facil-
ities reported very low rates of serious abortion-
related complications or had incomplete data.
Table 3 shows the complication rates used in
the sensitivity analysis that would be expected if
abortion were legally available in all settings.
According to the available data for Mexico City,
of all the women who presented at hospitals for
treatment after an abortion (14,163 total cases),
92.20% were treated for incomplete abortion,
7.69% required treatment for infection, and
0.06% required repair of a uterine perforation.12
We were unable to obtain direct information
 C Levin et al / Reproductive Health Matters 2009;17(33):120–132
about blood transfusion. Hospital discharge data
indicated that 1.29% of women presenting for
abortion-related care were diagnosed with hae-
morrhage, 12 and we estimated that 10% of
them required a blood transfusion. We therefore
estimated that 0.13% of women presenting for
treatment after abortion required a blood trans-
fusion. The complication rates listed for the
“low” scenario in Table 3 are similar to those
reported in settings where abortion is safe and
legal.14,15 Estimates for the “high” complication-
rate scenario are based on hospital discharge
data indicating a higher incidence of severe com-
plications, taken from other states in Mexico as
compared to Mexico City. For example, in Chiapas,
one of the poorest states in Mexico, the reported
incidence of uterine perforation is at least 0.16%,
or more than double that of Mexico City. 12
This was rounded up to 0.20% in the table.
Cost of treating incomplete abortion and/or
induced abortion
Figure 1 and Table 4 present data on the average
cost of post-abortion care or inducing abortion
for the three types of abortion procedure (D&C,
MVA and MA) at the four study sites in Mexico
City. Cost estimates are presented with and
without patient costs. The total cost per patient
was highest in the two largest public hospitals
(MX3 and MX2), located in the more central
parts of Mexico City and serving the largest
number of patients. The cost of providing abor-
tion was lowest in the private clinic providing
safe but illegal induced abortion, using MVA
and MA. In the private clinic, the total cost
per patient of providing MVA, excluding patient
costs, was US $53, almost 60% of the average
cost of MVA (US $93) used to treat incomplete
abortion in the three public hospitals. MVA cost
less than D&C. The total cost of treating an
incomplete abortion with D&C ranged from US
$103 to US $192 in the three hospitals. MVA
was slightly lower, ranging from US $96 to US
$124. At the private clinic, the cost of providing
MA was slightly more expensive than MVA, but
both methods were significantly less costly
compared to the treatment of incomplete abor-
tion in the public hospitals.
Cost profiles
The variation in costs across facilities is shown
in the breakdown of costs by category in Table 4.
The general allocation of total costs to staff
time, drugs and supplies, and equipment was
similar across the three public hospitals. Operat-
ing expenses were the largest contributor to
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 C Levin et al / Reproductive Health Matters 2009;17(33):120–132
average cost per patient, followed by labour
costs, drugs and supplies, and lastly, equipment.
Among the direct service-related expenses, per-
sonnel time was the largest cost item across all
four facilities. In each public hospital setting,
average staff costs per patient were lower for
MVA compared to D&C. In the private clinic,
staff costs for MVA were higher than for MA,
accounting for 85% to 94% of direct input
costs, respectively. However, drugs accounted
for 34% of total costs for the provision of med-
ical abortion, due to the high cost of misoprostol
tablets in Mexico. In the hospital settings, the
share of costs for drugs and supplies used for
D&C and MVA was between 2% and 13%, and
was generally lower for MVA, which requires
only local anaesthesia. The share of total costs
126
for equipment was slightly higher for MVA,
reflecting the need to purchase MVA cannulas
and syringes.
Cost of treating abortion complications
We estimated the average cost per woman treated
by complication type for each public hospital,
shown in Table 5. Costs of treating complica-
tions were in addition to initial costs of treating
an incomplete abortion. On average, infection
was the least costly to treat, although it was
the most prevalent complication. Treatment
costs on average were: septic shock (US $2,140),
hypovolemic shock (including blood transfusion)
(US $1,602), mild to moderate sepsis (US $601),
and repair of uterine perforation (US $1,408).
The Mexico City public hospital (MX1) had
 C Levin et al / Reproductive Health Matters 2009;17(33):120–132
the lowest average treatment costs for shock
(US $595), infections (US $596) and uterine per-
foration (US $907). Average costs were highest at
the Mexico City Social Security System public
hospital (MX2) for treating shock (US $3,170),
infections (US $912) and uterine perforation
(US $2,270). These costs included hospitalisa-
tion for inpatient care, some 4–7 days for shock,
2–3 days for infection, and 4–10 days for repair of
uterine perforation.
