The economic value of contraception: a comparison of 15 methods

Comparing American Indian/Alaska Native Adolescent Daughters' and Their Mothers' Awareness, Knowledge, Attitudes, and Behaviors Regarding Risk for Gestational Diabetes: Implications for Mother-Daughter Communication on Reproductive Health

PURPOSE

The purpose of the study was to describe, compare, and examine associations at baseline of reproductive health awareness, knowledge, health beliefs, communication and behaviors related to gestational diabetes (GDM) and GDM risk reduction in a vulnerable population of both American Indian/Alaska Native (AIAN) adolescent girls and their mothers.

METHODS

Descriptive/comparative/correlational analyses examined multitribal baseline data on 149 mother-daughter (M-D) dyads (N = 298; daughter age = 12-24 years) enrolled in a longitudinal study to adapt and evaluate a culturally relevant diabetes preconception counseling (PC) program (Stopping-GDM). The associations between GDM risk reduction awareness, knowledge, health beliefs, and behaviors (eg, daughters' eating, physical activity, reproductive-health [RH] choices/planning, M-D communication, daughters' discussions on PC) were examined. Data collected online from 5 national sites.

RESULTS

Many M-D lacked awareness/knowledge of GDM and risk reduction. Both M-D were unaware of the girl's risk for GDM. Mothers' knowledge and beliefs on GDM prevention/RH were significantly higher than daughters. Younger daughters had greater self-efficacy healthy living. Overall sample reported low to moderate scores for both M-D communication and daughters' GDM and RH risk-reduction behaviors.

CONCLUSIONS

Knowledge, communication, and behaviors to prevent GDM were low in AIAN M-D, especially daughters. More than daughters, mothers perceive greater risk of GDM for daughters. Early culturally responsive dyadic PC programs could help decrease risk of developing GDM. Implications for M-D communication is compelling.

Making the financial case for immediate postpartum intrauterine device: a budget impact analysis

BACKGROUND

Clinical guidelines support inpatient postpartum intrauterine device insertion. However, inpatient placement remains infrequent, in part because of inconsistent private insurance reimbursement.

OBJECTIVE

The purpose of this study was to explore how the payer's costs and number of unintended pregnancies associated with a postpartum intrauterine device differed on the basis of placement timing.

STUDY DESIGN

Using a decision tree model and following a hypothetical cohort of people who intend to use an intrauterine device after their delivery, we conducted a cost analysis comparing the planned approach of inpatient vs outpatient postpartum insertion. Using a 2-year time horizon, the probability and cost estimates were derived from literature review. Our primary outcome was the total accrued costs to the payer. Secondarily, we examined the rates of early repeat pregnancy and sensitivity to estimates of key inputs, including the expulsion rates and the intrauterine device cost.

RESULTS

Although an inpatient intrauterine device placement's upfront costs were higher, the total cost of this approach was lower. Including the costs of managing expulsions and complications, our model suggests that for every 1000 people desiring a postpartum intrauterine device, the intended inpatient intrauterine device placement resulted in total cost savings of $211,100 and the prevention of 37 additional pregnancies compared with outpatient placement. The inpatient cost savings were superior to the outpatient savings, largely because of a known high proportion not returning for outpatient placement and the resulting higher number of unintended pregnancies among the patients desiring outpatient placement. In sensitivity analyses, we found that the total cost to the payer was sensitive to the probability of expulsion after immediate postpartum intrauterine device placement.

CONCLUSION

For beneficiaries desiring postpartum intrauterine device, payers are likely to save money by fully reimbursing inpatient intrauterine device placement rather than incentivizing placement at the frequently missed postpartum visit. These results support the financial case for private insurers to fully and separately reimburse (ie, "unbundle" from the single payment for delivery) inpatient postpartum intrauterine device placement.

Quantifying the economic burden of unintended pregnancies due to drug–drug interactions with hormonal contraceptives from the United States payer perspective

Background: In the United States of America (USA), nearly 10 million women use oral contraceptives (OCs). Concomitant administration of certain medications can result in contraceptive failure, and consequently unintended pregnancies due to drug–drug interactions (DDIs). The objective of this analysis was to estimate the economic impact of unintended pregnancies due to DDIs among women of reproductive age using an OC alone or in combination with an enzyme inducer co-medication in the USA from a payer perspective. Methods: A Markov model using a cohort of 1,000 reproductive-age women was developed to estimate costs due to contraceptive failure for OC alone versus OC with concomitant enzyme inducer drugs. All women were assumed to begin an initial state, continuing until experiencing an unintended pregnancy. Unintended pregnancies could result in birth, induced abortion, spontaneous abortion, or ectopic pregnancy. The cohort was analyzed over a time horizon of 1 year with a cycle length of 1 month. Estimates of costs and probabilities of unintended pregnancy outcomes were obtained from the literature. Probabilities from the Markov cohort trace was used to estimate number of pregnancy outcomes. Results: On average, enzyme inducers resulted in 20 additional unintended pregnancies with additional unadjusted and adjusted costs median (range) of USD136,304 (USD57,436–USD320,093) and USD65,146 (USD28,491–USD162,635), respectively. The major component of the direct cost is attributed to the cost of births. Considering the full range of events, DDIs with enzyme inducers could result in 16–25 additional unintended pregnancies and total unadjusted and adjusted costs ranging between USD46,041 to USD399,121 and USD22,839 to USD202,788 respectively. Conclusion: The direct costs associated with unintended pregnancies due to DDIs may be substantial and are potentially avoidable. Greater awareness of DDI risk with oral contraceptives among payers, physicians, pharmacists and patients may reduce unintended pregnancies in at-risk populations.

Economic evaluation of Zika Contraception Access Network in Puerto Rico during the 2016-17 Zika virus outbreak

OBJECTIVE

During the 2016-2017 Zika virus (ZIKV) outbreak, the prevention of unintended pregnancies was identified as a primary strategy to prevent birth defects. This study estimated the cost-effectiveness of the Zika Contraception Access Network (Z-CAN), an emergency response intervention that provided women in Puerto Rico with access to the full range of reversible contraception at no cost and compared results with a pre-implementation hypothetical cost-effectiveness analysis (CEA).

