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Research Article
Revised

Postpartum family planning in Rwanda: a cost effectiveness analysis

[version 3; peer review: 3 not approved]
PUBLISHED 27 Aug 2019
Author details Author details

This article is included in the International Conference on Family Planning gateway.

Abstract

Background: Globally, there is a large unmet need for family planning in the postpartum period: 90% of women in this group want family planning for birth spacing or to avoid unintended pregnancies and stop child bearing once desired family size has been reached. In total 76% of Rwandan women want family planning postpartum, yet a 26% unmet need remains. Currently, the four most commonly used postpartum family planning methods in Rwanda are injections, subdermal implants, pills, and condoms. The economic and health benefit impact of the current method selection has not yet been evaluated.
Methods: To evaluate the impact of current usage rates and method types, this cost effectiveness analysis (CEA) compared the most frequently used family planning methods in Rwanda broken into two categories, longer-acting reversible contraception (LARC) (injections and subdermal implants) and shorter-acting reversible contraceptives (non-LARC) (pills and condoms). A time horizon of 24 months was used to reflect the World Health Organization suggested two-year spacing from birth until the next pregnancy, and was conducted from a health systems perspective. This CEA compared two service package options to provide a comparator for the two method types, thus enabling insights to differences between the two.
Results: For women of reproductive age (15-49 years) in Rwanda, including LARC postpartum family planning methods in the options, saves $18.73 per pregnancy averted, compared to family planning options that offer non-LARC methods exclusively.
Conclusion: There is an opportunity to avert unplanned pregnancies associated with increased utilization of LARC methods. The full benefits of LARC are not yet realized in Rwanda. Under the conditions presented in this study, a service package that includes LARC has the potential to be cost-saving compared with one non-LARC methods. Effective health messaging of LARC use for the postpartum population could both enhance health and reduce costs.

Keywords

Postpartum family planning, cost savings, cost effectiveness analysis, LARC, faith-based, pregnancy averted, access, contraceptive

Revised Amendments from Version 2

This revision incorporates a re-framing of the abstract and clarifications to methods and purpose of analysis highlighted by the thoughtful comments of the first reviewer's second round.

See the authors' detailed response to the review by Kristin Wall

Introduction

A multitude of variables influence maternal and child health outcomes, such as delivery of and access to antenatal care, giving birth in facilities, and many more. However, the postpartum period, is equally important and often overlooked. The evidence of reduced maternal mortality upon engagement in postpartum family planning (PPFP), and the absence of robust PPFP programs globally, leads the World Health Organization (WHO) to distinguish the postpartum period as a key opportunity for promoting the health of mothers and babies1.

Women spend on average about 30 years, or three-quarters of their reproductive lives, attempting to avoid pregnancy2. Globally, there is a large unmet need for family planning in the postpartum period: 90% of women in this group want family planning, for birth spacing or to avoid unintended pregnancies and stop child bearing once desired family size has been reached. In Rwanda, where there has been a coordinated response to maternal and child health; family planning provides a platform to continue the nation’s trend of improved maternal and child health. The WHO recommends at least 24 months between a birth and the next pregnancy for improved maternal and child health outcomes3. Rwanda’s commitment to scale up PPFP is well established4. In total 76% of Rwandan women want PPFP; a 51% unmet need for PPFP exists of which 26% is an unmet need for spacing and 25% an unmet need for limiting5. Despite this, about one half of births are conceived before the recommended interval of 24 months6.

Faith-based health facilities make up 30% of Rwanda’s healthcare system and fill critical gaps in care7,8. Some denominations do not include comprehensive contraceptive options, leading to possible barriers to access9,10. “More effective” family planning methods, such as those included in this analysis, remain absent at these facilities but are made available at nearby health posts9. Thus, attention to potential cost savings with the inclusion of these methods at all of Rwanda’s health facilities warrants further attention.

This cost effectiveness analysis (CEA) compared two categories of family planning methods of postpartum women of reproductive age (15–49 years) in Rwanda. Each consisted of one of the two most utilized methods in Rwanda: longer-acting reversible contraceptives (LARC) identified as injections and subdermal implants; and shorter-acting reversible contraceptives (non-LARC), pills and condoms11. A total of 45% of women do not use contraception postpartum, and this comparator is also represented in the model5.

Methods

This CEA compared two interventions, addressing whether the additional cost of LARC is justified by the additional health benefits from a health systems perspective (Figure 1). TreeAge Pro 2018 R1 was used to develop the model and run the sensitivity analysesa. A time horizon of 24 months was used to reflect the WHO suggested two-year spacing from birth until the next pregnancy, defined for this analysis as the postpartum period, with time zero designated as time of birth. Pregnancy averted within this time horizon is the outcome of interest.

