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.

Costs of administering injectable contraceptives through health workers and self-injection: evidence from Burkina Faso, Uganda, and Senegal.

OBJECTIVE: To evaluate the 12-month total direct costs (medical and nonmedical) of delivering subcutaneous depot medroxyprogesterone acetate (DMPA-SC) under three strategies - facility-based administration, community-based administration and self-injection - compared to the costs of delivering intramuscular DMPA (DMPA-IM) via facility- and community-based administration. STUDY DESIGN: We conducted four cross-sectional microcosting studies in three countries from December 2015 to January 2017. We estimated direct medical costs (i.e., costs to health systems) using primary data collected from 95 health facilities on the resources used for injectable contraceptive service delivery. For self-injection, we included both costs of the actual research intervention and adjusted programmatic costs reflecting a lower-cost training aid. Direct nonmedical costs (i.e., client travel and time costs) came from client interviews conducted during injectable continuation studies. All costs were estimated for one couple year of protection. One-way sensitivity analyses identified the largest cost drivers. RESULTS: Total costs were lowest for community-based distribution of DMPA-SC (US$7.69) and DMPA-IM ($7.71) in Uganda. Total costs for self-injection before adjustment of the training aid were $9.73 (Uganda) and $10.28 (Senegal). After adjustment, costs decreased to $7.83 (Uganda) and $8.38 (Senegal) and were lower than the costs of facility-based administration of DMPA-IM ($10.12 Uganda, $9.46 Senegal). Costs were highest for facility-based administration of DMPA-SC ($12.14) and DMPA-IM ($11.60) in Burkina Faso. Across all studies, direct nonmedical costs were lowest for self-injecting women. CONCLUSIONS: Community-based distribution and self-injection may be promising channels for reducing injectable contraception delivery costs. We observed no major differences in costs when administering DMPA-SC and DMPA-IM under the same strategy. IMPLICATIONS: Designing interventions to bring contraceptive service delivery closer to women may reduce barriers to contraceptive access. Community-based distribution of injectable contraception reduces direct costs of service delivery. Compared to facility-based health worker administration, self-injection brings economic benefits for women and health systems, especially with a lower-cost client training aid.

Cost of providing injectable contraceptives through a community-based social marketing program in Tigray, Ethiopia.

OBJECTIVE: To provide a cost analysis of an injectable contraceptive program combining community-based distribution and social marketing in Tigray, Ethiopia. METHODS: We conducted a cost analysis, modeling the costs and programmatic outcomes of the program's initial implementation in 3 districts of Tigray, Ethiopia. Costs were estimated from a review of program expense records, invoices, and interviews with health workers. Programmatic outcomes include number of injections and couple-year of protection (CYP) provided. We performed a sensitivity analysis on the average number of injections provided per month by community health workers (CHWs), the cost of the commodity, and the number of CHWs trained. RESULTS: The average programmatic CYP was US $17.91 for all districts with a substantial range from US $15.48-38.09 per CYP across districts. Direct service cost was estimated at US $2.96 per CYP. The cost per CYP was slightly sensitive to the commodity cost of the injectable contraceptives and the number of CHWs. The capacity of each CHW, measured by the number of injections sold, was a key input that drove the cost per CYP of this model. CONCLUSION: With a direct service cost of US $2.96 per CYP, this study demonstrates the potential cost of community-based social marketing programs of injectable contraceptives. The findings suggest that the cost of social marketing of contraceptives in rural communities is comparable to other delivery mechanisms with regards to CYP, but further research is needed to determine the full impact and cost-effectiveness for women and communities beyond what is measured in CYP.

[Cost of family planning care in 10-19 years old teenagers]. / Costo de atención por servicios de planificación familiar a adolescentes de 10-19 años.

Objetives: To identify the costs of family planning care in adolescents. Material and methods: Longitudinal study of the cost of care for family planning carried out in 2015 in a group of individuals with age limits of 10 and 19 years in a unit first level of health care in the state of Queretaro, Mexico. The profile of use of family planning (FP) was created for the teen was performed services through counseling, provision of contraception and review of intrauterine device (IUD) in a year; cost projections for the population of adolescents and different coverage scenarios between 5 and 100% were made. Results: The average annual cost was 228.84 Mexican pesos. Ideally the identified cost was 2,708.94 pesos. The projection with 20 % coverage was 207,251,330 pesos. The average annual family planning consultations was 0.9. The most commonly used method was with medroxyprogesterone-estradiol at doses of 25 and 5 mg. Conclusion: The cost of planning in adolescents is low, taking into account the costs that the care of high-risk pregnancies and associated comorbidities.

