Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 187–198

Contents lists available at ScienceDirect

Best Practice & Research Clinical

Obstetrics and Gynaecology
journal homepage: www.elsevier.com/locate/bpobgyn

Health economics of contraception

Ifigeneia Mavranezouli, MD, MSc, Senior Health Economist *
National Collaborating Centre for Mental Health, Centre for Outcomes, Research and Effectiveness, Research Department of Clinical,
Educational & Health Psychology, University College London, Philips House, 1–19 Torrington Place, London WC1E 7HB, UK

Keywords:
Unintended pregnancies constitute a global problem associated
contraception with substantial costs to health and social services, and emotional
costs distress to women, their families and society as a whole. Provision
economics of contraception has been demonstrated to be a particularly cost-
cost analysis effective healthcare intervention as, besides preventing a signifi-
cost-effectiveness analysis cant number of unintended pregnancies, it also results in great
cost-savings cost-savings to society. Male and female sterilization and long-
review
acting reversible methods (such as the copper-T intra-uterine
device and the subdermal implant) constitute the most cost-
effective contraceptive options, followed by other hormonal
methods (such as oral contraceptives); barrier and behavioural
methods (such as the male condom and withdrawal, respectively)
are least cost-effective compared with other contraceptive options.
Nevertheless, when compared with no method, they still prevent
a large number of unintended pregnancies, thus leading to
important cost-savings. Improvements in compliance and contin-
uation rates are expected to further enhance the contraceptive
benefits and cost-savings associated with contraceptive use.
Ó 2008 Elsevier Ltd. All rights reserved.

Unintended pregnancies and contraceptive use worldwide

Worldwide, of the approximately 210 million pregnancies occurring each year, 38% are estimated to
be unintended and 22% end in abortion. The percentage of unintended pregnancies reaches 49% in the
developed world and 36% in developing countries, leading to induced abortion 36% and 20% of all
pregnancies occurring annually in the developed and developing world, respectively.1 Projected figures
indicate that 42 million unintended births and 28 million induced abortions resulting from unintended

* Tel.: þ44 207 679 1964; Fax: þ44 207 91 68 511.

E-mail address: i.mavranezouli@ucl.ac.uk

1521-6934/$ – see front matter Ó 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.bpobgyn.2008.11.007
188 I. Mavranezouli / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 187–198

pregnancies will take place between 2005 and 2010 in sub-Saharan Africa alone.2 In the USA, an
estimated 3.1 million unintended pregnancies occurred in 2002; of these, 1.4 million resulted in birth,
1.3 million ended in induced abortion and another 0.4 million were miscarried. Based on these figures,
the total direct medical cost associated with outcomes of unintended pregnancy in the USA was
estimated to reach $5 billion in 2002.3
Use of contraception is widespread worldwide: 61% of women aged 15–49 years who are married or
in a consensual union (approximately 635 million women) use some form of contraception. However,
the percentage of women using contraception varies widely across regions, with the lowest percentage
of contraceptive use (14.5%) observed in West Africa and the highest percentage of women using some
form of contraception (79%) found in Northern Europe.4
This discrepancy between high levels of unintended pregnancy and high levels of contraceptive use
globally are attributed to a number of factors1:

 lack of contraceptive protection due to unawareness of or poor access to modern contraceptive

methods;
 use of forms of contraception that provide insufficient protection against pregnancy;
 inconsistent or incorrect use of contraception; and
 method failure.

The cost of contraceptive provision depends on the specific method. Some long-acting reversible
contraceptive (LARC) methods, such as the levonorgestrel intra-uterine system (IUS) and the
subdermal implant, are characterized by relatively high method costs. Barrier methods, on the other
hand, such as condoms and diaphragms, are inexpensive forms of contraception. Male and female
sterilization incur high but one-off intervention costs, and behavioural methods (such as withdrawal)
have no method costs for the couple or the healthcare provider.
The aim of this chapter is to explore whether the benefits associated with contraceptive use, mainly
the prevention of unintended pregnancies and related cost-savings, can justify the cost of providing
contraception. In other words, is provision of contraception cost-effective? If so, are some forms of
contraception more cost-effective than others?

