A Decision Analysis Model of 1-Year Effectiveness of Intended Postplacental Compared With Intended Delayed Postpartum Intrauterine Device Insertion

Patient Preferences for Immediate Compared With Delayed Postpartum Intrauterine Device Placement

OBJECTIVE

To use choice-based conjoint survey methodology to evaluate patient values and decision making regarding immediate compared with delayed placement of postpartum intrauterine devices (IUDs).

METHODS

We conducted a cross-sectional study in which we surveyed 200 nonpregnant, parous patients. Participants chose between hypothetical postpartum IUDs varying in multiple attributes (hormonal or nonhormonal IUD type, placement timing, 1-year efficacy, expulsion risk, risk of lost strings, and malposition risk). The primary outcome was preference for immediate compared with delayed postpartum IUD placement and importance of placement timing relative to other attributes. Secondarily, we evaluated whether demographic and neighborhood characteristics were associated with timing preference and attribute importance.

RESULTS

We included 190 participants for analysis. Most participants (62.6%) preferred delayed placement. There was no significant difference in timing preference by race ( P =.28) or block-level Area Deprivation Index score ( P =.27). Patients who preferred immediate placement were more likely to have public insurance than private insurance (70.4% vs 29.6%, P =.04); however, the majority of patients (55.1%) with public insurance still preferred delayed placement. Attributes of IUD type, malposition risk, 1-year efficacy, and expulsion risk all had greater effects on patient decision making than placement timing. There was no difference in attribute importance by race ( P =.30), Area Deprivation Index score ( P =.88), or insurance type ( P =.22).

CONCLUSION

Patients preferred the higher efficacy and lower complication rates of delayed postpartum IUD placement over the convenience of immediate placement. Insurance considerations may affect these timing preferences. There was no difference in attribute importance between demographic groups or based on neighborhood-level factors, indicating that, although both immediate and delayed postpartum IUD placement should be offered, counseling should not vary according to individual demographic characteristics.

Achieving Equity in Postpartum Contraception Access

Equitable access to contraception and contraceptive education has the potential to mitigate health disparities related to unintended pregnancy. Pregnancy and the postpartum window frequently offer reduced insurance barriers to healthcare, increased interaction with healthcare systems and family planning providers, and an opportune time for many individuals to receive contraception; however, there are additional considerations in method type for postpartum individuals, and contraceptive counseling must be thoughtfully conducted to avoid coercion and promote shared decision-making. This commentary reviews method-specific considerations and suggests priorities for achieving equity in postpartum contraceptive access.

History of IUD utilization and the risk of preterm birth: a cohort study

OBJECTIVE

To explore whether a history of IUD use could increase the risk of subsequent preterm birth.

METHODS

We performed a cohort study of 24,496 multipara aged 19-48 years in Dongguan City. Each subject was followed up for 1 year, and 12,508 women obtained pregnancy outcomes. They were divided into 2 groups: 2130 subjects with IUD use history (exposure group), and 10,378 subjects without IUD use history (control group). The exposure group will remove the IUD before pregnancy. The primary outcomes were preterm birth (less than 37 weeks of gestation) and early preterm birth (less than 34 weeks of gestation). We used log-binomial regression to estimate adjusted risk ratios (aRR) of preterm birth and early preterm birth for women with a history of IUD. According to the different adjusted baseline data, three regression models were established, and the propensity matching score method was also used to verify the stability of the results.

RESULTS

The delivery rate of women with IUD history was 51.24%, and that of women without IUD was 51.03% (² = 0.063, P = 0.802). Six hundred and eighty-five women had preterm birth (5.48%, 95% CI 5.08-5.88) and 133 women had early preterm birth (1.06%, 95% CI 0.83-1.24). Compared with the control group, the incidence of preterm birth and early preterm birth in the exposure group were significantly lower. The results are stable in all four models. Subgroup analysis also supported the result. This study also found that the longer the women used IUD before pregnancy, the younger the age of first using IUD, and the shorter the time from condom removal to pregnancy, the lower the incidence of premature birth.

CONCLUSION

The women with a history of IUD use are less likely to have premature birth after the IUD is removed. More prospective studies are needed to confirm it.

Provision of contraceptive implants in school-based health centers: A cost-effectiveness analysis

OBJECTIVE

To evaluate the cost-effectiveness of providing contraceptive implants in school-based health centers (SBHCs) compared to the practice of referring adolescents to non-SBHCs in New York City.

STUDY DESIGN

We developed a microsimulation model of teen pregnancy to estimate the cost-effectiveness of immediate provision of contraceptive implants at SBHCs over a 3-year time horizon. Model parameters were derived from both a retrospective chart review of patient data and published literature. The model projected the number of pregnancies as well as the total costs for each intervention scenario. The incremental cost-effectiveness ratio was calculated using the public payer perspective, using direct costs only.

RESULTS

The health care cost of immediate provision of contraceptive implants at SBHCs was projected to be $13,719 per person compared to $13,567 per person for delayed provision at the referral appointment over 3 years. However, immediate provision would prevent 78 more pregnancies per 1000 adolescents over 3 years. The incremental cost-effectiveness ratio for implementing in-school provision was $1940 per additional pregnancy prevented, which was less than the $4206.41 willingness-to-pay threshold. Sensitivity analyses showed that the cost-effectiveness conclusion was robust over a wide range of key model inputs.

CONCLUSION

Provision of contraceptive implants in SBHCs compared to non-SBHCs is cost-effective for preventing unintended teen pregnancy. Health care providers and policymakers should consider expanding this model of patient-centered health care delivery to other locations.

The cost of improving care: a multisite economic analysis of hospital resource use for implementing recommended postpartum contraception programmes

BACKGROUND

The costs of quality improvement efforts in real-world settings are often unquantified. Better understanding could guide appropriate resource utilisation and drive efficiency. Immediate postpartum contraceptive care (ie, placement of an intrauterine device or contraceptive implant during hospitalisation for childbirth) represents an excellent case study for examining costs, because recommended services are largely unavailable and adoption requires significant effort. We therefore evaluated the cost of implementing immediate postpartum contraceptive services at four academic centres and one private hospital in USA.

METHODS

In this mixed-methods cost analysis, implementation activities were retrospectively identified using standardised data collection. Activities were categorised as preimplementation activities (infrastructure building, tool creation and stakeholder engagement) or execution activities (workforce training and process refinement). Costs were assigned based on national median salaries for the roles of individuals involved. Cross-case comparison and rapid qualitative analysis guided by the Consolidated Framework for Implementation Research were used to identify factors driving cost variation observed across sites.

RESULTS

On average, implementation activities required 204 hours (range 119-368), with this time costing $14 433.94 (range $9955.61-$23 690.49), and involving 9 (range 7-11) key team members per site. Preimplementation activities required more resources than execution activities (preimplementation: average 173 hours, $11 573.25; execution: average 31 hours, $2860.67). Sites that used lower-cost employees (eg, shifting tasks from a physician to a project manager) observed lower costs per hour for implementation activities. Implementation activities and costs were associated with local contextual factors, including stakeholder acceptance, integration of employees and infrastructure readiness for the change effort.

CONCLUSIONS

Our findings provide the first estimates of health system costs for adopting recommended contraceptive care in maternity units in USA. More broadly, our findings suggest that the budget impact of improvement efforts may vary widely depending on local context.