Original Research Gynecology| Volume 222, ISSUE 4, P348.e1-348.e9, April 2020

Download started.


Healthcare costs for abortions performed in ambulatory surgery centers vs office-based settings

Published:October 17, 2019DOI:


      Several states require that abortions be provided in ambulatory surgery centers. Supporters of such laws argue that they make abortions safer, yet previous studies have found no differences in abortion-related morbidities or adverse events for abortions performed in ambulatory surgery centers versus office-based settings. However, little is known about how costs of abortions provided in ambulatory surgery centers differ from those provided in office-based settings.


      To compare healthcare expenditures for abortions performed in ambulatory surgery centers versus office-based settings using a large national private insurance claims database.

      Materials and Methods

      A retrospective cohort study compared expenditures for abortions performed in ambulatory surgery centers versus office-based settings. Data on women who had abortions in an ambulatory surgery center or office-based setting between January 1, 2011, and December 31, 2014 were obtained from the MarketScan Commercial Claims and Encounters database. The sample was limited to women who were continuously enrolled in their insurance plans for at least 1 year before and at least 6 weeks after the abortion. Healthcare expenditures were assessed separately for the index abortion and the 6-week period after the abortion. Costs were measured from the perspective of the healthcare system and included all payments to the provider, including insurance company payments and any patient out-of-pocket payments.


      Overall, 49,287 beneficiaries who had 50,311 abortions met inclusion criteria. Of the included abortions, 47% were first-trimester aspiration, 27% first-trimester medication, and 26% second-trimester or later abortions. Most abortions (89%) were provided in office-based settings, with 11% provided in ambulatory surgery centers. Unadjusted mean index abortion costs were higher in ambulatory surgery centers than in office-based settings ($1704 versus $810; P < .001). After adjusting for patient clinical and demographic characteristics, costs of index abortions were $772 higher (95% confidence interval, $746–$797), total follow-up costs for abortions that had any follow-up care were $1099 higher (95% confidence interval, $1004–$1,195), and total follow-up costs for abortions that had an abortion-related morbidity or adverse event were not significantly different in ambulatory surgery centers compared to office-based settings. There were also no significant differences in the likelihood of having any follow-up care or abortion-related event follow-up care.