Basic concepts in economic evaluation of healthcare interventions

The principle underpinning the development of health economics is the scarcity of healthcare
resources. When resources are used in one way to provide some form of health benefit, other benefits
are forgone by not using resources in an alternative way (opportunity cost). In order to maximize the
overall benefit, choices need to be made between alternative courses of action. The aim of economic
evaluation is, by comparing both costs and health outcomes associated with alternative healthcare
pathways, to achieve optimal allocation of a given amount of healthcare resources in order to maximize
the health of the population.5
The first step in estimating the costs associated with a healthcare pathway is to determine the
perspective of the economic analysis.6 This could be, for example, the perspective of the health
service, a third party payer such as health insurance, the government, the patient or the society.
Depending on the perspective adopted, costs considered may include direct healthcare costs (e.g.
costs of drugs, healthcare staff time, hospitalization), direct non-healthcare costs (e.g. costs borne to
social services, other public bodies, the patients and their families) or indirect costs (e.g. productivity
losses due to disability, time off work etc.). In order to estimate costs associated with a specific care
pathway, related quantities of resource use must be measured and combined with appropriate unit
prices. The latter can be national healthcare unit costs, local prices, user charges etc. depending on
the perspective of the analysis and the availability of data. At the estimation of total costs, one
should ideally consider short- and long-term costs associated with a healthcare pathway, as well as
expected future cost-savings, especially when preventive strategies, such as contraceptive provision,
are evaluated.
Depending on the measure of health outcome used, four types of economic evaluation can be
identified: cost-consequence analysis, cost-benefit analysis, cost-effectiveness analysis and cost-utility
 I. Mavranezouli / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 187–198 189

analysis.7 In cost-consequence analysis, there is no summary measure of health outcome. Instead,

various measures are used to reflect different types of health outcome associated with the healthcare
strategies assessed. In cost-benefit analysis, health outcomes are given a monetary value; this can be
determined, for example, by asking individuals to state the maximum amount of money they are
willing to pay in order to gain the health benefit produced by the assessed strategy. In cost-effec-
tiveness analysis, a single measure of health outcome is used, expressed in physical units (e.g. mean
change in cholesterol levels, number of lives saved). Finally, in cost-utility analysis, a summary measure
of health outcome is used, capturing both quantitative and qualitative aspects of health (mortality and
morbidity) affected by the pathways under assessment. The most commonly used measure of outcome
in this type of economic analysis is the quality adjusted life year (QALY).
QALYs express the amount of time spent by an individual in a health state, weighted by a utility
score representing the health-related quality of life (HRQoL) relating to this state. Utility scores reflect
people’s preferences over health; they measure HRQoL on a scale from 0 (¼ death) to 1 (¼ perfect
health). For example, 1 year of life with HRQoL equalling a score of 0.8 provides 0.8 QALYs. By incor-
porating quantity and quality of life in a single summary measure, QALYs allow broad cost-effective-
ness comparisons across interventions aimed at different disease areas and patient populations.
In order to determine whether a healthcare strategy is more cost-effective than its comparator, it is
necessary to conduct incremental analysis to examine the incremental costs in relation to the incre-
mental health benefits obtained by adopting the strategy under assessment rather than its comparator.
Incremental costs and benefits can be combined in the form of an incremental cost-effectiveness ratio,
which is the difference in costs divided by the difference in effectiveness (health benefits) between the
two strategies. The decision maker needs to assess whether the incremental benefits are worth the
incremental costs in order to make a judgement on the cost-effectiveness of the evaluated strategy. One
special case where this judgement is straightforward is when one strategy is more effective and less
costly than its comparator. In this case, this strategy is called ‘dominant’ and is obviously more cost-
effective than its comparator.
Economic evaluations can be conducted either alongside clinical studies, where the health
outcomes and the healthcare resources used by the study samples are measured in parallel, or by
undertaking decision-analytic economic modelling. Decision-analytic economic models are real-world
simulations; such models use hypothetical cohorts of people and allow the estimation of the relative
cost-effectiveness of different programmes by synthesizing clinical and cost data derived from various
sources, such as clinical trials, observational studies, patient notes, population surveys and expert
opinion. Markov models are a type of decision-analytic model useful when assessing the cost-effec-
tiveness of strategies designed for the management of conditions that evolve over time, for example
when a decision problem involves a continuous risk, when the timing of events is important, or when
important events may happen more than once.8,9 The robustness of the results of economic modelling
should be tested in a sensitivity analysis, which explores the impact of different assumptions and of the
uncertainty characterizing the model input parameters on the results and conclusions of the economic
analysis.10