Costs of unsafe vs. safe abortion
To estimate the total cost of treating incomplete
abortion, including costs associated with treating
more severe abortion complications, we used
7.9% as the estimate for the 2005 baseline rate
of more severe abortion complications, asso-
ciated with legally restricted access. This gave a
total cost of US $2.6 million to treat all compli-
cations related to unsafe abortion for one year
for Mexico City, or an average cost per woman
treated of US $186. Assuming a high rate of
complications from unsafe abortion, as pertains
in the poorest parts of Mexico, with 11% of
women experiencing more severe complications,
the cost to the government of treating all abortion-
related complications would reach US $2.9 million
or $209 per woman treated. In contrast, if a low
complication rate associated with legal abortion
is assumed, the total complication rate would
be an estimated 1.1%, and the total cost for treat-
ing abortion-related complications would be US
$2 million, or an average cost per woman treated
of US $144 (see Table 6).
These estimates show that modest cost sav-
ings would be achievable if efforts were made
to reduce complications associated with unsafe
abortion. For instance, reducing the rate of more
severe complications from 7.9% to 1.1% by
making safe and legal abortion more broadly
available could save US $43 per woman treated,
or over US $600,000 per year for the government
of Mexico City. Similarly, a reduction of com-
plication rates from 11% to 1.1% would lead to
savings of US $65 per woman or a total of close
to US $1 million annually.
Even greater savings would be possible, how-
ever, if lower-cost methods for treating incomplete
abortions were introduced, alongside increased
access to safe and legal abortions. We explored
the potential savings for the government of this
change through two scenarios. Table 7 presents a
summary of the differences in the cost of abor-
tions for Mexico City for the situation current in
2005 (baseline) and for two different scenarios
that increase access to safe, legal abortions.
In Scenario 1, we assumed that 10% of all
abortion patients were still receiving treatment
from public hospitals using D&C at the same
average cost as in the current or baseline situa-
tion, at US $143. In Scenarios 1 and 2, an aver-
age cost of US $53 was used for providing MVA
in non-hospital settings, based on the cost of
providing services in the private clinic MX4. In
Scenario 2, a cost of US $79 was used for MA,
also based on estimates from MX4 (see Table 4).
Table 7 presents the total costs and cost sav-
ings associated with increasing access to safe
and simpler methods of abortion for Mexico
City. In Scenario 1, increasing access to legal
and safe abortion using primarily MVA would
reduce costs to the government by 62%, with
a potential savings of up to US $1.6 million. In
Scenario 2, even a modest increase in access to
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 C Levin et al / Reproductive Health Matters 2009;17(33):120–132
MA would provide additional cost savings of
over US $50,000. Key to these scenarios is that
the cost of providing abortion services declines
as access increases at smaller public and private
health facilities, which can provide abortion care
efficiently and at less cost than large hospitals.
Discussion
This study demonstrates that unsafe abortion is
costly to the Mexican health system for a
number of reasons, both health-related and eco-
nomic, and that significant cost savings per
woman can be realised through increasing
access to safe abortion services. Complications
after unsafe abortion are more common in legally
restricted settings,15,16 and treatment for them is
expensive, especially serious complications for
which prolonged hospitalisation is required.
However, at the time this study was done, prior
128
to abortion law reform in Mexico City, health
facilities were reporting many incomplete abor-
tions but few other post-abortion complications.
This may be because women and providers were
increasingly using medications such as miso-
prostol to induce abortion or because clandestine
providers might have begun using MVA more
frequently instead of dangerous invasive tech-
niques. Widespread antibiotic prophylaxis has
also been cited as a reason for a reduction in
morbidity and mortality associated with unsafe
abortion in Latin American settings.2
Despite the apparent reduction in morbidity
in recent years, the incidence of complications
reported in the hospital discharge data is still
much higher than that reported in settings
where abortion is safe and legal, and we have
demonstrated significant cost savings to the
health system in Mexico City if complications
are reduced even further. Even small reductions
 C Levin et al / Reproductive Health Matters 2009;17(33):120–132
in the incidence of serious complications has an
important impact on cost, as well as women's
health. Because the incidence of complications
is higher in other parts of Mexico, savings
would also likely be higher. In addition, the pub-
lished data on the incidence of abortion com-
plications reflect reported cases only and likely
underestimate the total costs and health burden
for women seeking abortions outside the national
health system.
In Mexico City, at the time these data were
collected, D&C was the preferred method of
treating incomplete abortion. D&C is more
costly than MVA because general anaesthesia
in an inpatient setting is required. In addition
to the expense, D&C is no longer recommended
by the World Health Organization unless MVA
is not available because D&C has a higher com-
plication rate.16,17 In two of the three public
hospitals we studied, when MVA was provided,
women were often made to stay in a recovery
area as long as women who underwent D&C,
even though MVA was provided with local
anaesthesia. In hospital MX3, where the average
recovery time was shorter after MVA, the costs
were significantly less than for D&C. Our data
suggest that treatment of incomplete abortion
could be provided through a less costly model
that relies on MVA under local anaesthesia in
an outpatient setting, combined with a shorter
recovery period.
