More than half of U.S. pregnancies are unintended.1 Maternal and neonatal care costs for unintended pregnancies amount to $11.1 billion annually for public insurance programs alone.2 The immediate postpartum period (after delivery but before discharge home) provides an ideal opportunity for initiating contraceptives because patients are motivated and timing is convenient.3,4
The etonogestrel subdermal contraceptive implant, a long-acting reversible contraception (LARC) method, is safe and effective for immediate postpartum insertion, including for breastfeeding women.4–6 Studies showed that adolescents with immediate postpartum implant insertion have lower repeat pregnancy rates within 2 years than adolescents with delayed insertion,7 because sexual activity without contraception before the insertion visit and failure to return for the visit can increase unintended pregnancy risk.4,8–10 However, there are no similar studies of adult women.
Moreover, cost-effectiveness of immediate compared with delayed postpartum implant insertion (eg, at the 6-week postpartum visit) is not established, although cost-effectiveness of other LARC methods inserted in the postpartum period such as intrauterine devices (IUDs) has been demonstrated.11 The implant has several advantages over IUDs and warrants separate assessment. Implants are permitted regardless of obstetric complications that preclude IUD insertion (eg, chorioamnionitis) and are unaffected by concerns for expulsion.5
Therefore, we evaluated the cost-effectiveness of immediate compared with delayed postpartum implant insertion and potential cost savings from avoiding unintended pregnancies.2,8 Obstetric “global delivery fees,” which preclude separate reimbursement of individual procedures, are one important barrier to immediate postpartum LARC use.3,9,10 Understanding cost-effectiveness of immediate postpartum implant insertion can inform policy discussions regarding reimbursement for contraception.3,9,10
MATERIALS AND METHODS
We constructed a decision-analytic model for a hypothetical cohort of postpartum women of reproductive age at risk for repeat pregnancy (ie, without prior sterilizations or hysterectomies) desiring the contraceptive implant after delivery. Decision analysis is a modeling method for comparing two or more interventions by mapping the clinical pathways after each intervention and incorporating uncertainty in the occurrence of health events and outcomes. The analysis was conducted from the health care system's perspective and therefore only included medical care costs. We compared the number of subsequent unintended pregnancies for a policy offering immediate postpartum implant insertion compared with the current practice of delayed insertion.
Immediate postpartum placement was defined as insertion of the implant at any time after delivery but before discharge from the hospital. Delayed placement was defined as insertion of the implant at the first postpartum visit. The postpartum visit was assumed to occur at 6 weeks after delivery and to be consistent with the current standard of practice. A decision tree was constructed to map out contraceptive events (implant insertion and removal, implant continuation or discontinuation, use of alternative contraceptive methods, lactational amenorrhea secondary to exclusive breastfeeding, contraceptive failure, and lost to follow-up) and outcomes (pregnant or not pregnant) over the 1-year period after, but not including, the index delivery (Fig. 1). We evaluated the cost-effectiveness and cost–benefit of immediate compared with delayed implant placement. Effectiveness was measured as pregnancy avoidance during the 1-year period, whereas benefit was assessed by cost savings associated with pregnancy prevention.
Assumptions of the model:
- 1) Women were assumed to be anovulatory for the first 4 weeks postpartum and therefore not at risk of pregnancy regardless of sexual activity.12
- 2) As a result of a lack of age-specific data in the current literature regarding the parameters in the model, we estimated the average experience of women of reproductive age, consistent with prior cost-effectiveness research.13
- 3) We assumed that distribution of contraceptive method choice among postpartum women was the same as an average woman's experience reflected in 2011–2013 national data from the National Survey of Family Growth, focusing on women who used reversible methods. The National Survey of Family Growth is a national survey conducted by the Centers for Disease Prevention and Control of men and women ages 15–44 years about contraceptive practices, pregnancy, and pregnancy outcomes.14 We also used national estimates of exclusive breastfeeding to estimate the contraceptive protection provided by lactational amenorrhea.15
- 4) There is a lack of data regarding the contraceptive methods used by women who do not return for a postpartum visit. Therefore, we assumed that they engaged in contraception beginning at the midpoint of the year and that they would use reversible contraceptive methods (both prescription and nonprescription forms of birth control) with the same distribution as that found in the National Survey of Family Growth.
- 5) Women who initiated a birth control method other than the implant continued that method for the study duration.
- 6) Women who discontinued the implant either proceeded without a contraceptive method or immediately initiated another (nonimplant) reversible contraceptive method for the remainder of the year. We assumed that distribution of reversible contraceptive methods in these women was the same as that found in the National Survey of Family Growth.
- 7) We assumed that women not undergoing implant insertion at their postpartum visit (unless they were exclusively breastfeeding) or choosing to have the implant removed started their alternative method of contraception at the same visit when the implant was not placed or removed.
