One of the critical targets for countries that are trying to meet the sustainable development goals is reducing the number of mothers who die from complications during or immediately after their pregnancies. The target for 2030 is that each country will have less than 70 mothers dying for each of the 100 000 live births that happen each year. This would eliminate almost all preventable maternal deaths.
In Kenya, this is still a challenge. Every year for every 100 000 births 495 women die. One of the major contributors to this figure are the complications that women sustain during unsafe abortions.
Unsafe abortions happen when a pregnancy is terminated by someone who lacks the necessary skills and in places that aren't medically certified.
In Kenya, abortion is only legal when there is a need for emergency treatment or the life or health of the mother is in danger. Permission for an abortion must be made by a trained health professional.
The latest data for Kenya (from 2012) shows that there were close to half a million unsafe abortions in the country that year. At least 100 000 of those women needed to be treated in hospital. And roughly a quarter died due to complications.
In our study we evaluated the costs - both financial and those related to human resources in health facilities - that Kenya's public health facilities incurred treating complications stemming from unsafe abortions.
We calculated that in 2012 the Kenyan government would have spent an estimated USD $5.1 million treating women who had developed complications from unsafe abortions. We estimated that by 2016 this figure would have gone up to USD $5.2 million.
This is roughly what the Kenyan government spends funding free primary health care for six months of the year. And the same amount could provide effective contraceptives to about 50 000 Kenyan women who are of reproductive age. Treating these women also puts additional strain on Kenya's already stretched health care system.
To manage the problem Kenya needs to take urgent action to implement policies and laws that it has in place that are designed to protect women, particularly their reproductive rights. For example, women need better access to a range of contraceptives.
But this kind of change requires political will to strengthen governmental institutions and agencies mandated to protect women's health.
Counting the costs
For our study we analysed the national and regional distribution of abortion complications by caseload and severity along with data on the direct costs attached to these. We interviewed health care providers in panels and individually. And then we also looked at the amount of time health care providers spent with patients, the drugs they prescribed, and the supplies they required.
Using these details we were able to calculate the costs for treating mild, moderate and severe complications. We were also able to establish which region in Kenya spent the most to treat complications.
We found that most of the complications were moderate to severe. These were classified as medical emergencies, meaning they either were or could quickly become life threatening if they were not treated immediately. To treat these complications patients required extended hospital stays, intensive care, and needed to be attended by highly skilled health providers.
Health care workers could spend over 12 hours treating a patient with such complications. The procedures ranged from draining an abscess in the pelvis to repairing a cervical or vaginal tear.
About 35% of the cases were classified as severe but they accounted for more than half of the total costs. As expected, severe complications cost the most: USD $2.7 million in total while treating moderate complications totalled USD $ 1.7 million. Mild complications cost USD $ 646,234.
At the per-case level, typical treatment could cost on average US$ 39 for mild complications to USD $108 for severe complications. But our cost estimates were conservative. They exclude patients' missed days of work, facility space, cost of referrals, and overheads.
Our analysis showed that facilities in Rift Valley and Western regions of Kenya had spent more than the other seven regions treating the complications of unsafe abortions. They also had the greatest numbers of women admitted.
Responding to the problem
To reduce the number of unsafe abortions in Kenya, the root cause of the problems need to be addressed. There are several.
For one, Kenya has a variety of policies around sexual and reproductive health rights through which public facilities are mandated to protect girls' and women's health. But in many regions women don't have access to contraceptives.
If these policies are implemented it would accelerate access to contraception. Health providers, women, and communities need to be educated about these policies and what they mean for womens' rights to contraception, the prevention of unsafe abortions, and the availability of quality post abortion care.
Women and men must also be able to access information about the most effective methods of contraception to reduce the number of unintended pregnancies, unsafe abortions, and the complications that arise from these procedures.
In addition, family planning services need to be improved and more contraceptive choices need to be offered to girls and women. And post-abortion services - both family planning counselling and access to services - need to be available.
* Hailemichael Gebreselassie, a senior research advisor at Ipas, a global non-profit that works to reduce maternal mortality, contributed to the writing of this article.