Our findings regarding cost differences between
D&C and MVA are consistent with findings from
other studies conducted in Mexico and Latin
America, where the cost of providing MVA through
ambulatory services was 30–70% lower than the
cost of providing D&C through inpatient ser-
vices.17 Also consistent with other studies in
Latin America, 6 our findings suggest that
improvements in service delivery and increased
access to abortion services using MVA can trans-
late into potential cost savings.
Differences in the costs across methods alone
were less pronounced than differences in costs of
the different methods related to where treatment
was delivered. Excluding operating expenses
across the three public hospitals and focusing
only on the direct inputs of staff time, drugs,
supplies and equipment used to provide abortion
services, personnel time was the largest cost item
across all four facilities. The variation in costs is
explained by the choice of procedure, average
length of stay and personnel costs associated
with the provision of care. In general, average
staff costs per patient were lower for MVA com-
pared to D&C. In the two larger hospitals (MX2
and MX3), personnel costs were higher than in
the smaller secondary hospital (MX1) due to
both higher salaries and greater use of labour
resources in the provision of abortion care.
When the recovery times were equal, there
were only marginal differences between D&C
and MVA in the public hospitals because of
the higher inpatient overhead costs regardless
of which method was used. However, the cost
of providing MVA in the outpatient clinic set-
ting was 40–50% less than the cost of providing
either MVA or D&C in the hospital. The reduc-
tion in cost is explained by differences in costs
associated with local anaesthesia, lower operat-
ing expenses and less personnel time required for
post-operative care. Furthermore, the resources
used to treat incomplete abortions in a large hos-
pital would be better used to improve maternity
care and other critical obstetric and gynaecolo-
gical care,18 while moving abortion services to
smaller facilities and/or primary care settings.
In the private clinic providing safe abortion,
the cost of MA was somewhat higher than
MVA, especially when women's transportation
costs were included. This cost differential was
largely due to the additional follow-up visit
that was required with MA. A previous study in
a Latin American country where abortion was
illegal documented a similar MA protocol involv-
ing two follow-up visits; providers seemed par-
ticularly eager to ensure that women had a
complete abortion as soon as possible,19 likely
because of the fear that women might seek
care at a different clinic if they had prolonged
bleeding or other unexpected symptoms. Only
one follow-up visit is the norm in settings where
the method is approved. Under a more liberal
abortion law, providers are likely to feel more
comfortable following evidence-based protocols
with only two visits to provide MA,20 reducing
the associated costs. In addition, the cost of miso-
prostol has risen rapidly throughout Latin Amer-
ica in recent years, possibly related to the high
demand on the black market.5 With legalisation
and the appearance of generic products, this
likely would fall.
This study has several limitations. First, since
it focused on the costs of treating unsafe abortion
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from the perspective of the health system, we
were unable to capture the cost of women's
time waiting for treatment in the three hospital
settings, the cost of the initial intervention that
led to an incomplete abortion, the cost of any
abortifacient medication purchased, payment to
a provider who supplied pills or carried out a sur-
gical or other procedure, transportation costs,
childcare costs or cost of days lost from work
due to complications but prior to treatment.
Second, we could not compare the costs of
abortion provision by doctors vs. mid-level pro-
viders such as nurses or midwives, because in
Mexico only doctors are currently permitted to
provide abortion or treat incomplete abortion.
A recent study in the United States examined
different MA service delivery models using clini-
cians of varying levels and found cost differen-
tials were at least partially related to provider
level.21 Third, our sensitivity analysis did not
explore the possibility that some costs to the
patient might increase with access to safe and
legal abortion, such as increased user fees and
SECRETARIA DE SALUD DEL DISTRITO FEDERAL
out-of-pocket expenses related to recommended
follow-up visits. Future studies should attempt
to estimate these differences to capture a more
complete picture of the true costs associated
with both safe and unsafe abortions in Mexico
for women and providers.
Finally, it was beyond the scope of this study
to conduct a full economic evaluation of the costs
and health outcomes (morbidity and deaths)
associated with unsafe abortion in Mexico. This
cost analysis draws on primary data from four
facilities representative of Mexico City, along
with secondary data on abortion complications
from Mexico City only. These are not representa-
tive of other parts of Mexico. A full economic
analysis could model both the costs and effec-
tiveness of alternative policy options and at the
same time extend the geographic representation
and the analytical horizon.
