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Costs of Induced Abortion and Cost-Effectiveness of Universal Access to Modern Contraceptives in Uganda

ProQuest Dissertations and Theses, 2011
Dissertation
Author: Joseph B Babigumira
Abstract:
Despite being illegal and highly restricted, induced abortions are common in Uganda and usually result in serious complications because procedures are performed in clandestine and unhygienic practices. Part of the reason for this is a low level of contraceptive coverage in the country--over two thirds of women who need contraception lack access to modern effective methods. The aim of this dissertation was to estimate the average and national cost of induced abortion and the potential cost-effectiveness of universal access to modern contraceptives in Uganda. We used decision analysis and Markov modeling and obtained data from primary studies, an on-going prospective study of women following treatment for post-abortion complications, and the published literature. We accounted for uncertainty in parameter estimates using Monte Carlo simulation. We found that the average societal cost per induced abortion (95% credibility range) was $124 ($95 to $160). Patients incurred an average of $68 ($50 to $115), 91% of the healthcare costs of induced abortion, while government incurred an average of $7 ($5 to $10), 9% of the healthcare costs of induced abortion. This amounts to $37 million in annual spending on induced abortions which is 4.6% of the approximately $800 million in annual national health expenditure in Uganda. We also found that universal access to modern contraception would reduce the mean pregnancies per woman from 9.51 to 7.90 and mean live births from 6.92 to 5.79 compared to current access levels. The incremental cost-effectiveness ratio comparing a new national contraceptive program that achieves universal coverage to modern contraception to the current program in which access to modern contraception is limited was $88 per disability-adjusted life year (DALY) averted (societal perspective) and $138 per DALY averted (governmental perspective). The results were robust to sensitivity analysis. We concluded that induced abortions are associated with substantial costs in Uganda and that patients incur the bulk of these costs. We also concluded that universal access to modern contraceptives in Uganda appears to be highly cost-effective. We recommend that efforts by the government to reduce induced abortions by increasing contraceptive coverage should be considered among Uganda's public health priorities.

TABLE OF CONTENTS Page List of Figures ii List of Tables iii Acknowledgments iv Dedication v 1. Estimating the costs of induced abortion in Uganda 1 1.1. Introduction 1 1.2. Methods 2 1.2.1. Model structure 2 1.2.2. Estimation of costs of induced abortion 4 1.2.3. Analysis 6 1.3. Results 6 1.3.1. Costs per average case of abortion 6 1.3.2. National estimates 6 1.3.3. Sensitivity analysis 7 1.4. Discussion 7 References 14 2. Projecting the potential cost-effectiveness of universal access to modern contraceptives in Uganda 18 2.1. Introduction 18 2.2. Methods 19 2.2.1. Markov Model 19 2.2.2. Starting distribution of the hypothetical cohort among Markov states 20 2.2.3. Transition between states of contraceptive use and pregnancy 21 2.2.4. Mortality 22 2.2.5. Disability-Adjusted Life Years (DALYS) 22 2.2.6. Costs 22 2.2.7. Sensitivity analysis 23 2.3. Results 24 2.3.1. Model validation 24 2.3.2. Cost-consequences analysis 24 2.3.3. Base case analysis 24 2.3.4. Sensitivity analysis 25 2.4. Discussion 26 References 38 3. Appendices 41 3.1. Appendix A. Estimating the health resource use and costs of treating induced abortion complications 41 3.2. Appendix B. Estimation of transportation, upkeep and lost productivity costs associated with induced abortion 45 3.3. Appendix C. Calculation of out-patient costs of induced abortion 47 3.4. Appendix D. Calculation of the costs of the modern contraception (MOC) state in the Markov model 48 3.5. Appendix E. Calculation of the costs of the pregnant (PRE) state in the Markov model 50 References 53 i

LIST OF FIGURES Page Figure 1.1. Decision tree showing the consequences of induced abortion in Uganda 12 Figure 1.2. Tornado diagram of univariate sensitivity analysis 13 Figure 2.1. Markov model : 34 Figure 2.2. Tornado diagrams of univariate sensitivity analysis from the societal perspective 35 Figure 2.3. Incremental cost-effectiveness scatter plot obtained from probabilistic sensitivity analysis 36 Figure 2.4. Cost-effectiveness acceptability curves obtained from probabilistic sensitivity analysis 37 II