Assessing the cost-effectiveness of contraceptives

The cost-effectiveness of contraceptives is determined by several factors that include health

benefits (contraceptive protection reflected in prevention of unintended pregnancies plus any non-
contraceptive benefits), health harms (harmful side-effects of contraception), and any costs or savings
associated with contraceptive use and outcomes of unintended pregnancy (that is, birth, abortion,
miscarriage and ectopic pregnancy). If the comparator is ‘no method’, the cost-effectiveness of any
contraceptive method depends on whether its overall benefits (health benefits and cost-savings)
outweigh the costs and harmful effects associated with the method. When other contraceptive
methods are available in clinical practice, incremental analysis should be undertaken in order to
determine the relative cost-effectiveness between different contraceptive methods.
Most published economic evaluations of contraceptive methods have adopted the perspective of
the healthcare payer, such as a public-funded health service or a third party payer (health insurance),
and therefore have only estimated direct medical costs. These consist of method costs (e.g. ingredient
190 I. Mavranezouli / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 187–198

and equipment costs, consultation time with physicians, gynaecologists, nurses and other healthcare
staff, procedure costs incurred by e.g. insertion and removal of contraceptive devices or sterilization
techniques), costs of managing side-effects of contraceptives, and costs associated with the outcomes
of unintended pregnancy. In addition to healthcare costs, there are other costs associated with
provision of contraception or management of the outcomes of unintended pregnancy, such as costs
incurred by adoptions, costs to the social services or welfare payments to families with babies coming
from an unintended pregnancy, costs to the couples using contraception (e.g. travel costs to access
family planning clinics), as well as other intangible costs, such as emotional distress from an unin-
tended pregnancy, which may affect not only the woman but also her partner and family.
The time horizon is crucial when assessing the cost-effectiveness of contraceptives. Firstly,
a number of contraceptive methods, such as male and female sterilization and, at a lower degree,
some LARC methods, incur high method costs at initiation. This means that long periods of contra-
ceptive use may be required in order for the contraceptive benefits to outweigh the high start-up
costs. Moreover, all reversible methods are characterized by discontinuation rates that vary over
time; discontinuation may lead to the use of less effective contraceptive methods or no method,
resulting in lower contraceptive benefits and higher costs associated with the management of
unintended pregnancy. Given that discontinuation rates are expected to be higher over the first
months/years of initiation of a method, the choice of time horizon may affect the estimated cost-
effectiveness of some methods. The selected time horizon needs to reflect realistic situations; for
example, female sterilization has been designed to provide protection over a long period of time, so
measuring the cost-effectiveness of this form of contraception relative to other methods over short
time periods (e.g. 1 year) would not be appropriate. Finally, it should be noted that the same time
horizon must be used in comparisons between two or more contraceptive methods, otherwise the
results are subject to bias.
In terms of measure of outcome, most economic analyses of contraceptives have used the
number of unintended pregnancies averted by use of contraception. Some literature has made
a distinction between unwanted pregnancies, which would never occur later in time, and unplanned
or mistimed pregnancies, which would occur at some point in the future; according to the meth-
odology adopted in these studies, this distinction has impacted on the estimation of related costs, as
prevention of the former would result in cost-savings, while prevention of the latter would only
defer costs to a later time. Another less commonly used health outcome is the couple year of
protection (CYP), which is defined as the length of time over which a unit of a contraceptive method
provides protection against unintended pregnancy; the adjusted CYP measures the length of
contraceptive protection provided by a unit of a contraceptive method, adjusted by the failure rate of
the method.