STUDY DESIGN

We evaluated costs and outcomes of Z-CAN from a health sector perspective compared to no intervention using a decision tree model. Number of people served, contraception methods mix, and costs under Z-CAN were from actual program data and other input parameters were from the literature. Health outcome measures included the number of Zika-associated microcephaly (ZAM) cases and unintended pregnancies. The economic benefits of the Z-CAN intervention were ZIKV-associated direct costs avoided, including lifetime medical and supportive costs associated with ZAM cases, costs of monitoring ZIKV-exposed pregnancies and infants born from Zika-virus infected mothers, and the costs of unintended pregnancies prevented during the outbreak as a result of increased contraception use through the Z-CAN intervention.

RESULTS

The Z-CAN intervention cost a total of $26.1 million, including costs for the full range of reversible contraceptive methods, contraception related services, and programmatic activities. The program is estimated to have prevented 85% of cases of estimated ZAM cases and unintended pregnancies in the absence of Z-CAN. The intervention cost was projected to have been more than offset by $79.9 million in ZIKV-associated costs avoided, 96% of which were lifetime ZAM-associated costs, as well as $137.0 million from avoided unintended pregnancies, with total net savings in one year of $216.9 million. The results were consistent with the previous CEA study.

CONCLUSION

Z-CAN was likely cost-saving in the context of a public health emergency response setting.

Development of a pharmacoeconomic registry: an example using hormonal contraceptives

BACKGROUND

Disease-specific registries, documenting costs and probabilities from pharmacoeconomic studies along with health state utility values from quality-of-life studies could serve as a resource to guide researchers in evaluating the published literature and in the conduct of future economic evaluations for their own research. Registries cataloging economic evaluations currently exist, however they are restricted by the type of economic evaluations they include. There is a need for intervention-specific registries, that document all types of complete and partial economic evaluations and auxiliary information such as quality of life studies. The objective of this study is to describe the development of a pharmacoeconomic registry and provide best practices using an example of hormonal contraceptives.

METHODS

An expert panel consisting of researchers with expertise in pharmacoeconomics and outcomes research was convened and the clinical focus of the registry was finalized after extensive discussion. A list of key continuous, categorical and descriptive variables was developed to capture all relevant data with each variable defined in a data dictionary. A web-based data collection tool was designed to capture and store the resulting metadata. A keyword based search strategy was developed to retrieve the published sources of literature. Finally, articles were screened for relevancy and data was extracted to populate the registry. Expert opinions were taken from the panel at each stage to arrive at consensus and ensure validity of the registry.

RESULTS

The registry focused on economic evaluation literature of hormonal contraceptives used for contraception. The registry consisted of 65 articles comprising of 22 cost-effectiveness analyses, 9 cost-utility analyses, 7 cost-benefit analyses, 1 cost-minimization, 14 cost analyses, 10 cost of illness studies and 2 quality of life studies. The best practices followed in the development of the registry were summarized as recommendations. The completed registry, data dictionary and associated data files can be accessed in the supplementary information files.

CONCLUSION

This registry is a comprehensive database of economic evaluations, including costs, clinical probabilities and health-state utility estimates. The collated data captured from published information in this registry can be used to identify trends in the literature, conduct systematic reviews and meta-analysis and develop novel pharmacoeconomic models.

Long-Acting Reversible Contraceptive Users' Knowledge, Conversations with Healthcare Providers, and Condom Use: Findings from a U.S. Nationally Representative Probability Survey

Objectives To describe long-acting reversible contraceptive (LARC) users' knowledge, patient-provider interactions, and condom use associated with LARC use. Methods: Data are from the 2018 National Survey of Sexual Health and Behavior, a probability survey of Americans aged 14-49. Results: Of 1,451 sexually active women, 11.2% used intrauterine devices, and 3.1% used implants. Approximately 19-26% of LARC users reported inaccurately on LARC longevity, and 30% reported relying on their provider to indicate the timing of intrauterine device removal. Consistent condom use among LARC users was rare (6.1%). Conclusions: Our findings have implications for how clinicians educate patients on LARC and condom use.

Potential for Improving Intrauterine Device (IUD) Service Delivery Quality: Results from a Secondary Data Analysis

Background: To accelerate progress toward Family Planning 2020 (FP2020) goals, the government of India focused on improving the quality of intrauterine device (IUD) services. EngenderHealth, an international sexual and reproductive health and rights organization, has been supporting the governments of Gujarat and Rajasthan since 2014 through the Expanding Access to IUD Services in India (EAISI) project by building the capacity of service providers, monitoring compliance with standard practices, and strengthening health systems. This study sought to assess whether EAISI-trained providers offer higher quality IUD services than non-EAISI-trained providers, as indicated by a reduction in confirmed IUD complications.

Methods: The study team conducted an analytical cross-sectional study of secondary data collected from follow-up registers at 176 intervention facilities (38 in Gujarat and 138 in Rajasthan) during Phase I of the EAISI project. The analysis included follow-up clients who returned to the same facility between April 2018 and March 2019. We performed a multivariate logistic regression to determine factors associated with IUD complications.

Results: During the period of assessment, 56,733 clients received IUD insertions, and 10,747 (18.9%) clients returned for follow-up services. Of the returning clients, 49.4% (N=5,305) had received IUDs from EAISI-trained providers, while 50.6% (N=5,442) had received IUDs from non-EAISI-trained providers. A total of 4.0% (N=432) of all returning clients experienced complications (expulsion: 1.3%, missing strings: 1.7%, infection: 1.1%). Clients who received IUDs from non-EAISI-trained providers were 55.5% more likely (95% CI [26.2%, 91.5%], p<0.0005) to have experienced complications than clients who received insertions from EAISI-trained providers. The type of IUD, the timing of the insertion, and the timing of the follow-up visit also affected complication prevalence.