After this study was completed (2005), elec-
tive abortion up to 12 weeks gestation was legal-
ised in Mexico City (2007) and access to safe
abortions has increased.22 It is too early to assess

Doctors at the inauguration ceremony of the Reproductive Health area of the Centro de Salud Beatriz
Velasco de Aleman, in Mexico City, where safe legal abortions are now being provided, 22 May 2008

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 C Levin et al / Reproductive Health Matters 2009;17(33):120–132

whether the increase in demand on the health
system for legal abortions in this new environ-
ment will translate to savings to the public
health system. This is because the reduction in
per capita costs might be outweighed by a
larger number of women seeking elective abor-
tion than those seeking treatment for incomplete
abortion in the past. It is clear, however, that
many more women could have safe abortions
with the same amount of funds. We hope to con-
duct a follow-up cost analysis within 3–5 years
of the change in legislation, when services
should be well established, in order to further
document the cost impact of improving access
to safe, legal abortion.
Our data provide overwhelming support for
shifting abortion management from emergency,
inpatient procedures to routine, outpatient pro-
cedures in Mexico City, as well as shifting away
from D&C to MVA and MA. In 2008, the Mexico
City Ministry of Health opened the first legal
abortion service at the health centre level.
They have also made important strides in reduc-
ing the use of D&C to induce abortion and
moving toward more widespread use of MVA
and MA. It is hoped that Mexico City will
serve as a model for other parts of Mexico and
that our findings will help to convince other
countries where unsafe abortion is still preva-
lent that the provision of safe abortion care is
not only cost-effective but better addresses the
needs of women.
Acknowledgements
This study was funded by an anonymous donor.
A version of this paper was presented at the
annual meeting of the National Abortion Federa-
tion on 24 April 2006.

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Résumé
En 2005, avant la légalisation de l'avortement,
on a évalué les résultats et le coût de l'avortement
sur le système sanitaire à Mexico, dans des
établissements publics et privés. Les données
ont été obtenues auprès du personnel hospitalier
et des patientes, et dans les dossiers administratifs.
Les estimations directes des coûts incluaient le
personnel, les médicaments, les consommables
et l'équipement médical pour provoquer
l'avortement ou traiter les avortements incomplets
et d'autres complications. Les frais indirects de
déplacement, de garde d'enfants et de perte de
gain des patientes ont aussi été calculés. Le
coût moyen par avortement avec dilatation
et curetage était de $US143. Par aspiration
manuelle, il était de $US 111 dans trois hôpitaux
publics et $US 53 dans une clinique privée. Le
coût moyen de l'avortement médicamenteux
avec du misoprostol seul était de $US 79. En
moyenne, le traitement des complications
graves de l'avortement dans les hôpitaux
publics allait de $US 601 à plus de $US 2100.
Un accès élargi à l'aspiration manuelle et à
l'avortement précoce au misoprostol permettrait
de réduire de 62% les coûts gouvernementaux,
avec des économies potentielles se chiffrant
à $US 1,6 million par an. En réduisant les
complications par l'amélioration de l'accès à des
services ambulatoires sûrs, on diminuerait encore
le coût des soins de l'avortement, avec de nets
avantages pour le système de santé mexicain et
les femmes souhaitant avorter. Il faut mener des
recherches supplémentaires pour déterminer si
des économies ont été réalisées après l'adoption
de la légalisation.
Resumen
En 2005, antes de la legalización del aborto en
el Distrito Federal de México, se realizó una
evaluación del impacto y los costos del aborto
en el sistema de salud del D.F., en diversos
establecimientos públicos y privados. Se
obtuvieron datos de personal hospitalario,
registros administrativos y pacientes. Los
cálculos de costos directos incluían personal,
medicamentos, suministros desechables, y
equipo médico para inducir el aborto o tratar
abortos incompletos y otras complicaciones.
También se calcularon los costos indirectos de
las pacientes en viajes, cuido de niños y sueldos
perdidos. El costo promedio por cada aborto con
dilatación y curetaje fue de US $143. Para la
aspiración manual endouterina (AMEU), fue de
US $111 en tres hospitales públicos y US $53 en
una clínica privada. El costo promedio del aborto
inducido con misoprostol solo fue de US $79.
El costo promedio de tratar las complicaciones
graves del aborto en los hospitales públicos
varió de US $601 a más de US $2,100. Al
ampliar el acceso a la AMEU y al aborto precoz
con misoprostol, se podrían disminuir los costos
gubernamentales en un 62%, un posible ahorro
de hasta US $1.6 millones al año. Al disminuir
las complicaciones tras mejorar el acceso a los
servicios seguros en ámbitos ambulatorios,
disminuirían también los costos de la atención
del aborto, lo cual sería un gran beneficio tanto
para el sistema de salud de México como para las
mujeres que buscan servicios de aborto. Aún se
necesitan más investigaciones para explorar si se
han logrado ahorros en costos post-legalización.

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