Review of economic literature on contraceptives

Cost-effectiveness of contraceptives vs no method

Provision of contraception has been proven to be cost-effective worldwide as, besides the contra-
ceptive benefits, the huge cost-savings from unintended pregnancies averted far outweigh the costs of
providing contraception. It has been estimated that, in the USA, use of contraception prevents 12
million unintended pregnancies annually, leading to direct medical cost-savings of $19 billion in 2002.3
In the UK, public provision of family planning services saved the National Health Service (NHS) over
£2.5 billion in 1991; when additional savings from income maintenance payments (e.g. child benefit
and single parent allowance) were considered, the overall cost-savings to the public purse reached £25
billion.11
According to published evidence, all forms of contraception are cost-effective compared with no
method.11–16 Four modelling studies in the USA, which examined a wide range of contraceptive
methods, demonstrated that all contraceptives were associated with net cost-savings and therefore
they were dominant over no method (i.e. they led to better health outcomes and incurred overall lower
costs).12–15 The methods assessed included withdrawal and periodic abstinence, male and female
condoms, spermicides, cervical cap, diaphragm and sponge, vaginal ring, copper-T intra-uterine device
 I. Mavranezouli / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 187–198 191

(IUD), oral contraceptives, transdermal contraceptive patch, injectable contraceptives, IUS, subdermal
implant, tubal ligation and vasectomy. Medical costs included method costs and costs associated with
outcomes of unintended pregnancy, costs of adverse events and, in some cases, cost-savings resulting
from non-contraceptive benefits. The time horizons of the analyses ranged between 2 and 5 years. All
contraceptives were cost-saving either from the perspective of a public payer (e.g. Medicaid)12,13 or
a private payer.12–14 One of the studies adopted a wider perspective; in addition to medical costs, it also
examined social welfare costs associated with payments to families with dependent children, food
programmes providing nutritional advice and food supplements, as well as Medicaid-provided health
care to low-income individuals. All types of social welfare costs were translated into substantial net
cost-savings following use of contraception, due to prevention of a high number of unintended
pregnancies.15 Another model-based analysis conducted from the perspective of the UK NHS11,16
concluded that all contraceptive methods dominated no method, whether provided by general prac-
titioners (oral contraceptives), family planning clinics (male condom, diaphragm, spermicides, oral
contraceptives, copper-T IUD, contraceptive implant and injectable contraceptive) or in hospital
(vasectomy and female sterilization).

Emergency contraception
A number of studies have explored the cost-effectiveness of emergency contraception in the
USA17,18, Canada19,20 and Australia.21 Emergency contraceptive pills provided by physicians when
emergency occurs, or given in advance to be used at the event of unprotected intercourse, have been
shown to reduce the number of unintended pregnancies and produce overall cost-savings in both
managed care and publicly funded settings in the USA17 and Canada.19 Pharmacist-prescribed emer-
gency contraception also results in a reduction in the number of unintended pregnancies and subse-
quent net cost-savings in the USA18, Canada20 and Australia.21 Minipills used as emergency
contraception are associated with overall cost-savings in the USA, both in managed care and public-
funded settings17; in contrast, copper-T IUDs do not lead to net cost-savings when used solely as
emergency contraception, but would most likely produce significant savings if, instead of being
removed, they were used as an ongoing method of contraception.17

Adolescent contraceptive use

One US modelling study has assessed the cost-effectiveness of 11 contraceptive methods
appropriate for adolescents relative to no method.22 The methods examined were withdrawal,
periodic abstinence, male and female condoms, cervical cap, diaphragm, sponge, spermicides, oral
contraceptives, the subdermal implant and the injectable contraceptive. Dual method use was also
assessed. The analysis considered medical costs from the perspective of a public or private payer.
Costs consisted of contraceptive method costs, costs associated with the outcomes of unintended
pregnancy, costs of treating side-effects, and costs of treating sexually transmitted infections (STIs);
the latter were assumed to be reduced in women using condoms, spermicides or any method used
in conjunction with spermicides. Since the study population consisted of women aged 15–19 years, it
was assumed that 79% of unintended pregnancies were mistimed rather than unwanted; this
percentage was higher than respective figures estimated for women of reproductive age in any other
economic studies that distinguished between these two types of unintended pregnancy. Therefore,
in adolescent women, a large proportion of savings associated with prevention of unintended
pregnancies expressed costs being deferred to a later time in the future (in the case of mistimed
pregnancies) rather than actual savings (as in the case of unwanted pregnancies). Moreover, it was
assumed that more adolescent women would terminate an unintended pregnancy compared with
the overall population of women of reproductive age, thus reducing the average cost of managing an
unintended pregnancy.
All contraceptive methods were found to reduce the number of unintended pregnancies and
produce net cost-savings when compared with no method. Further analysis demonstrated that
advance provision of emergency contraception for use at the event of unprotected intercourse would
lead to substantial extra cost-savings. Finally, combination of male condoms with any other method of
those examined (except female condoms) was shown to increase cost-savings in the adolescent
population.
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Relative cost-effectiveness between contraceptive methods