LIST OF TABLES Page Table 1.1. Average probabilities of induced abortion consequences, complications and treatment 9 Table 1.2. Itemized costs used in the analysis 10 Table 1.3. Average costs of induced abortion in Uganda by the different cost categories 11 Table 2.1. Age-specific transition probabilities from different states of contraceptive use, pregnancy and death 29 Table 2.2. Parameters of the Markov model 30 Table 2.3. Results of a cost-consequences analysis for a hypothetical cohort of 100,000 Ugandan women 31 Table 2.4. Results of the baseline analysis 32 Table 2.5. Mean incremental costs and health outcomes, and incremental cost-effectiveness ratios (ICERs) comparing the contraceptive programs 33 Table 3.1. Drugs used, unit costs and mean drug costs of treating induced abortion com plications 42 Table 3.2. Supplies used, unit costs and mean supplies costs of treating induced abortion com plications 43 Table 3.3. Diagnostic tests used, unit costs and mean diagnostic costs of treating induced abortion com plications 44 Table 3.4. Data inputs for calculation of transportation, upkeep and lost productivity costs associated with induced abortion 46 Table 3.5. Summary of the costs of treating out-patient complications of induced abortion 47 Table 3.6. Costs of the modern contraception technology in Uganda for nine months of coverage 49 Table 3.7. Non-contraceptive-technology costs of contraception in Uganda for nine months of coverage 49 Table 3.8. Estimating the cost of pregnancy outcomes 51 Table 3.9. Estimating the cost of term pregnancies 51 Table 3.10. Calculation of societal and governmental costs of the pregnant state in the Markov model 52 in

Acknowledgments I thank the Lord God for life, health, and the opportunity to make a modest contribution to improving healthcare in my country and other countries around the world. I am eternally grateful to my mother Judith for constant support and tireless daily prayers for me. My gratitude comes with much love and humility for the sacrifices you have made for your children over the years. To my beautiful sisters Janet and Hope and my loving brother Denis: thanks for your constant support and encouragement and for filling my life with much fun and humor. This dissertation is dedicated to your children. To my brother Edward, your wife Rose, and your children Eugene and Melissa: thanks for making my life in the US complete and for sharing your lives and resources. To my uncle Paul Kagwa: thank you for being like a father to me. I would like to thank my mentor and dissertation chair Lou Garrison in a very special way for friendship and support during my time at the University of Washington. I have learned a great deal from you as a scientist and a person and will always be grateful for your generosity and patience. I also thank Andy Stergachis not only for excellent mentorship and guidance, but for friendship and support and for enabling me to maintain ties to colleagues in Uganda. I am grateful to Dave Veenstra and Jackie Gardner for accepting to sit on my dissertation committee as well as support and guidance through the process. Many thanks also to Dean Jamison who took time from an extremely busy schedule to serve as my Graduate Student Representative and also made many contributions to my research. I thank Sean Sullivan for great advice and constant support and for always keeping an open door. I am greatly indebted to Penny Evans for taking care of some of the most important aspects of my graduate student experience. I acknowledge funding from the William and Flora Hewlett Foundation and Institute of International Education Dissertation Fellowship in Population, Reproductive Health, and Economic Development without which these studies would not have been possible. And I also acknowledge with much gratitude the contributions of Joseph Ngonzi and Peter Mukasa, my collaborators in Uganda. I thank all the graduate students and post doctoral fellows with whom I have shared my experience in the Pharmaceutical Outcomes Research and Policy Program (PORPP). I have learned a lot from each one of you and look forward to continued friendship and collaboration. I have been blessed with the support of many friends in the US and Uganda. I am particularly grateful to Michael Shyaka, Agripina Mwebesa, Edmund Kananura, Patricia Komugisha, Francis Asiimwe, Alfred Mulenga, Jackie Makaaru, Josh Carlson, Dost Bardouille-Crema, Sam Biraro, Richard Kyabihende, Brian Gatete, Florence Kagonyera, Griffin Kahakani, Ruth Namara, Douglas Bujara, Alex Shyaka, Sam Otada, and Laura Kamugisha. I share this achievement with you in gratitude for your friendship during good times and bad times. IV