Lessons from a geospatial analysis of depot medroxyprogesterone acetate sales by licensed chemical sellers in Ghana.

OBJECTIVES: To map access to depot medroxyprogesterone acetate (DMPA) from licensed chemical sellers (LCS); to estimate the proportion of women of reproductive age in areas with access; and to examine affordability and variability of costs. METHODS: A geospatial analysis was conducted using data collected from 298 women who purchased DMPA from 49 geocoded LCS shops in the Amansie West and Ejisu-Juabeng districts of Ghana from June 4 to August 31, 2012. The women reported on cost and average distance traveled to purchase DMPA. RESULTS: In Amansie West, 21.1% of all women of reproductive age lived within average walking distance and 80.4% lived within average driving distance of an LCS. In Ejisu-Juabeng, 41.9% and 60.1% of women lived within average walking and driving distance, respectively. Distribution of affordability varied across each district. CONCLUSIONS: Access to LCS shops is high, and training LCS to administer DMPA would increase access to family planning in Ghana, with associated time and cost savings.

Bodies of evidence: activists, patients, and the FDA regulation of Depo-Provera.

In January 1983, the FDA held one of only two scientific "Public Boards of Inquiry" in the history of the administration to determine whether to approve Depo-Provera for use as a contraceptive in the United States. At the hearing, ideas about gender and power played a central role in negotiations between scientists, doctors, patients, and women's health activists. The nature of the Depo-Provera Public Board of Inquiry lends itself to analysis of the interaction between and among these groups, each of which had a vested interest in the outcome of the FDA decision. The stories and strategies emerging from the actors involved in the Public Board of Inquiry reveal the enormous complexity of regulating reproduction in the late twentieth century.

Economic impact of Tibolone compared with Continuous-Combined Hormone Replacement Therapy in the management of climacteric symptoms in postmenopausal women.

BACKGROUND: Deciding whether to treat postmenopausal women suffering from climacteric symptoms with Continuous Combined Hormone Replacement Therapy (CCHRT) has become increasingly difficult after the release of the Women's Health Initiative results. As a result, development of alternatives to CCHRT is required. Tibolone, which is a synthetic steroid that has estrogenic, progestogenic and androgenic properties, is reported to be a promising alternative. It has been used in Europe, in the same indication as CCHRT, for approximately 20 years but is not yet available in Canada. OBJECTIVE: We carried out a cost-utility analysis comparing a 3-year-treatment course with Tibolone 2.5mg and conjugated equine estrogens (CEE)/medroxyprogesterone acetate (MPA) (0.625 mg/2.5 mg) in the management of postmenopausal women with climacteric symptoms. METHODS: A Markov model, considering persistence, vaginal bleeding and climacteric symptoms, was elaborated to compare the different options in terms of cost and Quality Adjusted Life Years (QALYs), according to a public third-party payer perspective. RESULTS: Compared with CEE/MPA, Tibolone led to an increase in cost (dollars 485 for Tibolone versus dollars 232 for CEE/MPA) and a slight increase in QALYs (2.08 for Tibolone versus 2.05 for CEE/MPA). Consequently, the incremental cost per QALY gained ratio was dollars 9198. CONCLUSION: According to the results, Tibolone seems to be a cost-effective alternative to CEE/MPA. However, those results should be interpreted with caution insofar as the difference in terms of QALY is clinically difficult to value and taking into account the limited data on Tibolone's long-term innocuity.

Relative cost effectiveness of Depo-Provera, Implanon, and Mirena in reversible long-term hormonal contraception in the UK.