8fcff8fd-0f2c-4135-81a6-44f7baf8b3c3_figure1.gif

Figure 1. The two primary arms comparing family planning menu types.

See Extended data12 for weighted calculation details. One includes the most common longer-acting reversible contraceptives (LARC), injections and subdermal implants; the second only provides the most common shorter-acting reversible contraceptives (non-LARC), pills and condoms11. Decision nodes are indicated with a circle; probability values are listed below each type and method.

Table 1 displays model input values collected from Rwanda-specific sources or other similar environments when Rwanda specific values were not available. Usage rates and discontinuation probabilities are specific to postpartum women in sub-Saharan Africa. Costs and chance of pregnancy were modeled for 24 months; single pregnancy incidence and costs were modeled for 12 months (two pregnancies postpartum is biologically unlikely for this timeframe). All cost data was: converted to dollars cost in Rwanda based on mean market exchange rate, adjusted to 2018 US$ for the first year, and applied a 3% inflation rate for the second year of the 24-month time frame for the analysis (3%/year). The health effects (number of pregnancies averted), were discounted at the same rate. Key inputs from Table 1 were used to model base-case results in TreeAge Pro 2018.

Table 1. Key input parameters5,1318.

Cost InputsEstimate
2 years (USD$)
ProbabilitySourceCountry/
Org
LARC
Injectables$22.150.509
0.807*
RDHS (2016)5Rwanda
Commodities$11.70Singh et al. (2012)13UNFPA
Supplies$1.40Singh et al. (2012)13UNFPA
Labor$8.72Singh et al. (2012)13UNFPA
discontinuation rate^0.41RDHS (2016)5Rwanda
chance of pregnancy0.0003RDHS (2016)5Rwanda
Implant$18.760.122
.193*
RDHS (2016)5Rwanda
Commodities$16.28Singh et al. (2012)13UNFPA
Supplies$0.38Singh et al. (2012)13UNFPA
Labor$1.82Singh et al. (2012)13UNFPA
discontinuation rate^^0.03RDHS (2016)5Rwanda
chance of pregnancy0.01RDHS (2016)5Rwanda
Non-LARC0.527*
Male Condom$10.050.056
0.288*
RDHS (2016)5Rwanda
Commodities$5.80Singh et al. (2012)13UNFPA
Supplies$-Singh et al. (2012)13UNFPA
Labor$4.11Singh et al. (2012)13UNFPA
discontinuation rate*0.57RDHS (2016)5Rwanda
chance of pregnancy0.3276RDHS (2016)5Rwanda
after discontinuing injectable, using condom0.0945RDHS (2016)5Rwanda
after discontinuing implant, using condom0.18RDHS (2016)5Rwanda
Pills$21.230.138
0.711*
RDHS (2016)5Rwanda
Commodities$14.21Singh et al. (2012)13UNFPA
Supplies$-Singh et al. (2012)13UNFPA
Labor$6.62Singh et al. (2012)13UNFPA
discontinuation rate0.38RDHS (2016)5Rwanda
chance of pregnancy0.172RDHS (2016)5Rwanda
after discontinuing injectable, using pill0.0461RDHS (2016)5Rwanda
after discontinuing implant, using pill0.09RDHS (2016)5Rwanda
No Contraception0.175
0.474*
RDHS (2016)5Rwanda
chance of pregnancy0.98RDHS (2016)5Rwanda
after discontinuing injection**0.623RDHS (2016)5Rwanda
after discontinuing implant0.86RDHS (2016)5Rwanda
Discount rate+3%/year
Pregnancy Costs
Antenatal care++$281Hitimana et al. (2018)18Rwanda
Hospitalization$3.721Vlassoff et al. (2015)16Rwanda
Normal vaginal
delivery**
$17.480.93Rwanda MOH (2011)17Rwanda
Obstructed labor
(C-section)
$43.660.0694Blaakman et al. (2008)15Rwanda

*Weighted value for tree established based on probability with consideration for Rwanda LARC prevalent methods only; “The three nodes stemming from the “LARC+Non-LARC” arm are weighted. LARC (0.48) +Non-LARC (0.29) + No Contraception (0.23) = 1, or 100%; the same method applied to the “Non-LARC Only” arm. Decision nodes must equal 1; thus, as defined by our parameters of the family methods included in this analysis, values were weighted based on percent uptake (proportion of women choosing selecting the method). **Value established from range ^Modeled discontinuation after 1 year of use (1 year postpartum) with consideration for effectiveness tapering (effectiveness is maintained for 6 months following missed injection date); see limitation #3 ^^Modeled discontinuation after 1 year of use (1 year postpartum) +Applied to all cost inputs19 ++Cost for antenatal care established assuming most women attend two visits: Visit 1 + (Visit 2 + Visit 3 + Visit 4)/3

One-way sensitivity analyses were executed for variables with the greatest impact on averted pregnancies, as determined by a tornado diagram. Input ranges were set to 50–150% of original value.