Dedication To Daniela, Babijo, Hannah, and Isaiah -/ v

1 1. Estimating the Costs of Induced Abortion in Uganda 1.1. Introduction Induced abortion is illegal in Uganda except to save the life of a pregnant mother or in the case of rape, to preserve the victim's physical and mental health.[1] Induced abortion is also the subject of substantial social stigma. The Catholic Church, the largest single religion in Uganda to which 42% of the population belong,[2] strictly prohibits it,[3] and the rapidly-growing evangelical movement condemns it.[4] Anti-abortion stigma has even been reported among the highly- educated[5] and health workers.[6] Yet the demand for induced abortion remains high, probably because of a high number of unintended pregnancies, at least 700,000 annually,[6] which are a consequence of the low access to modern contraceptives among women who want to avoid pregnancies (31 %)[7] and of other social factors such as poverty, illness, already having too many children, or abusive relationships.[8-11] Of the unintended pregnancies, almost 4 in 10 (38%) result in abortion and the rest continue and result in unintended births.[6] Women who decide to abort often resort to illegal, untrained, and usually unskilled practitioners who practice "underground" and often provide unsafe abortion procedures that result in a high rate of complications and sometimes death. Unsafe abortions are estimated to be the cause of 21% of all maternal deaths in Uganda[6] compared to about 13% of all maternal deaths in other developing countries[12] and are a major reason why the country has one of the highest levels of maternal mortality in the world.[6, 13, 14] Therefore the problem of induced abortion, while not unique to Uganda, is of special significance in this country. In 2003, there were an estimated 297,000 induced abortions performed that resulted in 85,000 complications treated in the health care system and 1,200 maternal deaths.[15] Illegal abortions in Uganda pose a large health risk for women because of inadequate skills of the providers, unsanitary environments, and hazardous techniques[16] which increase the rate of immediate complications such as severe bleeding, abdominal and genital injury, or death. If women survive the procedure, they may develop other complications - most commonly hemorrhage, sepsis, and genital perforation.[17, 18] Such severe complications need complex tertiary care which is only available at referral public hospitals with the capacity to perform extensive surgical operations, blood transfusions, and intensive care. Patients with these complications tend to have long hospital stays with 57% staying for more than 13 days.[18] This results in consumption of large amounts of healthcare resources such as personnel, theatre space, medications, and hospital beds.[19] Some of the women who survive their hospital stay also suffer long-term complications such as pelvic infection, ectopic pregnancy, vesico-vaginal fistulae, urinary incontinence, utero-vaginal prolapse, infertility, and many mental health problems:[20-23] these complications also usually require

2 specialist care and are associated with increased health resource utilization. In a country where total per capital health expenditure is only $24,[24] costs attributable to induced abortion may represent a substantial diversion of public healthcare resources from other disease areas which, if saved, could be better deployed. Previous studies of the cost of induced abortion in Uganda did not consider the consequences of failed induction and the impact of abortion provider on healthcare costs[25] or did not include other aspects of health resource use such as cost of the abortion procedure, cost of treating complications, cost of transportation, and cost of patient upkeep.[26] The objective of the current study was to perform a comprehensive assessment of the costs associated with induced abortion in Uganda. 1.2. Methods A decision tree was developed to represent the consequences of induced abortion and to estimate the cost of an average case in Uganda from a societal perspective. Data to inform the model were obtained from a primary chart abstraction study, an on-going prospective study of women treated for post-abortion complications, and the published literature. The national cost burden for 2010 was estimated by multiplying the average cost by an estimate of the annual incidence of induced abortion in Uganda. 1.2.1 Model Structure The decision tree showing the consequences of induced abortion is shown in Figure 1 and the probabilities used to estimate the average costs of an induced abortion case are shown in Table 1. Women who choose to abort are first divided into those who seek care from practitioners with the training to safely terminate a pregnancy and those who go to practitioners without such training. Prada et al.[27] in a study in which they interviewed health professionals, reported that the proportion of abortions induced by different providers were as follows: doctors (20%); clinical officers (17%); nurses or midwives (19%); pharmacists or dispensers in drug stores (7%); traditional healers or lay practitioners (22%); and the women themselves (15%). These estimates were used to calculate the average probability of training and abortion induction by provider assuming that doctors, clinical officers, nurses, and midwives are trained providers and dispensers, lay practitioners, traditional healers, and the women themselves are untrained providers. Women who receive abortion procedures from the different providers are further divided into those for whom induced abortion succeeds and those for whom it fails. Induced abortion failure is rare, and we found no studies that estimated its incidence in Uganda or similar countries, but studies in other settings have reported frequencies of 0.01%,[28] 0.05%,[29] and 0.07%.[30] Although these studies were performed in high-income countries, we used the estimates because Ugandan medical