Several studies have assessed the relative cost-effectiveness of different contraceptive methods in
the USA12–14,23–25 and the UK.26–29 All studies examined medical costs exclusively. Contraceptive
method costs and costs of unintended pregnancy were considered in all analyses; in addition, some
studies also included costs of treating adverse events12–14,23–25 and savings from beneficial side-
effects12,23 in the estimation of costs. Two studies incorporated costs associated with STIs.14,24 The
majority of studies considered the impact of method discontinuation on costs and health outcomes
associated with contraceptive use.14,24–28 The measure of outcome was the number of pregnancies
averted or the annual rate of contraceptive success, with the exception of one cost-utility analysis
which measured benefits in the form of QALYs.14 The time horizons of the analyses varied between
1 and 15 years of contraceptive protection.
The results of all studies were generally consistent and indicated, with small differentiations,
that male and female sterilization and LARC methods (copper-T IUD, IUS, contraceptive implant and
injectable contraceptive) were the most cost-effective options; these were followed by other
hormonal methods such as oral contraceptives, the transdermal patch and the vaginal ring. The
least cost-effective methods were the physical and chemical barrier methods (male and female
condoms, diaphragm, cap and spermicides) and behavioural methods (periodic abstinence and
withdrawal). It is evident that the cost-effectiveness results were primarily driven by the effec-
tiveness of each method; this can be explained by the fact that effectiveness (expressed in numbers
of unintended pregnancies averted) also determined the magnitude of cost-savings from prevention
of unintended pregnancies. It should be emphasized that methods with high method costs, such as
sterilization and some LARC methods (mainly subdermal implant and IUS), proved more cost-
effective than inexpensive methods (such as condoms) because they are much more effective and
therefore lead to far greater cost-savings from prevention of unintended pregnancies, outweighing
high method costs.
Vasectomy was shown to be one of the most cost-effective methods, dominating most of the other
forms of contraception even when the time horizon was as short as 2 years.12–14,23 In contrast, tubal
ligation, even though it is one of the most effective methods in preventing unintended pregnancies,
was not among the most cost-effective options in studies with time horizons up to 5 years, due to its
relatively high total costs.12–14,25 This finding, caused by the high procedure costs required for female
sterilization, suggests that longer periods of contraceptive protection may be required so that the high
intervention costs are offset by the high contraceptive effectiveness of female sterilization and asso-
ciated cost-savings. Indeed, when the full contraceptive effect of female sterilization was considered
(i.e. approximately 15 years), female sterilization dominated all other contraceptive methods except
vasectomy.23,26
LARC methods were overall found to dominate all other hormonal methods12–14,23,25,26, barrier
methods12–14,23,25,26 and behavioural methods.12–14 Results from comparisons across LARC methods
were not consistent. The injectable contraceptive was found to be dominated by one or more of the
other LARC methods (i.e. copper-T IUD, IUS and etonogestrel subdermal implant) in most economic
studies that made such comparisons.13,23,25–28 However, one cost-utility analysis showed that the
injectable contraceptive dominated all other contraceptive methods assessed in the analysis, with the
exception of vasectomy (i.e. 12 methods in total).14 It was also found to dominate the levonorgestrel
subdermal implant in another study.29 The etonorgestrel subdermal implant was found to be more
cost-effective than the IUS in two analyses26,27, and less cost-effective in a third study.28 Conclusions
from comparisons between the IUS and the copper-T IUD were less clear.
Other hormonal methods, such as oral contraceptives, the transdermal contraceptive patch and the
vaginal ring, were all more cost-effective than barrier and behavioural methods.12–14,23,25 The vaginal
ring was found to dominate oral contraceptives.13,14 The transdermal patch was found to dominate oral
contraceptives in two studies14,24 and to be dominated by oral contraceptives in a third study.13 The
transdermal patch had similar effectiveness with the vaginal ring in the two studies that performed
this comparison13,14; however, cost-effectiveness results were not consistent since the patch was
shown to incur lower total costs than the vaginal ring in one study14 and higher costs in the other one.13
Finally, barrier and behavioural methods were ranked last in terms of cost-effectiveness.12–14,23,25,26
 I. Mavranezouli / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 187–198 193

