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8/12/2019 Jurnal - Preventing Repeat Pregnancy

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Preventing Repeat Pregnancy In Adolescents:

Is Immediate Postpartum Insertion Of The

Contraceptive Implant Cost-effective?

Leo Han, MD Stephanie B. Teal, MD, MPH Jeanelle Sheeder,MSPH, PhD Kristina Tocce, MD, MPH


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Introduction

Adolescents are at high risk for rapid repeat pregnancy: 12%to 49% of adolescent mothers are pregnant again within oneyear of delivery.

Rapid repeat adolescent pregnancy has significant costs tothe healthcare system. Medical costs of adolescentpregnancy are estimated to be 1.5 billion dollars per year toUS taxpayers.

Adolescents are receptive to initiating LARC immediatelypostpartum, but reimbursement policies limit this practice to

the outpatient setting. A program attempting outpatientimplant insertion within the first two weeks postpartumresulted in fewer adolescent patients receiving implantinsertions than anticipated.


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Objective

The purpose of this study was to determine cost-effectiveness of a hypothetical state-funded programoffering immediate postpartum implant (IPI) insertionfor adolescent mothers.


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Methods

Participants in an adolescent prenatal-postnatal programwere enrolled in a prospective observational study of IPIinsertion (IPI group, n=171) versus standardcontraceptive initiation (comparison group, n=225).

Implant discontinuation, repeat pregnancies andpregnancy outcomes were determined.

We compared the anticipated public expenditures for IPIrecipients and comparisons at 6, 12, 24 and 36 monthspostpartum using the actual outcomes of this cohort and

Colorado Medicaid reimbursement estimates.

Costs were normalized to 1000 adolescents in each armand included one year of well-baby care for deliveredpregnancies


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Result

At 6 months, expenditures of the IPI group exceed thecomparison group by $73,000.

However, at 12, 24 and 36 months, publically funded IPIswould result in a savings of over $550,000, $2.5 and $4.5

million, respectively. For every dollar spent on the IPI program, $0.79, $3.54

and $6.50 would be saved at 12, 24, 36 months.

Expenditures between the IPI and comparison groupswould be equal if the comparison group pregnancy ratewas 13.8%, 18.6% and 30.5% at 12, 24 and 36 months.

Actual rates were 20.1% 46.5% and 83.7%.


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Discussion

Repeat pregnancy rates were significantly lower at eachtime point in the IPI group.

When comparing 1000 women choosing IPI to 1000 womenchoosing an outpatient contraceptive strategy, there is a

small initial loss for the program at 6 months of $73,000. However, evaluation at 12, 24 and 36 months demonstrated

a net savings of $550,000, $2.5 million and $4.5 milliondollars respectively.

It has been estimated that approximately $4.13 is savednationally in pregnancy related and newborn costs for everydollar Medicaid spends on contraceptive services


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Discussion

Strengths of our study include a design that was deliberatelybiased towards a conservative estimate of potential cost savings.

Costs of obstetrical complications such as preterm labormanagement or preeclampsia were not included. Moreover, wedid not include the cost of the contraceptives used by the

comparison group although Colorado Medicaid paid them. Thus,our calculations reflect the additional costs to Medicaid over apresumed baseline cost of contraception when IPI is notavailable.

Although allowing the participants to self select their groups

clearly introduces selection bias, self-selected groups allowaccounting for unmeasured factors that guide patientpreferences. Contraceptive and pregnancy choices were basedon real values of the adolescents


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Discussion

While the analysis is based on actual outcomes, the resultsmay be less generalizable than if we used hypotheticaloutcomes from the literature.

Incident pregnancy data was obtained from both chart reviewand patient report, introducing another potential source of biasas patients may have over or under reported bothspontaneous miscarriages and induced abortions.

Loss to follow-up was lower in the comparison group at threeyears than the implant group and this is a potential source of

bias. Moreover, given that pregnancy outcomes werecumulatively added over time, our data could be biased tolosing women who did not get pregnant, and thus potentiallyinflate overall pregnancy rates.


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Discussion

Last, these results cannot be extrapolated to immediatepostpartum placement of all LARC methods. Immediate post-placental IUDs were not included in this study and previousIUD cost analyses have not focused on the postpartumadolescent population.

IPI cost-effectiveness may differ from immediate postplacental IUDs if method retention and method failure ratesdiffer.


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Conclusion

Offering immediate postpartum implants toadolescent mothers is cost effective.

Payors that do not currently cover IPI should

integrate this data into policy considerations


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Critical Appraisal


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396 patients who attending ColoradoAdolescent Maternity Program (CAMP)and who delivered at the University ofColorado Hospital

POPULATION

Immediate postpartum subdermal implant(IPI)INTERVENTION

Intervention group (IPI) vs comparisongroup (other contraception methodsstarted at any time 4 weeks)

COMPARISON

Cost-effectiveness Implant discontinuation Repeat pregnancies Pregnancy outcomes

OUTCOME


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Are the aims clearly stated? Yes. To determine cost-effectiveness of a hypothetical

state-funded program offering immediate postpartumimplant (IPI) insertion for adolescent mothers.


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Were the basic data adequately described? Data used in this study was all adolescents who were

attending the Colorado Adolescent Maternity Program(CAMP) and who delivered at the University of Colorado

Hospital over the 18-month period of June 1, 2008, toNovember 30, 2009


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Was the sample size justified? Yes. Actually, All of the patients expressed the desire to

prevent pregnancy for at least one year after delivery wereeligible for inclusion in the study cohort. However, it still had

an exclusion criteria, included contraindications toetonogestrel use, relinquishing the child for adoption,stillbirth, being delivered at a different hospital, having nopostpartum visits at the CAMP and women who did not takehome infants.

The number of initial population and excluded samples werenot explained.


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Was the statistical significance assessed? Yes, the value of P < 0,05 was considered to indicate

statistical significance


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Are the statistical methods described? Summary statistics were used to describe the population

as well as the outcomes.

The Students t-tests were used to compare means; the X2

test were used to compare proportions, and the Fishersexact tests were used when cell sizes were


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Where are the biases? Allowing the participants to self select their groups clearly

introduces selection bias. Thus, it made unbalance samplesbetween groups.

Incident pregnancy data was obtained from both chart reviewand patient report, introducing another potential source ofbias as patients may have over or under reported bothspontaneous miscarriages and induced abortions.

Loss to follow-up was lower in the comparison group at three

years than the implant group and this is a potential source ofbias.


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Did untoward events occur during the study? There was no untoward events during the study


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How do the results compare with previousreports?

No comparative reports that held regarding this field. Thiswas the first study to determine the cost-effectiveness of twocontraception approaches.


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What implications does the study have for

your practice?

This study result indicate the cost-effectiveness of IPIprogram, with better outcome of repeat pregnancy andpregnancy outcome.

It is important to counsel our patient to use thisapproaches, primarily the adolescense ones. Becausealthough Indonesians policy have not integrated this

approach yet, it still shows significantly cost-saving and

better outcome to patient itself.


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Thank You

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