Conclusion: Our findings indicate that intensive, practical clinical skills training for IUD insertion can reduce the prevalence of complications.

K, O’Connell KA, Cagatay L, Sengupta S, Singal S. Could EAISI-trained providers provide better quality of IUD services? Results of a secondary data analysis of complications as a proxy indicator

Background: For accelerating its progress towards FP2020 goals, the Government of India has focused on improving the quality of intrauterine device (IUD) services. EngenderHealth has supported the Governments of Rajasthan and Gujarat since 2014 through its Expanding Access to IUD Services in India (EAISI) project by building the capacity of service providers, monitoring their compliance with standard practices, and strengthening health systems. This study sought to assess whether EAISI trained providers provide a better quality of IUD services as compared to non-EAISI trained providers, as indicated by a reduction in confirmed IUD complications? Methods: This study was an analytical cross-sectional study of secondary data collected from the follow-up registers of 176 intervention facilities (138 in Rajasthan and 38 in Gujarat) during Phase I of EAISI project. The analysis included clients who returned between April 2018 and March 2019 to the same facility for a follow-up visit. Multivariate logistic regression was performed to determine factors associated with IUD complications. Results: A total of 56,733 IUD insertions were conducted, and 10,747 (18.9%) client follow-ups were documented. Of these, 49.4% (N=5,305) clients received IUDs from EAISI-trained providers, while 50.6% (N=5,442) received IUDs from non-EAISI trained providers. A total of 4.0% (N=432) of clients experienced complications (Expulsion: 1.3%, Missing Strings: 1.7%, Infection: 1.1%). Clients who received IUDs from non-EAISI-trained providers were 55.5% more likely [95% CI (26.2%, 91.5%), p<0.0005] to have complications compared to clients who received insertions from EAISI-trained providers. Other significant factors include the type of IUD, timing of the follow-up visit and timing of the insertion. Conclusion: The findings demonstrate that intensive, hands-on training of providers to improve clinical skills for IUD insertions can have a positive impact on the reduction of post-insertion complications.

K, O’Connell KA, Cagatay L, Sengupta S, Singal S. Could trained providers provide better quality of IUD services? Results of a secondary data analysis of complications as a proxy indicator

Background: For accelerating its progress towards FP2020 goals, the Government of India has focused on improving the quality of intrauterine device (IUD) services. EngenderHealth has supported the Governments of Rajasthan and Gujarat since 2014 through its Expanding Access to IUD Services in India (EAISI) project by building the capacity of service providers, monitoring their compliance with standard practices, and strengthening health systems. This study sought to assess whether EAISI trained providers provide a better quality of IUD services as compared to non-EAISI trained providers, as indicated by a reduction in confirmed IUD complications? Methods: This study was an analytical cross-sectional study of secondary data collected from the follow-up registers of 176 intervention facilities (138 in Rajasthan and 38 in Gujarat) during Phase I of EAISI project. The analysis included clients who returned between April 2018 and March 2019 to the same facility for a follow-up visit. Multivariate logistic regression was performed to determine factors associated with IUD complications. Results: A total of 56,733 IUD insertions were conducted, and 10,747 (18.9%) client follow-ups were documented. Of these, 49.4% (N=5,305) clients received IUDs from EAISI-trained providers, while 50.6% (N=5,442) received IUDs from non-EAISI trained providers. A total of 4.0% (N=432) of clients experienced complications (Expulsion: 1.3%, Missing Strings: 1.7%, Infection: 1.1%). Clients who received IUDs from non-EAISI-trained providers were 55.5% more likely [95% CI (26.2%, 91.5%), p<0.0005] to have complications compared to clients who received insertions from EAISI-trained providers. Other significant factors include the type of IUD, timing of the follow-up visit and timing of the insertion. Conclusion: The findings demonstrate that intensive, hands-on training of providers to improve clinical skills for IUD insertions can have a positive impact on the reduction of post-insertion complications.

Is contraceptive self-injection cost-effective compared to contraceptive injections from facility-based health workers? Evidence from Uganda

OBJECTIVE

To assess the cost-effectiveness of self-injected subcutaneous depot medroxyprogesterone acetate (DMPA-SC) compared to health-worker-administered intramuscular DMPA (DMPA-IM) in Uganda.

STUDY DESIGN

We developed a decision-tree model with a 12-month time horizon for a hypothetical cohort of approximately 1 million injectable contraceptive users in Uganda to estimate the incremental costs per pregnancy averted and per disability-adjusted life year (DALY) averted. The study design derived model inputs from DMPA-SC self-injection continuation and costing research studies and peer-reviewed literature. We calculated incremental cost-effectiveness ratios from societal and health system perspectives and conducted one-way and probabilistic sensitivity analyses to test the robustness of results.

RESULTS

Self-injected DMPA-SC could prevent 10,827 additional unintended pregnancies and 1620 maternal DALYs per year for this hypothetical cohort compared to DMPA-IM administered by facility-based health workers. Due to savings in women's time and travel costs, under a societal perspective, self-injection could save approximately US$1 million or $84,000 per year, depending on the self-injection training aid used. From a health system perspective, self-injection would avert more pregnancies but incur additional costs. A training approach using a one-page client instruction sheet would make self-injection cost-effective compared to DMPA-IM, with incremental costs per pregnancy averted of $15 and per maternal DALY averted of $98. Sensitivity analysis showed that the estimates were robust. The one-way and probabilistic sensitivity analyses showed that the costs of the first visit for self-injection (which include training costs) were an important variable impacting the cost-effectiveness estimates.

CONCLUSIONS

Under a societal perspective, self-injected DMPA-SC averted more pregnancies and cost less compared to health-worker-administered DMPA-IM. Under a health system perspective, self-injected DMPA-SC can be cost-effective relative to DMPA-IM when a lower-cost visual aid for client training is used.

IMPLICATIONS

Self-injection has economic benefits for women through savings in time and travel costs, and it averts additional pregnancies and maternal disability-adjusted life years compared to health-worker-administered injectable DMPA-IM. Implementing lower-cost approaches to client training can help ensure that self-injection is also cost-effective from a health system perspective.