Cost-effectiveness of contraceptive methods in developing countries

Very little research has been undertaken on the cost-effectiveness of specific contraceptive methods
in the developing world. One study assessed the cost-effectiveness of vasectomy, tubal ligation, copper-
T IUD, subdermal implant, injectable contraceptive, oral contraceptives and male condom in Iran from
the perspective of the service provider.30 Based on the results of the analysis, which were expressed as
method cost per adjusted CYP, the authors concluded that vasectomy, the copper-T IUD and the
subdermal implant were the most cost-effective options in Iran. Another study adopted similar
methodology in order to compare the cost-effectiveness of the subdermal implant, the copper-T IUD
and the injectable contraceptive in Thailand.31 The results of the study indicated that the implant was
not a cost-effective option compared with the other two methods, as its method cost per CYP was much
higher than the respective figures for the other two comparators. These two analyses suffer from
a number of important methodological limitations, such as omission of costs associated with outcomes
of unintended pregnancy from estimation of total costs, and therefore their results should be
interpreted with great caution.

Factors affecting the relative cost-effectiveness between contraceptives

Contraceptive efficacy and compliance vs method cost

The effectiveness of a contraceptive method is the key driver of its cost-effectiveness. As dis-
cussed above, a review of relevant economic evidence demonstrated that the most cost-effective
methods were sterilization (male and female) and LARC methods (copper-T IUD, IUS, subdermal
implant and injectable contraceptive), followed by other hormonal methods (oral contraceptives,
transdermal contraceptive patch and vaginal ring). Barrier methods (male and female condoms,
diaphragm, cervical cap and spermicides) and behavioural methods (periodic abstinence and
withdrawal) were least cost-effective among contraceptive methods. These results illustrate that,
generally, the more effective a method is, the more cost-effective it is as well, because high effec-
tiveness is translated into better health outcomes and, at the same time, higher cost-savings from
prevention of unintended pregnancies. In contrast, method cost is not a key determinant of
a method’s cost-effectiveness, as highly effective methods are -usually- those with high method
costs. Therefore, it can be concluded that high method costs should not constitute a barrier to the
availability of certain methods.
Sterilization and LARC methods are characterized by very low failure rates which are practically
independent of users’ compliance (with the exception of the injectable contraceptive, the effec-
tiveness of which depends moderately on users’ compliance). In contrast, the effectiveness of oral
contraceptives (and, to a lower degree, the transdermal patch and vaginal ring) as well as of barrier
and behavioural methods relies to a great extent on users’ compliance. This means that typical use
(i.e. not always correct or consistent use) of such methods reduces their effectiveness significantly
compared with effectiveness observed under perfect use (i.e. efficacy), and consequently reduces
their cost-effectiveness. Four of the economic studies of contraceptives examined the difference
between typical and perfect contraceptive use in a sensitivity analysis.12,13,25,26 All four studies
reported that the relative cost-effectiveness of oral contraceptives26, barrier methods12,13,25 and
behavioural methods12 was improved substantially with perfect use. Therefore, in addition to
contraceptive efficacy, users’ compliance is another important parameter that determines the cost-
effectiveness of a contraceptive method.

Early discontinuation

All contraceptive methods apart from sterilization are characterized by high discontinuation
rates.32–41 Discontinuation levels reflect, up to a point, users’ acceptability of the method. Menstrual
disturbances are one of the major causes for discontinuation of contraceptives.32–36 It has been shown
that discontinuation has a substantial negative impact on the cost-effectiveness of LARC methods26,
and most likely affects the cost-effectiveness of other contraceptive methods as well, given that women
194 I. Mavranezouli / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 187–198

discontinuing a method are likely to move to a less effective method or no method32,33,37, thus
increasing both the number of unintended pregnancies they experience and respective costs associated
with the management of outcomes of unintended pregnancies. Continuation levels of contraceptives
may be improved, and their cost-effectiveness may be subsequently enhanced, if contraceptive users
are provided with adequate information on the potential adverse events and risks of contraceptives
before initiation, and are offered regular counselling for the management of experienced side-effects,
including menstrual disturbances, during contraceptive use.38,42,43