OBJECTIVE: To estimate the relative cost effectiveness for women aged > or =30 years, starting long-term hormonal contraception with either levonorgestrel intrauterine system (Mirena), etonogestrel subdermal implant (Implanon) or medroxyprogesterone acetate injection (Depo-Provera). DESIGN AND SETTING: This was a modelling study, performed from the perspective of the UK NHS, of contraceptive services supplied by a general practitioner. STUDY PARTICIPANTS AND INTERVENTIONS: A dataset was created from the General Practice Research database (GPRD) comprising 16 835 women aged > or =30 years who received levonorgestrel intrauterine system (n = 6080), etonogestrel subdermal implant (n = 277) or medroxyprogesterone acetate injection (n = 10 478) for their long-term contraception between 1997 and 2002. METHODS: Contraception-related healthcare resource utilisation values and contraception continuation rates were obtained from the GPRD. The incidence of pregnancy associated with each contraceptive was obtained from the published literature. By combining the GPRD dataset with published clinical outcomes, a decision model was constructed. This was used to estimate the expected annualised direct healthcare costs and consequences of the provision of each type of contraception per woman-year in pounds sterling (pound) at 2002/03 prices. RESULTS: Our model suggests that starting long-term contraception with levonorgestrel intrauterine system or etonogestrel subdermal implant instead of medroxyprogesterone acetate injection is a dominant strategy from the UK NHS perspective. In contrast, starting long-term contraception with etonogestrel subdermal implant instead of levonorgestrel intrauterine system is likely to be the least cost-effective option, since it would lead to an additional cost for each additional avoided pregnancy (pound 21,000). CONCLUSION: Long-acting reversible hormonal contraception has the benefit of being extremely effective (>99%), and not reliant on patient compliance nor dependent on correct usage. The relative cost effectiveness of using any one contraceptive should be considered in the light of the additional clinical benefits it may confer, user acceptability, QOL, past medical history and the estimated cost of an unintended pregnancy. Choice of contraception is essential to meet diverse user needs and preferences that may change with the user's stage of life. Only by offering choice will the maximum number of women be protected and therefore the greatest savings to the health service be gained.

Promotion and prescribing of hormone therapy after report of harm by the Women's Health Initiative.

CONTEXT: Little is known about how the pharmaceutical industry responds to evidence of harm associated with its products, such as the publication in July 2002 of the Women's Health Initiative Estrogen Plus Progestin Trial (WHI E+P) report demonstrating that standard-dose Prempro produced significant harm and lacked net benefits. OBJECTIVE: To examine pharmaceutical industry response to the WHI E+P results by analyzing promotional expenditures for hormone therapy before and after July 2002. DESIGN AND SETTING: Nationally representative and prospectively collected longitudinal data (January 2001 through December 2003) on prescribing and promotion of hormone therapies were obtained from IMS Health and Consumer Media Reports. MAIN OUTCOME MEASURES: Trends in quarterly prescriptions for hormone therapy and expenditures on 5 modes of drug promotion: samples, office-based detailing, hospital-based promotion, journal advertisements, and direct-to-consumer advertising. RESULTS: Prior to the WHI E+P report, prescribing rates and promotional spending for hormone therapy were stable. In the quarter before the WHI E+P report (April-June 2002), 22.4 million prescriptions for hormone therapy were dispensed and 71 million dollars was spent on promotion (in annual terms, 350 dollars per year per US physician). Within 9 months of the report's publication (quarter 1 of 2003), there was a 32% decrease in hormone therapy prescriptions, and a nadir had been reached for promotional spending (37% decrease compared with pre-WHI E+P levels). Spending decreased for all promotional activities and most hormone therapies. Overall, the greatest declines were for samples (36% decrease as of quarter 1 of 2003) and direct-to-consumer advertising (100% decrease). The greatest declines in promotion occurred for standard-dose Prempro (61% decrease as of quarter 1 of 2003), the agent implicated by the WHI E+P report. More recently, promotional efforts have increased, particularly for lower-dose Prempro, a resurgence associated with modestly increased prescriptions for this newer agent. CONCLUSIONS: Concordant with its widespread use, hormone therapy was among the most heavily promoted medications prior to the WHI E+P report. Following reporting of the evidence of harm from this trial, there was a substantial decline in promotional spending for hormone therapy, particularly for the agents most directly implicated in the trial. Interrelated with the impact of the trial results themselves and the ensuing media coverage, reduced promotion may have contributed to a substantial decline in hormone therapy prescriptions.

Quality of life and costs associated with micronized progesterone and medroxyprogesterone acetate in hormone replacement therapy for nonhysterectomized, postmenopausal women.