Reviewing the cost-effectiveness of long-acting reversible contraceptive methods in an Australian context

BACKGROUND

Relative to the oral contraceptive pill, uptake of long-acting reversible contraceptive methods (LARCs) in Australia continues to be lower than might be suggested by the evidence on their clinical and economic benefits.

AIM

To undertake a critical appraisal of published economic evaluations of LARCs to assess the generalisability of their results to the Australian healthcare context.

MATERIALS AND METHODS

A search of the literature was conducted to identify studies of economic evaluations of LARCs using the Medline, Embase and PubMed databases. The quality of the studies was evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

RESULTS

A total of 1009 citations were screened, from which 20 papers, typically reporting the cost per pregnancy avoided, were reviewed. The overall quality of the studies varied but was generally poor (average score of 62/100). To aid comparisons, results have been grouped under the headings IUS (all hormonal intrauterine systems), IUDs (all non-hormonal intrauterine devices), injectables (all contraceptive injections) and implants (all subdermal contraceptive implants). Overall, the results indicated that LARCs were more effective and less costly than oral contraceptives.

CONCLUSIONS

Despite evidence that LARCs represent value for money, limitations in study quality and approaches must be taken into account when applying these results to Australia. Differences in healthcare settings aside, LARCs may also have benefits beyond their effect on pregnancy that might be captured in broader analyses, such as cost-benefit analyses using willingness to pay methods. These would capture benefits beyond health, which seem to be particularly relevant to contraception.

Update on emergency contraception

PURPOSE OF REVIEW

Emergency contraception provides a critical and time-sensitive opportunity for women to prevent undesired pregnancy after intercourse. Both access and available options for emergency contraception have changed over the last several years.

RECENT FINDINGS

Emergency contraceptive pills can be less effective in obese women. The maximum achieved serum concentration of levonorgestrel (LNG) is lower in obese women than women of normal BMI, and doubling the dose of LNG (3 mg) increases its concentration maximum, approximating the level in normal BMI women receiving one dose of LNG. Repeated use of both LNG and ulipristal acetate (UPA) is well tolerated. Hormonal contraception can be immediately started following LNG use, but should be delayed for 5 days after UPA use to avoid dampening the efficacy of UPA. The copper intrauterine device (IUD) is the only IUD approved for emergency contraception (and the most effective method of emergency contraception), but use of LNG IUD as emergency contraception is currently being investigated. Accurate knowledge about emergency contraception remains low both for patients and healthcare providers.

SUMMARY

Emergency contraception is an important yet underutilized tool available to women to prevent pregnancy. Current options including copper IUD and emergency contraceptive pills are safe and well tolerated. Significant gaps in knowledge of emergency contraception on both the provider and user level exist, as do barriers to expedient access of emergency contraception.

Increasing the uptake of long-acting and permanent methods of family planning: A qualitative study with village midwives in East Java and Nusa Tenggara Barat Provinces, Indonesia

OBJECTIVE

this analysis aims to explore midwives' insights into the provision of long-acting and permanent methods of contraception (LAPMs) in the selected areas of East Java and Nusa Tenggara Barat (NTB) Provinces, Indonesia.

DESIGN

a qualitative study using in-depth interviews was conducted with 12 village midwives from 12 villages, to explore their perceptions and experiences in delivering family planning services.

SETTING

the study was carried out in May-June 2013, as part of the baseline assessment in the Improving Contraceptive Method Mix (ICMM) study. We interviewed 12 village midwives working in 12 villages in six study districts: Tuban, Kediri, and Lumajang Districts in East Java Province; and Lombok Barat, Lombok Timur, and Sumbawa Districts in NTB Province.

MEASUREMENT

an interview guideline was used in all interviews. It covered several topics, such as community perceptions of LAPMs, availability of contraception and related equipment, availability of human resources, and midwives' efforts to improve LAPM coverage. All interviews were recorded and transcribed. Content and thematic analyses were carried out by grouping and coding the information based on the identified themes and topics.

FINDINGS

according to village midwives interviewed in this study, community-level acceptance of LAPMs has increased over time; however, some still prefer using short-acting methods for a long period. The reasons include lack of awareness about the benefits and side effects of LAPMs, fear of surgical procedures, rumored consequences (for example, that LAPMs would limit women's ability to perform hard physical labor), and religious beliefs. There were several challenges reported by village midwives in delivering LAPM services, such as confusion about midwives' eligibility to provide LAPM services, lack of Contraceptive Technology Update (CTU) and counseling trainings, and shortage of supporting equipment (such as exam tables and IUD and implant insertion kits). There were several strategies implemented by village midwives to improve LAPM use, including strengthening the counseling services, accompanying clients to higher health facilities to obtain LAPM services, and providing services for groups of clients. All village midwives emphasized the importance of strengthening collaboration among stakeholders to increase the uptake of LAPM services.

KEY CONCLUSIONS

as midwives are the main family planning providers in Indonesia, efforts to address their challenges is essential. Enabling a supportive policy environment, strengthening promotional activities, increasing the number of training programs designed for village midwives-in addition to enhancing inter-sectoral collaboration-are some recommendations to improve LAPM uptake in study areas.

Long-acting reversible contraceptive acceptability and unintended pregnancy among women presenting for short-acting methods: a randomized patient preference trial

BACKGROUND

Measures of contraceptive effectiveness combine technology and user-related factors. Observational studies show higher effectiveness of long-acting reversible contraception compared with short-acting reversible contraception. Women who choose long-acting reversible contraception may differ in key ways from women who choose short-acting reversible contraception, and it may be these differences that are responsible for the high effectiveness of long-acting reversible contraception. Wider use of long-acting reversible contraception is recommended, but scientific evidence of acceptability and successful use is lacking in a population that typically opts for short-acting methods.

OBJECTIVE

The objective of the study was to reduce bias in measuring contraceptive effectiveness and better isolate the independent role that long-acting reversible contraception has in preventing unintended pregnancy relative to short-acting reversible contraception.