Adverse and beneficial side-effects

Adverse and beneficial side-effects have a potential impact on the cost-effectiveness of contra-
ceptive methods because, besides costs (or savings) associated with their management, they also
affect the HRQoL of contraceptive users. The relatively limited time horizon of economic studies did
not allow for a full assessment of the impact of adverse and beneficial side-effects, especially
regarding future risks and long-term benefits, on the relative cost-effectiveness of contraceptives.
Moreover, only one analysis expressed health outcomes in the form of QALYs, which enabled
consideration of the decrement in users’ HRQoL caused by adverse events (on the other hand, no
consideration was given to any improvements in HRQoL due to non-contraceptive benefits).14 A
number of economic evaluations have examined the cost-effectiveness of contraceptive methods in
treating menstrual bleeding44–47; their findings indicate that the IUS and oral contraceptives may be
more cost-effective than surgical procedures for the management of menstrual bleeding. Consider-
ation of such non-contraceptive benefits associated with these methods is likely to improve their
estimated cost-effectiveness.

Protection against STIs

With the exception of barrier methods, contraceptive methods do not protect against STIs. The cost
of treating STIs and/or the scenario of using a male condom in conjunction with another contraceptive
method in order to protect from STIs was considered in four economic studies.12,14,22,26 One of the
studies, which estimated the cost-savings from contraceptive use in adolescents, reported that the
male condom was associated with greatest cost-savings, because the cost of treating STIs represented
a large proportion of total costs in this population.22 In the overall population of women of repro-
ductive age, considering the cost of treating STIs did not substantially change the ranking of methods in
terms of cost-effectiveness, but moderately increased the cost-savings associated with use of barrier
methods.12 Combined use of the male condom with another contraceptive method was shown to
reduce overall costs for adolescents because it reduced the number of unintended pregnancies and the
incidence of STIs.22 Combined use of the male condom with another contraceptive method did not have
a negative impact on the cost-effectiveness of this method in the overall population of women of
reproductive age14, and, in fact, it improved the cost-effectiveness of barrier and behavioural methods
such as the sponge, the cervical cap, withdrawal and periodic abstinence.12 In addition, combined use
of the male condom with LARC methods was found to be more cost-effective than use of the male
condom alone.26 Conclusively, dual method use should be encouraged also on cost-effectiveness
grounds, especially in women at high risk for STIs, such as adolescents.

Duration of contraceptive protection relative to the life span of a method

The duration of use of a contraceptive method affects its relative cost-effectiveness, especially
when the method is associated with high method costs at initiation, such as male and female
sterilization and some LARC methods. All of these methods require a relatively longer period of
contraceptive protection compared with other hormonal contraceptives or barrier methods, so that
the cost-savings from the prevention of unintended pregnancies offset their high method costs at
initiation. Existing evidence has demonstrated that the time horizon of an economic analysis (which
reflects expected duration of contraceptive use) affects the ranking of methods in terms of associated
cost-savings14, as well as the relative cost-effectiveness between methods, especially when LARC
 I. Mavranezouli / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 187–198 195

methods and sterilization are assessed.13,26 The cost-effectiveness of any contraceptive method is
maximized when the duration of contraceptive protection equals the life span of the method, as
then the highest contraceptive benefits (and associated cost-savings) from method use are realized
for a given method cost.

HRQoL associated with use of contraception

The HRQoL of women/couples using contraception is an important factor affecting cost-effective-

ness. Consideration of HRQoL should capture aspects such as satisfaction and convenience from
contraceptive protection following use of specific methods, as well as psychological distress caused by
contraceptive failure and method-related adverse events, not only to the women themselves, but also
to their partners and families. It has been suggested that an unplanned birth could threaten the
wellbeing of every member of the family, including children and dependent parents.1 Moreover, an
unintended pregnancy may carry a disproportionately high psychological burden for specific groups in
the population, such as unmarried women or adolescents and their families, in many parts of the
world.1
Only one cost-utility analysis measuring the health outcome in the form of QALYs has been pub-
lished to date.14 The study used utility scores obtained from a sample of female members of the
research team and advisory panel, using a validated technique (time trade-off). Another study has
measured the effect of unintended pregnancy on women’s HRQoL.48 This study generated utility scores
associated with unintended pregnancy recording preferences of 192 non-pregnant women using
validated techniques (visual analogue scale, time trade-off and standard gamble). Both sets of utility
scores reported in the literature14,48 come from preliminary studies of women’s preferences, and their
use in future cost-utility analyses carries important limitations. However, these two studies demon-
strated the feasibility of eliciting women’s preferences on issues relating to unintended pregnancy,
thus encouraging further future research.

