Based on the first search, we found 275 potentially relevant papers thorough out the sources. After reviewed based on its title as well as excluded duplication, a total of 55 distinct articles was selected for initial screening based on titles and abstracts (Fig. 1). From this step, we dropped 45 articles which mostly because either they were not a cost analysis study, or they were not specifically cover the issues of PAC or both. The other two studies were not original articles, and the other one was an institutional report.
A total of 10 full-text articles were retrieved to assess for more detailed evaluation, including examining their quality and clarity in terms of reporting using CHEERS statement. From this process, three studies were excluded because one study was based on household perspective and other chosen studies superseded two studies. We then manually searched potential articles from reference lists of the seven articles and found five chosen studies to include. Table 2 summarize information related twelve chosen studies, including their reported component cost.
Table 3 shows that the component cost reported were varied across the studies. The variability is caused by several factors, such as available data and chosen tools. However, all studies reported the direct medical cost of post abortion care per patient at a national level. It should be noted, regardless of not reporting the direct medical cost explicitly, we decided to include study in Tanzania  because they reported labour cost and supplies & drug cost, which are components for direct medical cost based on our operational definition. Also, the variability occurred in terms of reporting the cost of each component. While some only reported their average value [10, 18, 21], the others provided the cost by severity, resulting in range of cost when summarized in this study. Those who did not report the average values tend to avoid any misleading because the nature of PAC services is not typically generalizable, as a small number of cases can be quite disproportionate than the other cases.
Field and study setting
Twelve studies were located in Eastern Africa (Ethiopia ; Malawi ; Rwanda ; Uganda ; Tanzania ), Western Africa (Burkina Faso ; Nigeria ; Senegal ; Sierra Leone ), Southern Asia (Bangladesh ), South America (Colombia ), and Central America (El Salvador ). All of these countries are in a group of Low-Middle Income Countries (LMICs) based on World Bank classification, with seven of them are low-income countries. Based on the Guttmacher Institute, in this group, about 16% of pregnancies ending in unsafe abortions in 2019 .
In terms of approach, costing analysis can be divided into two types, a “top-down” and a “bottom-up”. When a study uses the first approach, it scrutinizes large administrative datasets and derives PAC related cost for estimating its overall cost per patient [15, 26]. When it uses the latter approach, at first, it identifies and estimates each component then adding it up to final estimation. All chosen studies tend to use a bottom-up approach, meaning they first collect data on component costs (i.e., direct costs and indirect medical costs) then compose into the health system cost of PAC. However, some of them also used a large number of the patient database to estimate resources used, such as study in El Salvador, which was emphasized that their methodology is more specific to patient-derived costs .
Most of the studies used the Post-Abortion Care Costing Methodology (PACCM) as their tools. The PACCM is a bottom-up ‘ingredients’ approach that relies on expert opinion for estimating the health-system-cost component . Study in Sierra Leone used the modified Delphi approach to solicit information . Two studies in Nigeria and Malawi used savings, an excel-based tool to estimate per-case PAC costs [11, 23].
Table 4 describes (i) direct medical costs, (ii) labour costs and (iii) supplies and drugs costs, in 2019 US dollars and international dollars, of post-abortion care (PAC) from 12 countries. From the table above, the costs show a lot of variabilities. There are three types of costs reported in the table, namely cost by MVA method, cost by D&C method, and unspecified abortion method costs. In terms of range, the highest direct cost of PAC with MVA services can be found in Colombia, between $US50.58-212.47, while the lowest is in Malawi ($US15.2-139.19). The highest direct cost of PAC with D&C services was in El Salvador ($US65.22-240.75), while the lowest is in Bangladesh ($US15.71-103.85).
Table 4 also shows that only three studies reported both methods: MVA and D&C. From the three studies above (El Salvador, Bangladesh, and Malawi), the MVA cost tends to be lower than the D&C (dilation and curettage) cost. In El Salvador, the cost is generally lower when MVA is used, ranging from $US58.82 to $US105.39, while D&C costs more, ranging from $US65.22 to $US240.75. In Bangladesh the cost when MVA is used extremely lower, ranging from $US15.71 to $US27.68, while the use of D&C can cost up to $103.85. Last, in Malawi, the cost for MVA use, ranging from $US15.2 to $US139.19, while D&C costs between $US22.22 and $US161.42.
Additionally, two study reports the labor cost and supplies/drugs cost of UE using MVA & D&C, which are Bangladesh and El salvador. For the use of MVA, the labor cost in Bangladesh ranging from $US7.15 to $US8.48 while for the use of D&C, from $US5.94 to $US13.46. For the supplies/drugs cost, the use of MVA in Bangladesh also cost less ($US7.22-20.53) compared to D&C ($US13.33 - 90.38). Similar with Bangladesh, the use of D&C in El Salvador generally requires more labor hour, as the use of D&C tend to require patients stay longer in hospital, consequently it will raise the labour cost [9, 24], as well as it cost more on supplies/drugs cost, as a result of higher complication rates for D&C method thus it needs general anesthesia for pain management  and require more other drugs/supplies.
Unlike the direct medical cost, the studies that reported indirect cost of providing PAC, did not distinguish between the use of UE method, as shown in Table 5. Among two studies that were providing average indirect cost data, Uganda with $US105.04 is the highest country averagely, while Rwanda with $US51.44 is the lowest on the cost of indirect medical. The high cost in Uganda was burdened by the capital cost which accounts around 80% of the indirect medical cost, while in Rwanda that of cost only accounts to less than 30%.
Table 6 shows the results of direct medical cost distinguished by five major abortion complications included in the WHO study on costing in its “Mother-Baby Package” . The total amount of direct cost from complication shows a lot of variation.
Looking from complications’ point of view, in terms of the average amount of direct cost, Rwanda has the highest direct medical cost for incomplete abortion ($US103.14), shock ($US67.22), and perforations ($US175.91) compared to other countries. In Senegal, the highest average cost is a result of shock ($US39.53), while its lowest is incomplete abortion ($US15.77). Lastly, in Uganda, complication that cost the most, in average, is perforation ($US133.25), and the least is shock ($US44.48).