3 schools use international curricula. The rate of abortion failure is likely higher for procedures performed by practitioners with less training.[6, 26] To estimate this probability, we calculated the incidence of second abortion attempts using data from an on-going cohort of women treated for induced abortion at Mbarara University Teaching Hospital in Uganda. According to these data, of the 47 women who received induced abortions from untrained providers, 8 needed a second attempt and 1 needed a third attempt. The initial, failed methods were: 1) herbs for 4 women, 2) an object inserted into the birth canal for 2 women, 3) crude surgical procedures for 2 women, and 4) over-the- counter medication for 1 woman. This distribution of procedures suggests that these abortion providers were untrained and this analysis uses the proportion of women needing a second or third attempt (17%) as the probability of induced abortion failure when procedures are performed by untrained providers. We assumed that when induced abortion by an untrained provider fails, women will try a trained practitioner before ultimately succeeding in terminating their pregnancy or failing and continuing with their pregnancy. Women who have had successful induced abortions are divided in the model into those who develop complications and those who do not. The type of abortion provider has a direct influence on the probability of having abortion complications. A survey of health workers in Uganda estimated the proportion of induced abortion complications by provider.[6, 27] It reported rates of abortion complications as: 25% for doctors, 42% for nurses/midwives, 45% for clinical officers, 50% for pharmacists/dispensers, 66% for traditional healers/lay practitioners, and 73% when self-induced. Women who develop complications following induced abortion were divided into those who need out-patient care and those who need hospital care. According to Prada et al.[27] of the 109,926 estimated number of patients treated for post-abortion complications, 47,828 (43.5%) received hospital care and the rest received out-patient care. Those who need out-patient or hospital care were further divided into those who have access and those who do not have access to services. It has been reported that only 66.5% of those who need this care are able to access it depending on income and geographical location.[27] In the model, women who need and obtain hospital treatment following abortion either improve and are discharged alive, or they die in hospital. The in-hospital rate of abortion mortality ranges from 1.3%[10] to 3.3%[18] in Uganda. We assumed that those who need hospital care but are unable to access it are divided into those who die at home and those who worsen and belatedly seek hospital care - a practice which has been reported in Uganda.[31] Because data were lacking for patients who do not access services, we assumed a doubling in the mortality rate in the community (compared to hospital mortality) at baseline. We assumed that women who do not access out-patient care resort to self-mediation - a practice common in Uganda[32] - and subsequently get better. In the case of abortion failure after an attempt by a trained practitioner, the woman carries the pregnancy and faces the consequences of pregnancy. These include: a) miscarriage before 13

4 weeks gestation, b) miscarriage between 13 and 22 weeks which usually requires treatment, or c) birth of a child which includes preterm birth as well as term live or still birth. Miscarriages at 13 to 22 weeks account for 2.9% of all recognized pregnancies and live births account for 84.8%.[33, 34] The rate of still births in the East Africa region is reported to be 1.9%.[35] This was added to the rate of live births to obtain the average proportion of births both live and still (86.8%). We assumed that those who miscarry between 13 and 22 weeks face health and economic consequences similar to women who suffer induced abortion. We divided women who give birth into those who give birth at home and those who give birth in health facilities. Data from Uganda suggest that 39.3% of women deliver in health facilities.[13] In a recent study in Ugandan healthcare facilities, of the 194,029 deliveries, there was a reported 1,302 deaths for an in-hospital mortality rate among women who deliver in hospital of 0.007%.[36] We assumed that the community mortality rate was at least double that at baseline. 1.2.2. Estimation of the costs of induced abortion We estimated the average cost of each outcome in the decision tree (Figure 1). The overall average cost of induced abortion is the sum of these average costs weighted by their probability of occurrence as shown in Table 1. Cost categories The following cost categories were estimated: 1) direct medical costs, 2) direct non-medical costs, 3) indirect (productivity) costs, 4) patient costs, 5) government costs, and 6) societal costs. The total healthcare cost is the sum of the direct medical and direct non-medical costs. Direct medical costs included personnel, medical supplies, drugs, radiology tests, laboratory tests, and patient out-of-pocket costs. Direct non-medical costs included recurrent and capital expenditures, patient transportation, and patient upkeep while seeking healthcare. Indirect costs included lost productivity while seeking abortions and getting treatment for complications as well as productivity losses from abortion morbidity while convalescing and premature abortion-related maternal mortality. Government costs include the costs of treating abortion complications and pregnancy-related costs when abortions fail, but exclude the healthcare costs associated with the procurement of abortions which are illegal in Uganda and are not provided by the national healthcare system. Patient costs included the costs of procuring abortions, out-of-pocket costs, transportation, and upkeep while procuring abortions and seeking treatment for complications, and self-medication. The societal cost estimate is the sum of all the different kinds of costs. Estimation of direct medical costs of induced abortion The cost to women of abortion services by provider were obtained from a survey of health workers (see Table 2).[27]

