Economic Evaluation of Provision of Postpartum Intrauterine Device Services in Bangladesh and Tanzania

Abstract

Introduction: Postpartum family planning is an effective means of achieving improved health outcomes for women and children, especially in low- and middle-income settings. We assessed the cost-effectiveness of an immediate postpartum intrauterine device (PPIUD) initiative compared with standard practice in Bangladesh and Tanzania (which is no immediate postpartum family planning counseling or service provision) to inform resource allocation decisions for governments and donors.

Methods: A decision analysis was constructed to compare the PPIUD program with standard practice. The analysis was based on the number of PPIUD insertions, which were then modeled using the Impact 2 tool to produce estimates of cost per couple-years of protection (CYP) and cost per disability-adjusted life years (DALYs) averted. A micro-costing approach was used to estimate the costs of conducting the program, and downstream cost savings were generated by the Impact 2 tool. Results are presented first for the program as evaluated, and second, based on a hypothetical national scale-up scenario. One-way sensitivity analyses were conducted.

Results: Compared to standard practice, the PPIUD program resulted in an incremental cost-effectiveness ratio (ICER) of US$14.60 per CYP and US$91.13 per DALY averted in Bangladesh, and US$54.57 per CYP and US$67.67 per DALY averted in Tanzania. When incorporating estimated direct health care costs saved, the results for Bangladesh were dominant (PPIUD is cheaper and more effective versus standard practice). For Tanzania, the PPIUD initiative was highly cost-effective, with the ICER (incorporating direct health care costs saved) estimated at US$15.20 per CYP and US$18.90 per DALY averted compared to standard practice. For the national scale-up model, the results were dominant in both countries.Conclusions/implications: The PPIUD initiative was highly cost-effective in Bangladesh and Tanzania, and national scale-up of PPIUD could produce long-term savings in direct health care costs in both countries. These analyses provide a compelling case for national governments and international donors to invest in PPIUD as part of their family planning strategies.

FIGURE 1

Overview of Impact 2 Tool Used to Assess Cost-Effectiveness of Postpartum Intrauterine Device Initiative Abbreviations: ANC, antenatal care; CPR, contraceptive prevalence rate; DALYs, disability-adjusted life years; FP, family planning; LAPM, long-acting permanent method; PAC, postabortion care; PPIUD, postpartum intrauterine device. Source: Weinberger et al.

FIGURE 2

Cost-Effectiveness Plane Representing 4 Potential Outcomes of Cost-Effectiveness Analyses of Postpartum Intrauterine Device Initiative Abbreviation: ICER, incremental cost-effectiveness ratio. Source: Cost-effectiveness plane figure adapted from Cohen et al.

FIGURE 3

Sensitivity Analyses for Cost Adjustments Showing Incremental Cost-Effectiveness Ratio for Postpartum Intrauterine Device Initiative in Bangladesh and Tanzania Abbreviations: CYP, couple-years of protection; ICER, incremental cost-effectiveness ratio.

FIGURE 4

Sensitivity Analyses for Uptake of Alternate Postpartum Family Planning Methods During the Extended Postpartum Period in Bangladesh and Tanzania Abbreviations: CYP, couple-years of protection; ICER, incremental cost-effectiveness ratio; PPFP, postpartum family planning.