- 8) Implant discontinuations were assumed to occur at the midpoint of the study year (for immediate insertion) or midpoint of the remainder year (for delayed insertion).16
- 9) Individuals were assumed to have intercourse at a rate of 83 times per year, consistent with previous literature on the cost-effectiveness of contraception.17
- 10) We assumed that exclusive breastfeeding (and its contraceptive effects) will end by 6 months postpartum.
Probability estimates for each health event in the model were obtained through a thorough literature review (Table 1). Online searches were conducted on PubMed, Medline, and relevant web sites (Centers for Disease Control and Prevention web site, the Guttmacher Institute web site, and Kaiser.org) from database inception through March 2015 using the following keywords and MeSH search terms: Implanon, Nexplanon, etonogestrel, implant, subdermal, immediate, delayed, cost, cost-effectiveness, failure, postpartum, pregnancy, unintended pregnancy, pregnancy rates, follow-up, compliance, continuation, contraception, breastfeeding, and combinations of these terms.
Failure rates for each reversible contraceptive method reflect typical use and were based on annual or monthly failure rate reported in the literature.18–20 This information was then used to construct a weighted average failure rate in our model for women who chose to use reversible contraceptive methods other than the implant or who had the implant removed based on the percentage of women using each method of contraception (other than implant) and the expected failure rate associated with each of those methods. A similar approach was used to estimate the weighted average failure rate for women who did not return for the postpartum visit but used a reversible contraceptive method (including implant). These weighted average failure rates were then used to calculate expected pregnancies during the applicable time period (eg, between the postpartum visit and end of the first year). Unless they already received the implant, women who were exclusively breastfeeding were assumed to initiate other contraceptive methods after they stopped breastfeeding. All pregnancies resulting from implant discontinuation or contraceptive failure were assumed to end in ectopic pregnancy, miscarriage, abortion, or delivery based on published data regarding the relative proportion of these outcomes.21,22
Cost estimates for each form of contraception in our model accounted for the cost of the device or drug as well as the cost of the contraceptive counseling visit and the insertion or removal procedure where applicable (Table 2). Cost for the contraceptive counseling visit and procedures included the full expenses of providing services, including health care providers' effort as well as practice expenses. We did not include the cost of the 6-week postpartum visit itself, because it is not affected by immediate compared with delayed implant insertion. Cost estimates were obtained from several data sources including the published literature19,23 (eg, implant device, IUD device, patch, ring, condom), the 2010 Red Book Drug Topics (eg, oral contraceptive pills), and the Medicare fee schedule (eg, implant insertion and removal procedure, IUD insertion, depot injection).24,25 Because the oral contraceptive pill, vaginal ring, and depot injections are purchased by complete cycles (28 days and 3 months, respectively), we did not allow for fractions of per-cycle costs. However, we accommodated fractions of per-cycle costs for condom use. Costs associated with oral contraceptive pills were based on a weighted average of the most commonly used oral contraceptives.26 We included cost of a contraceptive counseling visit when women had implant removal or did not return for a postpartum visit but obtained contraceptives from other sources.
Costs associated with subsequent unintended pregnancies were based on published estimates for childbirth expenses (including prenatal care) for commercially insured and Medicaid-funded women and the percentage of U.S. deliveries funded by Medicaid.21,27 We also accounted for the costs of abortion, miscarriage, and ectopic pregnancy consistent with previous contraception cost-effectiveness studies.21 All cost estimates were reported in 2014 U.S. dollars. Cost estimates from other years were inflation-adjusted to 2014 dollars using the medical care component of the Consumer Price Index.28
For both immediate and delayed implant insertion, we calculated the expected costs and pregnancy rates. Incremental cost-effectiveness ratio of immediate compared with delayed insertion indicates the additional costs associated with immediate insertion for each additional pregnancy prevented. One-way sensitivity analyses were conducted to investigate the effect of uncertainty in model parameters on the results. When data ranges were not available from the literature, we used ±25% of the base value for the sensitivity analysis.29 To demonstrate the potential net savings of immediate postpartum implant insertion, we also conducted a cost–benefit analysis by accounting for avoided costs associated with potential subsequent pregnancies from the health care system's perspective. All analyses were conducted with TreeAge software. This study was exempt from institutional review board review because it only used published data.
At 1 year postpartum, immediate insertion is associated with a higher expected per patient cost of $1,091 (compared with $650 for delayed insertion) (Table 3). However, immediate postpartum implant insertion has a lower expected pregnancy rate than delayed insertion: 2.4% and 21.6%, respectively. In other words, for each 1,000 women planning to receive the implant postpartum, immediate insertion is expected to prevent 191 unintended pregnancies compared with delayed insertion. Therefore, compared with delayed insertion, immediate insertion is associated with an incremental cost-effectiveness ratio of $2,304 per pregnancy prevented (Table 3).