Results

The use of LARC methods saved $18.73 per pregnancy averted compared to contraceptive selections with non-LARC methods only (Table 2). When LARC is included in the menu, LARC is the dominating option among the contraceptive methods – the use of this contraceptive type both saves money and averts unwanted pregnancies with higher probability when compared with the non-LARC or no contraception use options.

Table 2. Base case results.

Providing LARC postpartum family planning methods in the menu of options saves $18.73 per pregnancy averted compared to family planning options that offer non-LARC methods exclusively, for women of reproductive age (15–49 years) in Rwanda for two years following birth from a health systems perspective.

Net CostsSavingsPregnanciesPregnancies (Averted)Cost Saved per
Pregnancy Averted
Non-LARC$44.39N/A0.72N/AN/A
LARC$38.77$5.620.420.30$18.73

Sensitivity analysis outputs are illustrated in (Figures 2a–c).

8fcff8fd-0f2c-4135-81a6-44f7baf8b3c3_figure2.gif

Figure 2. Sensitivity analyses of most influential variables in the model: cost of pill, cost of injection, and cost of ANC.

(a) When the cost of the pill (non-LARC method) is varied from $10.62–$31.84, savings due to the inclusion of LARC increases from $23.91–$48.75. (b) When the cost of an injectable (LARC method) is varied from $11.06–$33.23, savings due to the inclusion of LARC decreases from $53.80–$18.87. (c) When cost of antenatal care is varied from $14–$42, savings due to the inclusion of LARC increases from $18.68–$39.38.

Limitations

There is uncertainty surrounding the following elements:

  • 1. Study population – This analysis is limited to the evaluation of women in Rwanda who access care at a public facility. It fails to capture those who do not seek care at a government institution. However, since about 92% of Rwandan women deliver at a public healthcare facility, our analysis reflects the majority of the population5.

  • 2. Contraception type – This analysis included two LARC methods and two non-LARC methods and therefore excludes some other contraceptive options. These four methods make up 77% of the contraceptive uptake in Rwanda and therefore is a reasonable representation of the population11. Yet, possible effects of the introduction of LARC methods on the methods not portrayed here could change the results. However, since these other methods are less effective than LARC, their inclusion is unlikely to diminish the estimated cost-effectiveness of LARC.

  • 3. Tapering effectiveness upon discontinuation of injection method – It is reported that the injection method continues to provide protection for nine months following the last injection20. This phenomenon is modeled through an altered discontinuation rate if injection follow-up stopped at nine months postpartum.

  • 4. This analysis does not include the societal perspective; LARC savings are thus likely undervalued.

Conclusion

This evaluation shows that the inclusion of LARC methods in contraceptive options results in savings of $18.73 per pregnancy averted compared to family planning menus that offer only non-LARC methods for women in Rwanda for two years following birth. With Rwanda’s current population of 12.8 million, a birth rate of 32.23/1,000, a 37% unplanned birth rate of which 50% are conceived before the recommended interval, if an additional 25% of this group uses a LARC method as their PPFP method choice, $951,000 US$ per year can be saved6,21,22. These are funds that the Rwanda Ministry of Health can apply to other high value interventions. With the incorporation of a greater than two-year postpartum window, additional cost savings is projected. This model does not capture the health benefits to the mother and second baby incurred if the two-year minimum window is observed. To extend rates of LARC PPFP use, the Rwanda Ministry of Health may see increased rates of uptake with public health messaging specifically targeting the benefits of LARC use such as male involvement, postpartum risk of pregnancy, and intrauterine device uptake (IUD), among others23,24. Future areas of research include: analysis of barriers and facilitators to PPFP uptake with particular focus to currently used LARC methods, exploration of barriers to access for women utilizing neighboring health posts of faith-based facilities in lieu of government health facilities, and investigation of reasons for low IUD (<0.07%)5.

Data availability

Underlying data

All data underlying the results are available as part of the article and no additional source data are required.

Extended data

Extended data can be found here: https://doi.org/10.6084/m9.figshare.9696311.v112

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Version 3
VERSION 3 PUBLISHED 18 Mar 2019
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Williams P, Morales K, Sridharan V et al. Postpartum family planning in Rwanda: a cost effectiveness analysis [version 3; peer review: 3 not approved]. Gates Open Res 2019, 3:887 (https://doi.org/10.12688/gatesopenres.12934.3)
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Comments on this article Comments (0)

Version 3
VERSION 3 PUBLISHED 18 Mar 2019
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Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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