Contraceptive update Y2K: need for contraception and new contraceptive options

Advances in contraception: IUDs from a managed care perspective

Contraceptive use in the United States is virtually universal among women of reproductive age. However, unplanned pregnancies continue to occur and can be largely attributed to the nonuse and misuse of contraception. Reducing unintended pregnancies constitutes a critical goal for managed care and the public. This can be achieved in part with intrauterine devices (IUDs), which are an effective method of contraception that require a one-time insertion and stay in place for 5-10 years. Therefore, compliance issues are largely mitigated, and actual use efficacy is the same as perfect use efficacy. The IUD is also reversible, unlike tubal ligation, and could potentially be the contraceptive of choice in today's environment. Unfortunately, safety concerns surrounding the use of older IUDs have precluded many women from recognizing the benefits of their use. Currently, the only approved IUDs in the United States are ParaGard, the copper IUD, and Mirena, the levonorgestrel-releasing intrauterine system (LNG-IUS). These devices offer superior safety profiles compared with those products that were withdrawn from the market in the 1970s. In addition to a favorable safety and tolerability profile, the LNG-IUS offers an advantage over copper IUDs, demonstrating improved efficacy in preventing intrauterine and ectopic pregnancies. Successful communication between patients and providers regarding the improved safety and efficacy of newer IUDs will ensure an appropriate place in therapy. Thus, greater numbers of women will recognize the IUD as a safe, cost-effective means to contraception, thereby reducing the economic and social burdens associated with unplanned pregnancies.

Maternal use of oral contraceptives and risk of fetal death

Intrauterine exposure to artificial sex hormones such as oral contraceptives may be associated with an increased risk of fetal death. Between 1996 and 2002, a total of 92 719 women were recruited to The Danish National Birth Cohort and interviewed about exposures during pregnancy. Outcome of pregnancy was identified through linkage to the Civil Registration System and the National Discharge Registry. The authors analysed the risk of fetal death after recruitment to the cohort by using proportional hazards regression models with gestational age as the underlying time scale. In total, 1102 (1.2%) women took oral contraceptives during pregnancy. Use of combined oestrogen and progesterone oral contraceptives (COC) or progesterone-only oral contraceptives (POC) during pregnancy was not associated with increased hazard ratios of fetal death compared with non-users, HR 1.01 [95% CI 0.71, 1.45] and HR 1.37 [95% CI 0.65, 2.89] respectively. Neither use of COC nor POC prior to pregnancy was associated with fetal death. Stratification by maternal age and smoking showed elevated risks of fetal death for women <30 years and smokers using oral contraception during pregnancy, but the interactions were not significant. In conclusion, there was no evidence that oral contraceptive use before or during pregnancy is associated with an increased risk of fetal death.

Economic analysis of contraceptives for women

OBJECTIVE

To examine from the health care services payer perspective the economic consequences of contraceptives available to women in the United States.

METHODS

A Markov model was constructed to compare effectiveness and costs among nine contraceptive methods (including 3-month injectable, oral contraceptives, intrauterine device (IUD), intrauterine system (IUS), barrier methods and surgical methods). Primary health states included initial/continued use, method failure and method discontinuation with transitions every year for 5 years. Plan disenrollment was also incorporated in the model. Estimates for probabilities of events, resource used, and costs for the base-case were derived from a comprehensive literature review, average wholesale drug prices, the 2000 Medicare Reimbursement Fee Schedule and MEDSTAT's 2000 DRG Guide, in conjunction with expert opinion. Sensitivity analyses were performed on all variables.

RESULTS

Aside from vasectomy, which was outside the scope of this study, the most effective methods were tubal ligation, levonorgestrel (LNG)-20 IUS and copper T 380A IUD. The least expensive methods (accounting for all costs) were LNG-20 IUS, copper T 380A IUD and 3-month injectable; the 5-year cost/person were $1646, $1678 and $2195, respectively.

CONCLUSION

From a third-party payer perspective, LNG-20 IUS and copper T 380A IUD dominated all reviewed methods, except for tubal ligation. However, the small increase in contraceptive efficacy with tubal ligation has a high cost. IUD and IUS device costs have a significant impact on the relative cost-effectiveness of these two methods.