BACKGROUND: Because natural progesterone is poorly absorbed and rapidly metabolized, synthetic derivatives of progesterone, such as medroxyprogesterone acetate (MPA), are used in combination with estrogen in hormone replacement therapy. A micronized form of natural progesterone is available that is readily absorbed and reaches peak serum concentrations from 1 to 4 hours after administration. OBJECTIVE: The purpose of this study was to compare the quality of life (QOL), menopausal symptoms, and costs associated with a natural micronized progesterone (MP) formulation versus MPA as add-on therapy to estrogen in hormone replacement for post-menopausal women. METHODS: This prospective, multicenter, randomized, fixed-dose, open-label, parallel-group study enrolled postmenopausal, otherwise healthy, nonhysterectomized women 45 to 65 years of age who had been amenorrheic for > or =6 months and exhibited symptoms of estrogen deficiency. All women received 0.625 mg conjugated equine estrogens on days 1 to 25 of a 30-day cycle; on days 12 to 25, women were randomized to receive either MP 200 mg or MPA 5 mg; patients were followed for 9 months. QOL, the primary end point, was measured at baseline and months 3, 6, and 9 using the 36-Item Short-Form Health Survey (SF-36), the Nottingham Health Profile (NHP), and the condition-specific Women's Health Questionnaire (WHQ). Bleeding pattern, compliance, menopausal symptoms, and cost were evaluated as secondary end points. Costs (in 1997 Canadian dollars) were assessed from the societal perspective and included costs of study medication, hormone therapy monitoring, concomitant medication, outpatient resources, out-of-pocket expenses, and patient and caregiver time loss. RESULTS: A total of 182 women were enrolled; 89 received MP and 93 received MPA. Improvements in climacteric symptoms were observed from baseline to month 9 for both treatments. Mean scores on all domains of the SF-36 at month 9 were greater than scores at baseline in both treatment groups but the increases were not statistically significant. All domains within the NHP and WHQ improved significantly over this period for both groups (P < or = 0.008). Only patients receiving MP showed specific improvements in the menstrual problems and cognitive domains of the WHQ. The difference in average 9-month cost per patient was not statistically significant, at Can 367 dollars +/- 120 dollars and Can 360 dollars +/- 369 dollars for patients receiving MP and MPA, respectively. CONCLUSIONS: MP is a clinically effective, well-tolerated, and cost-comparable alternative to MPA.

Counting the costs: comparing depot medroxyprogesterone acetate and norethisterone oenanthate utilisation patterns in South Africa.

BACKGROUND: In South Africa, where health care resources are limited, it is important to ensure that drugs provision and use is rational. The Essential Drug List includes depot medroxyprogesterone acetate (DMPA) and norethisterone oenanthate (NET-EN) as injectable progestagen-only contraceptives (IPCs), and both products are extensively used. OBJECTIVES AND METHODS: Utilisation patterns of the injectable contraceptive products DMPA and NET-EN are compared in the context of current knowledge of the safety and efficacy of these agents. Utilisation patterns were analysed by means of a Pareto (ABC) analysis of IPCs issued from 4 South African provincial pharmaceutical depots over 3 financial years. A case study from rural KwaZulu-Natal, South Africa, is used to examine utilisation patterns and self-reported side effects experienced by 187 women using IPCs. RESULTS: IPCs accounted for a substantial share of total state expenditure on drugs. While more DMPA than NET-EN was issued, NET-EN distribution from 2 depots increased over the 3-year period. Since DMPA was cheaper, if all NET-EN clients in the 1999/2000 financial year (annualised) had used DMPA, the 4 depots could have saved 4.95 million South African Rands on product acquisition costs alone. The KZN case study showed slightly more NET-EN (54%) than DMPA (46%) use; no significant differences in self-reported side effects; and that younger women were more likely to use NET-EN than DMPA (p = 0.0001). CONCLUSIONS: Providing IPCs on the basis of age is not appropriate or cost effective. Rational use of these products should include consideration of the cost of prescribing one over another.

Increased depot medroxyprogesterone acetate use increases family planning program pharmaceutical supply costs.

To measure the use rates of depot medroxyprogesterone acetate and oral contraceptives and compare the costs between the two methods to see whether these trends had impacted the pharmaceutical acquisition costs for a family planning program, we compared vendor invoice costs over three time periods, 1992, 1994, and 1999. Visit types and client demographic statistics were tabulated from existing encounter record data sources. A local pharmaceutical chain was queried about their acquisition costs for similar products. Since 1992, depot medroxyprogesterone acetate use has increased from 3 to 17% while oral contraceptive use has decreased from 45 to 40% of contraceptive clients. The cost to our program for depot medroxyprogesterone acetate is $4.75 for 28 days and the average pill package is purchased for $1.35. The cost to our program is 4 times greater for the injection contraceptive user than for the oral contraceptive user. Approximately 80% of our clients have household incomes less than 200% of the poverty level and obtain their services from our program for free. This combination of increasing popularity and the high cost of depot medroxyprogesterone acetate has resulted in a great increase in the pharmacy acquisition cost. The oral contraceptive manufacturers make their products available at large discounts (20-fold reduction), but depot medroxyprogesterone acetate is not provided at a similar discount (2.8-fold reduction). We believe this is because there is no generic or competing product. The high cost of depot medroxyprogesterone acetate could jeopardize our ability to offer this highly effective method of birth control to all women.