STUDY DESIGN

We conducted a partially randomized patient preference trial and recruited women aged 18-29 years who were seeking a short-acting method (pills or injectable). Participants who agreed to randomization were assigned to 1 of 2 categories: long-acting reversible contraception or short-acting reversible contraception. Women who declined randomization but agreed to follow-up in the observational cohort chose their preferred method. Under randomization, participants chose a specific method in the category and received it for free, whereas participants in the preference cohort paid for the contraception in their usual fashion. Participants were followed up prospectively to measure primary outcomes of method continuation and unintended pregnancy at 12 months. Kaplan-Meier techniques were used to estimate method continuation probabilities. Intent-to-treat principles were applied after method initiation for comparing incidence of unintended pregnancy. We also measured acceptability in terms of level of happiness with the products.

RESULTS

Of the 916 participants, 43% chose randomization and 57% chose the preference option. Complete loss to follow-up at 12 months was <2%. The 12-month method continuation probabilities were 63.3% (95% confidence interval, 58.9-67.3) (preference short-acting reversible contraception), 53.0% (95% confidence interval, 45.7-59.8) (randomized short-acting reversible contraception), and 77.8% (95% confidence interval, 71.0-83.2) (randomized long-acting reversible contraception) (P < .001 in the primary comparison involving randomized groups). The 12-month cumulative unintended pregnancy probabilities were 6.4% (95% confidence interval, 4.1-8.7) (preference short-acting reversible contraception), 7.7% (95% confidence interval, 3.3-12.1) (randomized short-acting reversible contraception), and 0.7% (95% confidence interval, 0.0-4.7) (randomized long-acting reversible contraception) (P = .01 when comparing randomized groups). In the secondary comparisons involving only short-acting reversible contraception users, the continuation probability was higher in the preference group compared with the randomized group (P = .04). However, the short-acting reversible contraception randomized group and short-acting reversible contraception preference group had statistically equivalent rates of unintended pregnancy (P = .77). Seventy-eight percent of randomized long-acting reversible contraception users were happy/neutral with their initial method, compared with 89% of randomized short-acting reversible contraception users (P < .05). However, among method continuers at 12 months, all groups were equally happy/neutral (>90%).

CONCLUSION

Even in a typical population of women who presented to initiate or continue short-acting reversible contraception, long-acting reversible contraception proved highly acceptable. One year after initiation, women randomized to long-acting reversible contraception had high continuation rates and consequently experienced superior protection from unintended pregnancy compared with women using short-acting reversible contraception; these findings are attributable to the initial technology and not underlying factors that often bias observational estimates of effectiveness. The similarly patterned experiences of the 2 short-acting reversible contraception cohorts provide a bridge of generalizability between the randomized group and usual-care preference group. Benefits of increased voluntary uptake of long-acting reversible contraception may extend to wider populations than previously thought.

Predictors of Men’s Acceptance of Modern Contraceptive Practice: Study in Rural Vietnam

Studies have shown family planning adoption is likely to be more effective for women when men are actively involved. The transtheoretical model of behavior change was used to examine men’s involvement in general contraception and intrauterine device (IUD) use by their wives. The study was carried out in rural Vietnam with 651 eligible participants. Cons of IUD use for men in precontemplation and contemplation/preparation were significantly higher than those in the action/maintenance stages, whereas the reverse was true for pros of IUD. The self-efficacy for convincing wife to have IUD in precontemplation was significantly lower than for those in higher stages. Women’s education and ages, spontaneous recall of modern contraceptive method, cons for IUD, and self-efficacy for contraception and for convincing wives to get IUD inserted (or continue use) were significant predictors of men’s readiness to accept IUD. Interventions are targeted to reduce cons and increase self-efficacy for IUD use.

Cost-Effectiveness of Introducing the SILCS Diaphragm in South Africa

BACKGROUND

Though South Africa has high contraceptive use, unintended pregnancies are still widespread. The SILCS diaphragm could reduce the number of women with unmet need by introducing a discreet, woman-initiated, non-hormonal barrier method to the contraceptive method mix.

METHODS

A decision model was built to estimate the impact and cost-effectiveness of the introduction of the SILCS diaphragm in Gauteng among women with unmet need for contraception in terms of unintended and mistimed pregnancies averted, assuming that the available contraceptives on the market were not a satisfying option for those women. Full costs were estimated both from a provider's and user's perspective, which also accounts for women's travel and opportunity cost of time, assuming a 5% uptake among women with unmet contraceptive need. The incremental cost-effectiveness ratio is computed at five and 10 years after introduction to allow for a distribution of fixed costs over time. A probabilistic sensitivity analysis was conducted to incorporate decision uncertainty.

RESULTS

The introduction of the SILCS diaphragm in Gauteng could prevent an estimated 8,365 unintended pregnancies and 2,117 abortions over five years, at an annual estimated cost of US$55 per woman. This comes to a cost per pregnancy averted of US$153 and US$171 from a user's and provider's perspectives, respectively, with slightly lower unit costs at 10 years. Major cost drivers will be the price of the SILCS diaphragm and the contraceptive gel, given their large contribution to total costs (around 60%).

CONCLUSIONS

The introduction of the SILCS diaphragm in the public sector is likely to provide protection for some women for whom current contraceptive technologies are not an option. However to realize its potential, targeting will be needed to reach women with unmet need and those with likely high adherence. Further analyses are needed among potential users to optimize the introduction strategy.

Impact of pay for performance on prescribing of long-acting reversible contraception in primary care: an interrupted time series study

BACKGROUND

The aim of this study was to evaluate the impact of Quality and Outcomes Framework (QOF), a major pay-for-performance programme in the United Kingdom, on prescribing of long-acting reversible contraceptives (LARC) in primary care.

METHODS

Negative binomial interrupted time series analysis using practice level prescribing data from April 2007 to March 2012. The main outcome measure was the prescribing rate of long-acting reversible contraceptives (LARC), including hormonal and non hormonal intrauterine devices and systems (IUDs and IUSs), injectable contraceptives and hormonal implants.

