Association between center procedure volume, socioeconomic factors, comorbidities, and adverse events related to procedural abortion: A nationwide population-based cohort study

ackground:

Limited evidence exists on the influence of center procedure volume, socioeconomic factors, and comorbidities on procedural abortion outcomes. 

Objective:

Our study aimed to assess the association between center procedure volume, individual and neighborhood deprivation, comorbidities, and abortion-related adverse events. 

Study Design:

A nationwide population-based cohort study of all pregnant persons admitted for procedural abortion day surgery was conducted from January 1, 2018, to December 31, 2019 in France. Annual procedure volume was categorized into four levels based on spline function visualization: very low (<80), low ([80-300[), high ([300-650[), and very high-volume (≥650) centers. The   primary   outcome   was   the   occurrence   of   at   least   one   surgical-related adverse event, including hemorrhage, retained products of conception, genital tract and pelvic infection, transfusion, fistulas and neighboring lesions, local hematoma, failure of abortion, admission to an intensive care unit or death. These events were monitored during the index stay and during a subsequent hospitalization up to 90 days. The secondary outcome encompassed general adverse events not directly linked to surgery.

Results:

Of the 112,842 day surgery stays, 4,951 (4.39%) had surgical-related adverse events and 256 (0.23%) had general adverse events. The multiple regression showed a volume-outcome relationship, with lower rates of surgical-related adverse events in very high-volume (2.25%, aOR=0.50, 95%CI [0.44-0.56], p<0.001), high-volume (4.24%, aOR=0.82, 95%CI [0.75-0.90], p<0.001), and   low-volume (4.69%,   aOR=0.80,   95%CI   [0.74-0.86],   p<0.001)   when compared to very low-volume centers (6.65%). Individual socioeconomic status (aOR=1.59, 95%CI [1.39-1.83], p<0.001), neighborhood deprivation (aOR=1.24, 95% CI [1.16-1.32], p<0.001), and comorbidities (aOR=1.52, 95%CI [1.27-1.82], p<0.001) were associated with surgical-related adverse events. Conversely, the multiple regression for general adverse events did not reveal any volume-outcome relationship.

Conclusion: 

The presence of a volume-outcome relationship suggests a need to enhance safety in low-volume centers, thereby ensuring equity in pregnant persons' safety during procedural abortions. However, our findings also highlight the complexity of this safety concern which involves multiple other factors including socioeconomic factors and comorbidities that policymakers

must consider.