5 A primary chart abstraction study was performed to estimate the resource use and costs for treatment of induced abortion complications in the hospital setting. In the study, which was performed at Mbarara Hospital in Uganda, a simple random sample of 200 charts was obtained from among the patients treated for abortion complications between January 2006 and December 2008. Data on health resource use - drugs, laboratory tests, radiological tests, blood transfusions, and disposable supplies - were abstracted and used to calculate the types and amounts of resources, which were multiplied by the unit costs obtained from the price catalogue of Uganda's Joint Medical Stores.[37] Data on the unit costs of laboratory tests were obtained from a study performed in a Ugandan hospital.[38] Data on the cost of radiology tests were obtained by surveying providers in Uganda's capital Kampala. Data on the cost of a single unit of transfused blood were not available for Uganda and were obtained from a study in Malawi which is similar to Uganda.[39] The calculations of the costs of drugs, supplies and diagnostic tests as shown in table 3 are described in detail in Appendix A. The costs of out-patient treatment for abortion complications were obtained from the same sources and their calculation is described in detail in Appendix C. The costs of healthcare personnel were based on a study in Uganda in which the personnel costs of treating abortion complications were estimated for public hospitals and missionary hospitals.[25] The unit costs of pregnancy-related care were obtained from the same study and included antenatal care as well as normal and cesarean birth.[25] These costs were adjusted for the proportion of women who attend at least 1 antenatal care visit which is 94%,[40] the rate of cesarean birth which is 15.7%,[41] the prevalence of common complications like post-partum hemorrhage (0.84 - 19.8%)[42] and eclampsia (0.53%).[43] Estimation of direct non-medical costs of induced abortion The overhead and recurrent (hotel) costs of out-patient and hospital treatment of abortion complications were estimated from the World Health Organization Choosing Interventions that are Cost-Effective (WHO-CHOICE) database for Uganda.[44] Transportation and upkeep costs for patients and caregivers were estimated using data from a prospective study of women treated for post-abortion complications at Mbarara University in Uganda. This study, which is ongoing, specifically asked women how much they spent to seek healthcare services and on upkeep while they sought services. The estimation of transportation and upkeep costs using data from the longitudinal study is described in detail in Appendix B. Estimation of indirect (productivity) costs Productivity losses due to morbidity were estimated using data from the prospective study by summing lost time spent in transit to hospitals (for patients and caregivers), seeking care, convalescing, and admitted to hospital (for patients and caregivers), and multiplying by wages. Wage data were obtained for formally-employed women in the same prospective study. The wage of the

6 proportion of women who were unemployed (subsistence farmers) was valued at Uganda's gross domestic product per capita at the official exchange rate which was $474 in 2009.[2] Productivity losses due to mortality were estimated using the human capital approach[45] valuing lost productivity based on GDP per capita for wage and the life expectancy for Ugandan women at age 28, the average age of women receiving treatment for induced abortion complications, obtained from World Health Organization life tables for Ugandan women.[46] The calculation of productivity costs is shown in detail in Appendix B. The unit costs used in the analysis are summarized in Table 2. 1.2.3. Analysis All costs were converted into United States dollars ($US) using the Bank of Uganda official exchange rate on 1st June 2010[47] and were adjusted to the year 2010 using Uganda's Consumer Price Index for health.[48] To take into account the potentially large amount of uncertainty in many of the parameter estimates, distributions were defined for each uncertain parameter estimate using the mean and the standard error estimated based on the assumption that all the ranges represented a 95% confidence interval (equal to four times the standard error).[49] Beta distributions were used for probabilities and normal distributions for costs. The model was run 10,000 times and on each occasion, a new set of estimates was randomly selected according to their distribution using Monte Carlo simulation. This provided an outcome distribution of the cost of an average case of induced abortion and allowed the reporting of a mean and a 95% credibility range (95% CRs) around the estimate. Univariate uncertainty analysis was also performed to determine which variables had the greatest influence on costs. The uncertainty analyses were performed using TreeAge Pro. 1.3. Resul ts 1.3.1. Cost per average case of abortion The average costs of induced abortion are shown in Table 3. The average societal cost per induced abortion (95% credibility range) was $124 ($95 to $160). The average direct medical cost was $56 ($39 to $78) and the average direct non-medical cost was $18 ($US15 to $22). The average indirect (productivity) cost was $50 ($29 to $77). Patients incurred an average of $68 ($50 to $US115), 91% of the healthcare costs of induced abortion while government incurred an average of $7 ($5 to $10), 9% of the healthcare costs of induced abortion. 1.3.2. National estimates The annual incidence of induced abortion in Uganda is 297,000 cases. Therefore the national annual expenditure on induced abortion is projected to be $16.8 million in direct medical