RESULTS

Prescribing rates of Long-Acting Reversible Contraception (LARC) were stable before the introduction of contraceptive targets to the QOF and increased afterwards by 4% annually (rate ratios  = 1.04, 95% CI = 1.03, 1.06). The increase in LARC prescribing was mainly driven by increases in injectables (increased by 6% annually), which was the most commonly prescribed LARC method. Of other types of LARC, the QOF indicator was associated with a step increase of 20% in implant prescribing (RR =  1.20, 95% CI =  1.09, 1.32). This change is equivalent to an additional 110 thousand women being prescribed with LARC had QOF points not been introduced.

CONCLUSIONS

Pay for performance incentives for contraceptive counselling in primary care with women seeking contraceptive advice has increased uptake of LARC methods.

Cost-savings from the provision of specific contraceptive methods in 2009

BACKGROUND

Previous studies have shown that contraceptive provision generates significant public sector cost-savings by preventing health care and social service expenditures on unintended pregnancies. Over the past decade, women's contraceptive options have expanded considerably, calling for the need to better understand the relative cost-benefit of new contraceptive methods.

METHODS

We estimated the number of pregnancies averted by each specific contraceptive method by subtracting the total number of pregnancies expected under Family PACT from the total number of pregnancies that would be expected if the program were not available. The cost of providing each method was compared with the savings in reduced public expenditures from averted pregnancies. A resultant cost-benefit ratio was calculated for 11 specific contraceptive methods provided to women under Family PACT.

RESULTS

Every contraceptive method studied saved more in public expenditures for unintended pregnancy than it costs to provide. Over half (51%) of the pregnancies averted in 2009 were attributable to the most commonly used method, oral contraceptives. Injectable methods accounted for 13% of averted pregnancies, followed by intrauterine contraceptives (12%), and barrier methods (9%). Intrauterine contraception and contraceptive implants had the highest cost-savings with approximately $5.00 of savings for every dollar spent for users of these methods.

CONCLUSIONS

Because no single method is recommended clinically for every woman, it is medically and fiscally advisable to offer women all contraceptive methods to enable them to choose methods that best meet their needs, increasing the likelihood of compliance with the method chosen and prevention of unintended pregnancies.

Obesity and oral contraceptives: a clinician's guide

Obesity and unintended pregnancy are two of the major health epidemics we are currently facing worldwide. Patient education is a clinician's greatest tool in combating both epidemics but many clinicians may be uncomfortable with counselling and prescribing contraception for obese women. Overall, the prevention of unintended pregnancy in obese women far outweighs any risk associated with oral contraceptive use. This review aims to provide the clinician with a practical guide to the use of oral contraceptive pills in obese women.

State-of-the-art of non-hormonal methods of contraception: III. Intrauterine devices

Since the 1959 revival of the IUD, non-hormonal devices have become the most widely used of all reversible contraceptives. Pregnancy rates of copper-releasing IUDs in current use range from approximately 0.5 to 1.5 per hundred continuing users in the first year, with somewhat lower annual pregnancy rates thereafter. Evidence-based research has been systematically conducted and translated into guidelines for eligibility criteria and problem management. Recent device research, beyond the T, Multiload and frameless devices has centred on improved designs such as U ,Y and Slimline shapes, or enhanced copper release, the latter through electrochemical effects or nanotechnology applications. Other IUD research foci concern devices that decrease bleeding and pain by releasing non-steroidal anti-inflammatory drugs. Yet other research lines indicate noncontraceptive benefits of copper intrauterine devices in protecting against endometrial cancer, and favourable risk-benefit analyses of IUD use by women at risk of or post HIV infection. IUD mechanisms of action and the relation of IUDs to pelvic infection and ectopic pregnancy are briefly reviewed. For our literature search we used Medline, Popline and Cochrane Library data bases, Google search, our personal files, and the references contained in articles in our files.

The state of hormonal contraception today: benefits and risks of hormonal contraceptives: progestin-only contraceptives

The progestin component of hormonal contraceptives accounts for most of their contraceptive effects. Several dosage forms of progestin-only contraceptives have been developed, including pills, injectables, implants, and intrauterine devices. Emergency contraceptives may also contain progestin only and are indicated for prevention of pregnancy following unprotected intercourse or contraceptive failure. Each form has benefits, some specific to the form. An understanding of benefits and risks allows clinicians a wider choice when recommending effective hormonal contraception.

Family planning and the burden of unintended pregnancies

Family planning is hailed as one of the great public health achievements of the last century, and worldwide acceptance has risen to three-fifths of exposed couples. In many countries, however, uptake of modern contraception is constrained by limited access and weak service delivery, and the burden of unintended pregnancy is still large. This review focuses on family planning's efficacy in preventing unintended pregnancies and their health burden. The authors first describe an epidemiologic framework for reproductive behavior and pregnancy intendedness and use it to guide the review of 21 recent, individual-level studies of pregnancy intentions, health outcomes, and contraception. They then review population-level studies of family planning's relation to reproductive, maternal, and newborn health benefits. Family planning is documented to prevent mother-child transmission of human immunodeficiency virus, contribute to birth spacing, lower infant mortality risk, and reduce the number of abortions, especially unsafe ones. It is also shown to significantly lower maternal mortality and maternal morbidity associated with unintended pregnancy. Still, a new generation of research is needed to investigate the modest correlation between unintended pregnancy and contraceptive use rates to derive the full health benefits of a proven and cost-effective reproductive technology.

The financial effects of expanding postpartum contraception for new immigrants

OBJECTIVE

To estimate the costs of expanding Emergency Medicaid coverage to include postpartum contraception.

METHODS

A decision-analytic model was developed using three perspectives: the hospital, state Medicaid programs, and society. Our primary outcome was future reproductive health care costs due to pregnancy in the next 5 years. A Markov structure was use to analyze the probability of pregnancy over a 5-year time period. Model inputs were retrieved from the existing literature and local hospital and Medicaid data related to reimbursements. One-way and multiway sensitivity analyses were conducted. A Monte Carlo simulation was performed to incorporate uncertainty from all of the model inputs simultaneously.