      Abortions performed at ambulatory surgery centers are significantly more costly than those performed in office-based settings, with no difference in the likelihood of receiving follow-up care. Laws requiring that abortions be provided in ambulatory surgery centers may only result in increased costs for abortions, with no effect on abortion safety.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Jones B.S.
        • Daniel S.
        • Cloud L.K.
        State law approaches to facility regulation of abortion and other office interventions.
        Am J Public Health. 2018; 108: 486-492
        • Roberts S.C.M.
        • Upadhyay U.D.
        • Liu G.
        • et al.
        Association of facility type with procedural-related morbidities and adverse events among patients undergoing induced abortions.
        JAMA. 2018; 319: 2497-2506
        • Raymond E.G.
        • Grossman D.
        • Weaver M.A.
        • Toti S.
        • Winikoff B.
        Mortality of induced abortion, other outpatient surgical procedures and common activities in the United States.
        Contraception. 2014; 90: 476-479
        • Paul M.E.
        • Mitchell C.M.
        • Rogers A.J.
        • Fox M.C.
        • Lackie E.G.
        Early surgical abortion: efficacy and safety.
        Am J Obstet Gynecol. 2002; 187: 407-411
        • National Academies of Sciences
        Engineering, and Medicine. The safety and quality of abortion care in the United States.
        National Academies Press, Washington, DC2018
        • White K.
        • Carroll E.
        • Grossman D.
        Complications from first-trimester aspiration abortion: a systematic review of the literature.
        Contraception. 2015; 92: 422-438
        • Berglas N.F.
        • Battistelli M.F.
        • Nicholson W.K.
        • Sobota M.
        • Urman R.D.
        • Roberts S.C.M.
        The effect of facility characteristics on patient safety, patient experience, and service availability for procedures in non-hospital-affiliated outpatient settings: a systematic review.
        PLoS One. 2018; 13e0190975
        • Jones B.S.
        • Weitz T.A.
        Legal barriers to second-trimester abortion provision and public health consequences.
        Am J Public Health. 2009; 99: 623
        • Roberts S.C.M.
        • Gould H.
        • Kimport K.
        • Weitz T.A.
        • Foster D.G.
        Out-of-pocket costs and insurance coverage for abortion in the United States.
        Womens Health Issues. 2014; 24: e211-e218
        • Van Bebber S.L.
        • Phillips K.A.
        • Weitz T.A.
        • Gould H.
        • Stewart F.
        Patient costs for medication abortion: results from a study of five clinical practices.
        Womens Health Issues. 2006; 16: 4-13
        • Jerman J.
        • Jones R.K.
        • Onda T.
        Characteristics of U.S. abortion patients in 2014 and changes since 2008.
        Guttmacher Institute. 2016. 2016; (Available at:)
        • Jones R.K.
        • Upadhyay U.D.
        • Weitz T.A.
        At what cost? Payment for abortion care by U.S. women.
        Womens Health Issues. 2013; 23: e173-e178
        • Colman S.
        • Joyce T.
        Regulating abortion: impact on patients and providers in Texas.
        J Policy Anal Manag. 2011; 30: 775-797
        • Lince-Deroche N.
        • Fetters T.
        • Sinanovic E.
        • Devjee J.
        • Moodley J.
        • Blanchard K.
        The costs and cost effectiveness of providing first-trimester, medical and surgical safe abortion services in KwaZulu-Natal Province, South Africa.
        PLoS One. 2017; 12e0174615
        • Shankar M.
        • Black K.I.
        • Goldstone P.
        • et al.
        Access, equity and costs of induced abortion services in Australia: a cross-sectional study.
        Aust N Z J Public Health. 2017; 41: 309-314
        • Creinin M.D.
        • Shore E.
        • Balasubramanian S.
        • Harwood B.
        The true cost differential between mifepristone and misoprostol and misoprostol-alone regimens for medical abortion.
        Contraception. 2005; 71: 26-30
        • Sjostrom S.
        • Kopp Kallner H.
        • Simeonova E.
        • Madestam A.
        • Gemzell-Danielsson K.
        Medical abortion provided by nurse-midwives or physicians in a high resource setting: a cost-effectiveness analysis.
        PLoS One. 2016; 11e0158645
        • Afable-Munsuz A.
        • Gould H.
        • Stewart F.
        • Phillips K.A.
        • Van Bebber S.L.
        • Moore C.
        Provider practice models for and costs of delivering medication abortion–evidence from 11 US abortion care settings.
        Contraception. 2007; 75: 45-51
      1. The Truven Health MarketScan databases for health services researchers. 2017.
        (Available at:)
        • Ailes E.C.
        • Simeone R.M.
        • Dawson A.L.
        • Petersen E.E.
        • Gilboa S.M.
        Using insurance claims data to identify and estimate critical periods in pregnancy: an application to antidepressants.
        Birth Defects Res A Clin Mol Teratol. 2016; 106: 927-934
        • Matcho A.
        • Ryan P.
        • Fife D.
        • Gifkins D.
        • Knoll C.
        • Friedman A.
        Inferring pregnancy episodes and outcomes within a network of observational databases.
        PLoS One. 2018; 13e0192033
        • Asemota A.O.
        • Ishii M.
        • Brem H.
        • Gallia G.L.
        Comparison of complications, trends, and costs in endoscopic vs microscopic pituitary surgery: analysis from a US health claims database.
        Neurosurgery. 2017; 81: 458-472
        • Roberts S.C.M.
        • Beam N.
        • Liu G.
        • et al.
        Miscarriage treatment-related morbidities and adverse events in hospitals, ambulatory surgery centers, and office-based settings.
        J Patient Saf. 2018 Dec 3; ( [Epub ahead of print])
        • Dieguez G.
        • Pyenson B.S.
        • Law A.W.
        • Lynen R.
        • Trussell J.
        The cost of unintended pregnancies for employer-sponsored health insurance plans.
        Am Health Drug Benefits. 2015; 8: 83-92
        • Taylor D.
        • Upadhyay U.D.
        • Fjerstad M.
        • Battistelli M.F.
        • Weitz T.A.
        • Paul M.E.
        Standardizing the classification of abortion incidents: the Procedural Abortion Incident Reporting and Surveillance (PAIRS) Framework.
        Contraception. 2017; 96: 1-13
        • Wilcox R.R.
        Introduction to robust estimation and hypothesis testing.
        3rd ed. Academic Press, San Diego, CA2012
        • Mullahy J.
        Much ado about two: reconsidering retransformation and the two-part model in health econometrics.
        J Health Econ. 1998; 17: 247-281
        • Guttmacher Institute
        Induced abortion in the United States. 2018.
        (Available at:)
        • Jones R.K.
        • Jerman J.
        Abortion incidence and service availability in the United States, 2014.
        Perspect Sex Reprod Health. 2017; 49: 17-27
      2. National Network of Abortion Funds. Available at: Accessed September 2, 2019.

        • Higgins A.
        • Veselovskiy G.
        • Schinkel J.
        National estimates of price variation by site of care.
        Am J Manag Care. 2016; 22: e116-e121
        • Borah B.J.
        • Carls G.S.
        • Moore B.J.
        • Gibson T.B.
        • Moriarty J.P.
        • Stewart E.A.
        Cost comparison between uterine-sparing fibroid treatments one year following treatment.
        J Ther Ultrasound. 2014; 2: 7
        • Upadhyay U.D.
        • Desai S.
        • Zlidar V.
        • et al.
        Incidence of emergency department visits and complications after abortion.
        Obstet Gynecol. 2015; 125: 175-183