Cost of Safe Abortion Care in Kigali, Rwanda: A Retrospective Analysis of Hospital Billing Data

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Background: Rwanda has progressively liberalized its abortion law over the past decade, most recently through a 2024 order decentralizing safe abortion care (SAC) to health centres and clinics. However, the financial accessibility of legally provided SAC remains poorly understood; existing cost evidence in Rwanda focuses on post-abortion care, which has a different clinical and cost profile. This study assessed the direct facility-based costs of legally provided SAC in Kigali, Rwanda.Methods: We conducted a retrospective analysis of itemized hospital billing data from the Health Development Initiative (HDI) Rwanda for 236 SAC patients treated at 4 public and 1 private facility in Kigali from June 2022 to December 2024, including total costs and costs across 9 categories. Total and category-specific costs were compared by visit type using the Mann-Whitney U test; associations between characteristics and visit type were assessed using chi-square or Fisher's exact tests.Results: The median total cost of a SAC visit was 62,353 RWF (range: 282-256,100 RWF). Consultation fees (94.9%) and commodities (92.8%) were incurred by nearly all patients, while medical acts (76.3%), imaging (75.4%), and laboratory tests (70.8%) were also common. Two-thirds of patients (66.1%) were treated as inpatients, with a mean length of stay of 3.1 days. Inpatients incurred more than twice the mean total cost of outpatients (96,572 RWF vs. 47,167 RWF; p<0.001), driven by significantly higher costs across most categories except examinations. Visit type varied by age group (p=0.014); adolescents (15-18 years) were least likely to be inpatients.Conclusions: Legally provided SAC in Kigali carries a non-trivial financial burden relative to household income, and heavy reliance on inpatient care, inconsistent with WHO guidance, inflates costs. These findings point to the need for a standardized SAC tariff, alignment of admission practices with evidence-based guidelines, and further research into drivers of cost variation in abortion care access.