RESULTS

Over a 5-year period, provision of contraception would save society $17,792 per woman in future pregnancy costs and incur a loss of $367 for hospitals. In states in which 49% of immigrants remain in the area for 5 years, such a program would save state Medicaid $108 per woman.

CONCLUSION

Under federal regulations, new immigrants are restricted to acute, hospital-based care only. Failure to provide the option of contraception postpartum results in increased costs for society and states with long-term immigrants.

Health economics of contraception

Unintended pregnancies constitute a global problem associated with substantial costs to health and social services, and emotional distress to women, their families and society as a whole. Provision of contraception has been demonstrated to be a particularly cost-effective healthcare intervention as, besides preventing a significant number of unintended pregnancies, it also results in great cost-savings to society. Male and female sterilization and long-acting reversible methods (such as the copper-T intra-uterine device and the subdermal implant) constitute the most cost-effective contraceptive options, followed by other hormonal methods (such as oral contraceptives); barrier and behavioural methods (such as the male condom and withdrawal, respectively) are least cost-effective compared with other contraceptive options. Nevertheless, when compared with no method, they still prevent a large number of unintended pregnancies, thus leading to important cost-savings. Improvements in compliance and continuation rates are expected to further enhance the contraceptive benefits and cost-savings associated with contraceptive use.

Cost effectiveness of contraceptives in the United States

BACKGROUND

The study was conducted to estimate the relative cost effectiveness of contraceptives in the United States from a payer's perspective.

METHODS

A Markov model was constructed to simulate costs for 16 contraceptive methods and no method over a 5-year period. Failure rates, adverse event rates and resource utilization were derived from the literature. Sensitivity analyses were performed on costs and failure rates.

RESULTS

Any contraceptive method is superior to "no method". The three least expensive methods were the copper-T intrauterine device (IUD) (US$647), vasectomy (US$713) and levonorgestrel (LNG)-20 intrauterine system (IUS) (US$930). Results were sensitive to the cost of contraceptive methods, the cost of an unintended pregnancy and plan disenrollment rates.

CONCLUSION

The copper-T IUD, vasectomy and the LNG-20 IUS are the most cost-effective contraceptive methods available in the United States. Differences in method costs, the cost of an unintended pregnancy and time horizon are influential factors that determine the overall value of a contraceptive method.

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.

Prior contraceptive use among women who gave birth in the US-Mexico border region, 2005: the Brownsville-Matamoros Sister City Project for Women's Health

INTRODUCTION

Dramatic population growth in the US-Mexico border region suggests more effective family planning services are needed, yet binational data are scarce. The Brownsville-Matamoros Sister City Project for Women's Health collected binational, standardized data from 947 postpartum women in Cameron County (Texas) and Matamoros (Tamaulipas, Mexico) hospitals from August through November 2005.

METHODS

We analyzed these data to estimate the proportion of women with unintended pregnancy and the proportion of these women who reported contraceptive use, and to identify associated factors.

RESULTS

The current pregnancy was unintended for 48% of women overall. Almost half of these women reportedly used birth control at conception, but many used low-efficacy methods. Among women with unintended pregnancy who did not use contraception, 34.1% of Mexico residents believed they could not become pregnant and 28.4% of US residents reported no reason for nonuse. Overall, contraceptive use to prevent pregnancy was less common among younger than older women and among women who had not graduated high school compared with those who had. Among Mexico residents, those who had a source of routine health care were more likely than those who did not to have used contraception.

CONCLUSION

More effective contraceptive practices are needed in this population, especially among younger and less-educated women. A cooperative binational approach that integrates reproductive and family planning services may be most effective.

Cost savings from the provision of specific methods of contraception in a publicly funded program

OBJECTIVES

We examined the cost-effectiveness of contraceptive methods dispensed in 2003 to 955,000 women in Family PACT (Planning, Access, Care and Treatment), California's publicly funded family planning program.

METHODS

We estimated the number of pregnancies averted by each contraceptive method and compared the cost of providing each method with the savings from averted pregnancies.

RESULTS

More than half of the 178,000 averted pregnancies were attributable to oral contraceptives, one fifth to injectable methods, and one tenth each to the patch and barrier methods. The implant and intrauterine contraceptives were the most cost-effective, with cost savings of more than $7.00 for every $1.00 spent in services and supplies. Per $1.00 spent, injectable contraceptives yielded savings of $5.60; oral contraceptives, $4.07; the patch, $2.99; the vaginal ring, $2.55; barrier methods, $1.34; and emergency contraceptives, $1.43.

CONCLUSIONS

All contraceptive methods were cost-effective-they saved more in public expenditures for unintended pregnancies than they cost to provide. Because no single method is clinically recommended to every woman, it is medically and fiscally advisable for public health programs to offer all contraceptive methods.

Hormonal contraceptive discontinuation patterns according to formulation: investigation of associations in an administrative claims database

BACKGROUND

Hormonal contraceptive use is generally characterized by poor adherence and relatively high discontinuation. This study investigated whether specific hormonal contraceptive formulations and/or delivery systems might be correlated with discontinuation of contraception.

STUDY DESIGN

This was a retrospective descriptive analysis within a large administrative claims database. The sample included women aged 15-40 years with a pharmacy benefit and at least one new hormonal contraception prescription during the study period and no prescription in the previous 6 months. Filled contraceptive prescriptions were grouped into several categories of delivery system, dosage, progestin type and monophasic vs. triphasic formulations. In each, a baseline number of women was established who filled a first prescription for a contraceptive formulation in the specified category. Then, the percentage of these women who filled a prescription for a contraceptive in the same category within 3 months' time was determined. Continuation or change rates were compared within each group.