In subsequent cost–benefit analysis, we considered medical costs (including prenatal care) associated with unintended pregnancies in each arm of the model. Accounting for the likelihood of ectopic pregnancy, miscarriage, abortion, and delivery, the expected medical cost of each unintended pregnancy is estimated to be $8,907. Because immediate implant placement is associated with a much lower unintended pregnancy rate compared with the delayed insertion arm (2.4% compared with 21.6%), immediate implant insertion is expected to save $1,263 per patient after we take into consideration the costs of unintended pregnancies (Table 3). In sensitivity analyses using per-pregnancy cost based on Medicaid expense compared with commercial insurers, immediate implant insertion is associated with an expected net saving of $703 and $1,781 per patient, respectively.
In one-way sensitivity analysis, the incremental cost-effectiveness ratio of immediate compared with delayed insertion in preventing unintended pregnancy was most influenced by the rate at which women become pregnant when not using contraception, cost of the implant device, probability of removing the implant within first year of use, probability of women returning for a postpartum visit, and the probability of pregnancy before a postpartum visit (Fig. 2). For example, when the annual pregnancy rate increased from 63.75% to 100% for women not using contraception, the incremental cost-effectiveness ratio associated with immediate insertion decreased from $3,054 to $1,491 per pregnancy prevented. When cost of the implant was varied from $645 to $1,075, the incremental cost-effectiveness ratio increased from $1,697 to $2,911 per pregnancy prevented. However, immediate insertion was more effective in preventing pregnancy than delayed insertion in all scenarios, and the incremental cost-effectiveness ratio ranged from $1,491 to $3,054 for each pregnancy prevented.
Using a cost-effectiveness analysis from a health care system's perspective, immediate postpartum implant insertion is cost-effective in preventing pregnancies compared with delayed insertion. Because immediate placement prevents more pregnancies, it results in net savings of $1,263 per patient. Based on these estimates, for every 1,000 women using postpartum implant, immediate placement is expected to avert 191 unintended pregnancies and save $1,263,000 compared with delayed insertion.
Higher expected cost of immediate insertion is because some women in the delayed insertion arm did not receive the implant. With delayed insertion, 35% of women did not return for their postpartum visit and 27% attending the visit declined the implant. By using less expensive, non-LARC methods or no contraception, these women would incur lower costs after delayed compared with immediate insertion.14 However, use of non-LARC methods or no contraception results in higher unintended pregnancy risk.18–20 When considering medical costs of subsequent unintended pregnancies, immediate postpartum implant insertion is associated with net savings. These findings support prior research demonstrating the cost-effectiveness of LARC.11,13,19,21
Given LARC's high efficacy and few contraindications, the American College of Obstetricians and Gynecologists advocates for obstetrician–gynecologists and insurance providers to reduce barriers to immediate postpartum LARC initiation.4,30,31 In general, women without insurance coverage of LARC methods are 11 times less likely to receive one.32 Insurance coverage of immediate postpartum LARC would expand access and facilitate uptake. Immediate insertion is ideal because motivation and doctor–patient interaction are high, no return visit is required, and the method starts before resumption of ovulation and sexual activity.4 Early implant initiation (1–3 days postpartum) shows no concerning effects on maternal or infant health, including breastfeeding outcomes.6,33
We also need to understand more about the approximately 27% of women who initially desire the implant but do not receive it at the postpartum visit.10,34 Are women receiving alternative contraception because they no longer want the implant, or are there barriers to care such as an additional office visit for insertion? Further research on this patient population would be informative to provide more patient-centered care and meet their contraceptive needs.
We recognize that our study had several limitations. First, our analysis was limited to the first postpartum year, which is shorter than the 3-year maximum duration of use for the contraceptive implant. However, given the upfront cost of the implant with minimal costs in subsequent years, extending the model for an additional 2 years would result in more favorable findings for immediate implant insertion. Likewise, we did not account for cost savings of immediate postpartum implant insertion (as a result of its lower expected pregnancy rate compared with delayed insertion) related to reduced likelihood of short interpregnancy intervals and associated adverse perinatal outcomes.35,36 Hence, our estimates provide a conservative view for the cost-effectiveness of immediate insertion.
Second, there are still important gaps in the current literature and we had to make assumptions in our analysis. For example, we know little about contraceptive methods used by women who do not attend their postpartum visit and among women awaiting delayed implant insertion. The literature also lacks representative estimates of the effect of unintended pregnancy on employment or education, household expenses (eg, diapers, child care), or patients' quality of life, which were therefore not accounted for in the model, biasing our results against immediate insertion.
Furthermore, consistent with previous contraception cost-effectiveness research,21 we assumed that women choosing non-LARC methods in the model did not discontinue or switch those methods. Because non-LARC methods have higher discontinuation rates than LARC methods20 and method switching can also be associated with a gap in use of any contraception, which could therefore result in a higher pregnancy risk, our model likely underestimates the benefits of immediate insertion. Future research characterizing patterns of contraceptives used by postpartum women is warranted.
In summary, findings from this analysis suggest that immediate postpartum insertion of the contraceptive implant is expected to be cost-effective compared with delayed insertion and to result in a decrease in unintended pregnancy and net savings for the health care system in the long run. Effort should be made to offer the contraceptive implant in the immediate postpartum period to all women who desire it and do not have contraindications.
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