Treatment of endometriosis with depot medroxyprogesterone acetate: a preliminary experience.

The efficacy of depot medroxyprogesterone acetate in the treatment of endometriosis was assessed in 19 patients with severe diseases. Assessment was based on changes in subjective symptoms and signs at 4 weekly interval during treatment and after 52 weeks follow up, and changes in visible deposits and adhesions at laparoscopy before and after treatment. There were significant reductions in mean total subjective and symptoms scores, mean total R-AFS adhesions and implants scores, and mean additive diameter of implant scores at the end of treatment and follow up. Treatment success occurred in 75% of the patients, majority (66%) of whom had complete resolution of deposits. Side effects encountered include menorrhagia, break through bleeding, excessive weight gain, myalgia, breast pain, acne and delay in return of menses. It was concluded that DMPA an effective, cheap and readily available medication which is worth using in patients who can not afford the expensive alternatives.

Beliefs about Depo-Provera among three groups of contraceptors.

This article examines the beliefs about Depo-Provera held by three groups of contraceptors utilizing urban family planning clinics in the United States (n = 836). Patients choosing Depo-Provera, oral contraceptives, and Norplant were asked about their beliefs regarding Depo-Provera in the following four domains: effectiveness in preventing pregnancy, convenience, side-effects, and risk to health; and also for their perceptions regarding the physical discomfort and cost associated with the method. Findings reveal that patients choosing the pill and Norplant give Depo-Provera significantly lower ratings for both convenience and effectiveness than do Depo-Provera acceptors. Given the documented effectiveness of Depo-Provera, this is a potential cause for concern. Moreover, Norplant and pill choosers are most likely to hold inaccurate beliefs regarding both the cost of Depo-Provera, and certain side-effects associated with its use. Although more than half of all patients believe the Depo-Provera would cause menstrual changes and weight gain, it is noteworthy that the proportions are not higher, given their known association with the method. Knowledge about the likelihood of these side-effects is essential, particularly for those choosing Depo-Provera. Implications for physicians, counselors, and other family planning professionals are discussed.

The use of Norplant and Depo Provera in adolescents.

PIP: Although oral contraception is the fertility control method most frequently selected by US adolescents, factors such as inconsistent usage, payment inability, and cognitive-emotional immaturity lead half of these young women to discontinue pill use in the first year. Norplant and Depo-Provera--long-acting hormonal methods that do not require daily compliance--offer the potential to reduce the number of unintended pregnancies among adolescents; however, no data exist on the use of either method in this population. Before Norplant and Depo-Provera can be unconditionally recommended for use by adolescents, numerous research questions must be addressed. For example, it must be determined whether the pregnancy rates and side effects (especially on bone deposition) are the same in adolescents as in adult women. The possibility that adolescents who use long-acting contraception will abandon condom use due to the low risk of pregnancy--and thus place themselves at increased risk of sexually transmitted diseases--must be assessed. For Norplant, the medical-legal issues and responsibilities regarding insertion and removal must be clarified. More research is needed on the impact of partner perceptions on method continuation. It must be determined whether the role of health care providers in ongoing reproductive health promotion will be diminished by the need for fewer clinic visits. Also in need of attention are the demographic factors associated with use of these methods and the impact of their initial high expense on accessibility. If the continuation rates among adolescents of Norplant and Depo-Provera do not exceed that for the pill, the invasiveness and high cost of these methods may outweigh their benefits.^ieng

Contraception update: implantable and injectable methods.

There are currently more options available to pediatricians caring for sexually active adolescents who wish to prevent pregnancy. The two progestin-only methods, levonorgestrel subdermal implants and DMPA injections, minimize or entirely remove the obstacle of patient compliance from contraceptive efficacy. Adolescents considering a progestin-only method of contraception should be counseled explicitly about the likelihood of menstrual irregularity with use. Perhaps more importantly, adolescents should be reminded that hormonal methods of contraception do not provide protection from sexually transmitted disease. Thus, male condom use should not only be recommended, but also concrete discussion and instruction on appropriate use should be given.