7 costs, $5.5 million in direct non-medical costs, $14.7 million in indirect/productivity costs, $2.1 million in costs to the government, $20.2 million in costs to patients, and $36.9 million in societal costs. 1.3.3. Sensitivity analysis Univariate sensitivity analysis (figure 2) showed that the societal cost of an average induced abortion was most sensitive to the uncertainty associated with the probability of complications when abortion is induced by a doctor, the probability of hospitalization for abortion complications, and the probability of formal training by the abortion provider. 1.4. Discussion Using a decision tree and data from multiple sources, we found that the average induced abortion in Uganda was associated with $124 in societal costs. This is over five times the per capita expenditure on health care in Uganda which is $24.[24] Given the 297,000 incident induced abortions annually,[15] this amounts to $37 million in annual spending on induced abortions which is 4.6% of the approximately $800 million in annual national health expenditure in Uganda.[2, 24] The bulk of the societal costs (60%) were healthcare costs and the remaining 40% were productivity costs. The government, which is responsible for providing healthcare in Uganda, incurred only 9% of the total healthcare costs with the bulk of the total healthcare costs (91%) incurred by patients. The annual abortion expenditure in Uganda is substantial and is a testament to the economic impact of abortion in countries where it is illegal and unsafe, which has been previously described.[50] The proportion of healthcare costs (9%) that are incurred by the government, which is, in theory, responsible for providing healthcare to all citizens, is surprising. This may be the reason for the policy maker apathy that characterizes efforts to end unsafe abortions in Uganda; the government faces only a small fraction of the costs and the problem remains invisible to government policy makers. The largest contributor to the average societal cost of induced abortion was the healthcare component of which direct medical costs were the largest. The largest part of these costs can be attributed to the treatment of the complications of unsafe induced abortions. The majority of trained and untrained providers choose surgical techniques - such as evacuation and manual vacuum aspiration - to terminate pregnancies but not misoprostol which is the safest form of medical abortion.[51] However, because abortion is illegal, the drug cannot be openly imported or sold and is therefore unavailable for the abortion indication. A limited amount is probably used off-label after importation for post-partum hemorrhage, but this is likely not enough to improve safety and reduce costs. The average healthcare cost (direct medical and direct non-medical) of induced abortion was $75. This estimate included the cost of abortion procedures as well as the treatment of post-abortion

Full document contains 64 pages
Abstract: Despite being illegal and highly restricted, induced abortions are common in Uganda and usually result in serious complications because procedures are performed in clandestine and unhygienic practices. Part of the reason for this is a low level of contraceptive coverage in the country--over two thirds of women who need contraception lack access to modern effective methods. The aim of this dissertation was to estimate the average and national cost of induced abortion and the potential cost-effectiveness of universal access to modern contraceptives in Uganda. We used decision analysis and Markov modeling and obtained data from primary studies, an on-going prospective study of women following treatment for post-abortion complications, and the published literature. We accounted for uncertainty in parameter estimates using Monte Carlo simulation. We found that the average societal cost per induced abortion (95% credibility range) was $124 ($95 to $160). Patients incurred an average of $68 ($50 to $115), 91% of the healthcare costs of induced abortion, while government incurred an average of $7 ($5 to $10), 9% of the healthcare costs of induced abortion. This amounts to $37 million in annual spending on induced abortions which is 4.6% of the approximately $800 million in annual national health expenditure in Uganda. We also found that universal access to modern contraception would reduce the mean pregnancies per woman from 9.51 to 7.90 and mean live births from 6.92 to 5.79 compared to current access levels. The incremental cost-effectiveness ratio comparing a new national contraceptive program that achieves universal coverage to modern contraception to the current program in which access to modern contraception is limited was $88 per disability-adjusted life year (DALY) averted (societal perspective) and $138 per DALY averted (governmental perspective). The results were robust to sensitivity analysis. We concluded that induced abortions are associated with substantial costs in Uganda and that patients incur the bulk of these costs. We also concluded that universal access to modern contraceptives in Uganda appears to be highly cost-effective. We recommend that efforts by the government to reduce induced abortions by increasing contraceptive coverage should be considered among Uganda's public health priorities.