RESULTS

Oral contraceptives (OCs) were the least likely to be discontinued at 3 months; injectables were the most likely. OC formulations associated with increased risk of discontinuation (odds ratios above 1.3 representing a 5% or higher increased discontinuation) included very-low-dose (20-25 mcg ethinyl estradiol) pills containing norethindrone acetate or norgestimate, as compared to a preparation with the same progestin type but with a higher dose of estrogen. Desogestrel and norethindrone-containing triphasics were more likely to be discontinued than other triphasic progestins. OC formulations with desogestrel and norethindrone/norethindrone acetate were more likely than formulations with other progestins to be discontinued overall.

CONCLUSIONS

This investigation in a sample of nearly 250,000 women suggests possible associations between discontinuation of hormonal contraception and factors such as estrogen dosing, progestin type and changes in dosage during the cycle. Identification of factors correlated with contraceptive discontinuation may inform management and improve adherence.

A comparison of contraceptive procurement pre- and post-benefit change

BACKGROUND

In 2002, the Kaiser Foundation Health Plan in California changed its coverage policy to include 100% universal coverage for the most effective forms of contraception and for emergency contraceptive pills (ECPs). This study sought to evaluate whether removing the cost of contraception as a potential barrier to utilization would lead to a change in the mix of contraceptive methods prescribed and purchased by a large health plan and whether those changes could theoretically result in averting a greater number of unintended pregnancies.

STUDY DESIGN

A retrospective observational study was conducted to describe the mix of reversible contraceptives procured before and after the benefit change at Kaiser Permanente Northern California. We then estimated couple-years of protection (CYP) to examine whether the contraceptive mix changed to more effective reversible methods.

RESULTS

After the contraceptive benefit change, CYP increased by 28% (from 2001-2002 to 2003-2004), while the number of females aged 15-44 enrolled in this health plan fell by 1%. CYP for intrauterine contraceptives (IUCs) and injectables rose by 137% and 32%, respectively, while CYP for the pill, patch and ring rose only by 16%. The estimated average annual contraceptive failure rate among women using hormonal contraceptives and IUCs declined from 7.0% to 6.4%. Purchasing of the ECP rose by 88%.

CONCLUSION

Removal of the cost of contraception may result in increased utilization of more effective methods and ECPs.

The perforated intrauterine device: endoscopic retrieval

BACKGROUND

Uterine perforation is the most serious complication associated with an intrauterine contraceptive device (IUD). Minimally invasive techniques, such as hysteroscopy and advanced laparoscopy, are ideally suited to the diagnosis and surgical management of the perforated IUD.

CASE REPORTS

Three cases of uterine perforation caused by an IUD and treated with endoscopic surgery are presented. In all 3 cases, the IUD was located by using x-rays, ultrasonography, or pelvic magnetic resonance imaging. Diagnostic laparoscopy was performed to identify the specific location of the IUD and to remove it. All patients recovered without incident.

CONCLUSION

The gynecologic surgeon should acquire familiarity with the complications of, and proficiency in managing, perforated and ectopic IUDs by using modern surgical techniques that permit the patient's rapid return to health.

Sterilization in the United States

Unintended pregnancies are expensive for patients and for society in terms of medical costs, the cost of caring for more children, and the cost to personal and professional goals. Sterilization is the most common contraceptive method utilized by couples in the United States. Given technological advances over the past few decades, male and female surgical sterilization has become a safe, convenient, easy, and highly effective birth control method for the long term. This article reviews current male and female sterilization options.

Long-acting and permanent contraception: an international development, service delivery perspective

Recent scientific findings about long-acting and permanent methods of contraception underscore their safety, effectiveness, and wide eligibility for individuals who desire them. This has led to new guidance from the World Health Organization to inform national policies, guidelines, and standards for service delivery. Although developing countries have made much progress in expanding the availability and use of family planning services, the need for effective contraception in general (and long-acting and permanent methods in particular) is large and growing because the largest cohorts in human history are entering their reproductive years. More than half a billion people will use contraception in developing countries (excluding China) by 2015, an increase of 200 million over levels of use in 2000. The health, development, and equity rationales that historically have underpinned and energized the international family planning effort remain valid and relevant today. Despite the other compelling challenges faced by the international health community, the need to make family planning services more widely available is pressing and should remain a priority.

Modelling cost-effectiveness of different vasectomy methods in India, Kenya, and Mexico

Background

Vasectomy is generally considered a safe and effective method of permanent contraception. The historical effectiveness of vasectomy has been questioned by recent research results indicating that the most commonly used method of vasectomy – simple ligation and excision (L and E) – appears to have a relatively high failure rate, with reported pregnancy rates as high as 4%. Updated methods such as fascial interposition (FI) and thermal cautery can lower the rate of failure but may require additional financial investments and may not be appropriate for low-resource clinics. In order to better compare the cost-effectiveness of these different vasectomy methods, we modelled the costs of different vasectomy methods using cost data collected in India, Kenya, and Mexico and effectiveness data from the latest published research.

Methods

The costs associated with providing vasectomies were determined in each country through interviews with clinic staff. Costs collected were economic, direct, programme costs of fixed vasectomy services but did not include large capital expenses or general recurrent costs for the health care facility. Estimates of the time required to provide service were gained through interviews and training costs were based on the total costs of vasectomy training programmes in each country. Effectiveness data were obtained from recent published studies and comparative cost-effectiveness was determined using cost per couple years of protection (CYP).

Results

In each country, the labour to provide the vasectomy and follow-up services accounts for the greatest portion of the overall cost. Because each country almost exclusively used one vasectomy method at all of the clinics included in the study, we modelled costs based on the additional material, labour, and training costs required in each country. Using a model of a robust vasectomy program, more effective methods such as FI and thermal cautery reduce the cost per CYP of a vasectomy by $0.08 – $0.55.

Conclusion

Based on the results presented, more effective methods of vasectomy – including FI, thermal cautery, and thermal cautery combined with FI – are more cost-effective than L and E alone. Analysis shows that for a programme in which a minimum of 20 clients undergo vasectomies per month, the cost per CYP is reduced in all three countries by updated vasectomy methods.