PIP: Two new progestin-only contraceptive methods--levonorgestrel subdermal implants and Depo-Provera injection--have the potential to overcome adolescents' traditional poor compliance with family planning methods. Both methods provide safe, highly effective, reversible fertility control, but require virtually no ongoing patient compliance. The levonorgestrel implants provide continuous contraception for up to five years and have a failure rate under 1%. The primary side effect is an alteration in menstrual patterns: prolonged bleeding in 40%, irregular bleeding in 38%, intermenstrual spotting in 32%, more frequent bleeding in 16%, and amenorrhea in 12%. An average weight gain of five pounds over the five-year period of use is expectable given the appetite stimulation associated with progestins. Depo-Provera, injected every three months, has a failure rate of 0.1-0.7% in the first year of use. Amenorrhea is the most commonly reported menstrual side effect. Although both methods are highly effective in preventing pregnancy, they confer no protection against sexually transmitted diseases; thus, adolescent acceptors should be counseled to use condoms concomitantly.

Long-acting contraceptives. Ethical guidance for policymakers and health care providers.

Realizing the promise of long-acting contraceptives depends on continuing efforts to distinguish appropriate from inappropriate policies and practices. The current debates concerning Norplant and other long-term methods generally have based ethical judgment on too slim a reed. It is insufficient and overly divisive to limit the tools of analysis to questions of freedom and coercion. A richer perspective is needed. We have sketched out an alternative approach that rests on a close, case-by-case analysis attentive to the social dimension and consequences of contraceptive decisionmaking, as well as to the individual interests at stake. The approach also takes special note of the need for access to long-acting contraceptive, the possibility for mistaken nonuse as well as mistaken use, and our country's past and present biases and power imbalances. We do not claim that this method will make judgments about justifiable or unjustifiable influence easy or automatic. However, it should prove adept at underscoring the factors that require particular scrutiny. Perhaps more importantly, the approach highlights that influences for the use of long-acting contraceptives ought to be judged, not merely dismissed.

The contraceptive implant and the injectable: a comparison of costs.

A comparison of the relative costs of the injectable contraceptive (depot medroxyprogesterone acetate) and the hormonal implant (Norplant) indicates that the implant is a less costly contraceptive option when it is used for its full five-year lifespan. Over a five-year period, the implant costs $107 annually, compared with $140 per year for the injectable. However, if a woman discontinues the implant before she has used it for at least four years, the injectable becomes the less costly option. Relatively high continuation rates--around 95% annually--are necessary to make the implant the more cost-effective contraceptive method.

PIP: The authors compared the relative costs of the injectable contraceptive depot medroxyprogesterone acetate (Depo-Provera) and the hormonal implant Norplant. Per-year costs for the implant were calculated using both published and theoretical yearly continuation rates. Woman-years of contraceptive use were then calculated to project the costs for a theoretical cohort of 100 women, and these costs were compared to the cost of Depo-Provera. Costs for the implant were $433.25 per insertion and $100.29 per removal based upon Current Procedural Terminology codes 11975 and 11976, and on Colorado Medicaid reimbursement rates for the two codes. The average Medicaid reimbursement in the US has been reported to be $466 for implant insertion and $90 for removal. The $35.19 cost of the injectable was based upon Current Procedural Terminology code X5560 and on the Colorado Medicaid reimbursement rate. Actual office charges are typically higher than medicaid reimbursement, so the costs reviewed in this analysis represent a low estimate, especially for the implant. It is also noted that many insurance companies will pay for neither contraceptive method. The analysis found Norplant to be the less costly of the two methods when used for its full five-year lifespan. Over a five-year period the implant costs $107 annually, compared with $140 per year for the injectable. If a woman discontinues the implant before she has used it for at least four years, however, the injectable becomes the less costly option. Annual continuation rates of approximately 95% are needed to make Norplant the more cost-effective of the two contraceptive methods.

A cost-benefit analysis of four hormonal contraceptive methods.

This paper presents the results of a cost-benefit analysis conducted for pregnancy prevention treatment with four hormonal methods of contraception using a managed-care viewpoint. The therapies analyzed are medroxy-progesterone acetate injection (Depo-Provera), levonorgestrel subdermal implants (Norplant), progestogenonly oral tablets (Nor-QD), and combination progestogen/estrogen oral tablets (Ortho-Novum 7/7/7). Cost and benefits associated with the use of therapies are identified and analyzed based on the cost per patient-day of effective pregnancy prevention. The analysis demonstrates that all four methods have a positive net benefit, with Depo-Provera having the highest net benefit. This information can provide decision makers within a pharmacy and therapeutics committee of a managed-care organization the framework on which to base formulary decisions.