Clinical setting and economic perspective

The clinical setting plays an important role in the relative cost-effectiveness between contraceptive
methods, as it determines healthcare resource use patterns and unit costs, which affect total costs
associated with provision of any specific method. Clinical practice is also likely to vary in different
clinical settings; for example, counselling before initiation of a method may be characterized by
varying levels of intensity, or the type of management of adverse events from contraception is possibly
different in different settings. In addition, cultural beliefs and attitudes of women towards contra-
ception are not the same in all settings; such factors may affect consistent and/or correct use of
contraception, women’s acceptability, and continuation rates of some forms of contraception. All these
parameters affect the cost-effectiveness of contraceptive methods.
Existing economic evidence comes almost exclusively from studies conducted in the USA and the
UK. Very little is known about the cost-effectiveness of contraceptives in the developing world, where
patterns of healthcare resource use and associated unit costs are likely to differ significantly from
respective figures in the USA, the UK and the rest of the developed world. Women’s attitudes and
acceptability of contraceptives are also likely to be different between developed and developing
settings. Therefore, the findings presented in this review should be interpreted with caution in other
settings where evidence is lacking, and factors affecting the cost-effectiveness of contraceptives should
be reviewed and analysed in the specific context examined.
The economic perspective may also affect the cost-effectiveness of contraceptives. All economic
studies examined in this review considered both large categories of medical costs associated with
contraceptive provision, i.e. method costs and costs associated with the outcomes of unintended
pregnancy. However, in some settings, private or public payers of health care may cover one category
of costs but not the other, thus transferring part of the economic burden to individuals seeking
contraception. In these cases, the selected perspective will probably affect the estimated cost-
effectiveness of contraception. In any case, costs borne to individuals should never be ignored
because they are likely to influence the choice of contraceptive method and also people’s attitudes
196 I. Mavranezouli / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 187–198

towards contraceptive use, associated adverse events and outcomes of unintended pregnancy,
possibly affecting the cost-effectiveness of contraceptive methods in a complex way.

Other factors to consider when advising prospective contraceptive users

The relative cost-effectiveness between contraceptive methods as discussed in this review should not
determine availability of contraceptive methods in clinical practice. Women and men should have access
to a wide range of contraceptive methods and choose the method that is most suitable for them based on
their needs, preferences and lifestyle. Offering contraceptive access and choice is likely to increase
consistent contraceptive use and method continuation, and improve relevant aspects of HRQoL, thus
increasing the cost-savings to society and the overall cost-effectiveness of contraceptive use.

Summary

Economic evaluation aims to achieve optimal allocation of healthcare resources in order to

maximize the health of the population. The relative cost-effectiveness between two healthcare
strategies is determined by comparing both their costs and health outcomes. Unintended preg-
nancies constitute a significant health and social problem in all parts of the world. Widespread use
of contraception can prevent a substantial number of unintended pregnancies, and subsequently
lead to great cost-savings for society. All forms of contraception have been demonstrated to be cost-
effective compared with no method. The potentially high method costs associated with provision of
some forms of contraception are offset by the large cost-savings from prevention of unintended
pregnancies. Male and female sterilization and LARC methods constitute the most cost-effective
contraceptive options, while barrier and behavioural methods are the least cost-effective forms of
contraception. Other hormonal methods, such as oral contraceptives, lie between these two groups
in terms of cost-effectiveness. Nevertheless, consistent and correct use of oral contraceptives, barrier
methods and behavioural methods increases their cost-effectiveness substantially as it improves
contraceptive effectiveness and therefore results in higher cost-savings. Improvements in continu-
ation rates of all methods also increase their cost-effectiveness. These findings are based on
economic literature from developed countries. Provision of contraception is undoubtedly cost-
effective in the developing world, as cost-savings from the prevention of unintended pregnancies
most likely outweigh contraceptive provision costs. However, the relative cost-effectiveness between
contraceptive methods has not been adequately explored in such settings. Besides cost-effectiveness,
individual needs, preferences and lifestyle should determine choice of contraceptive method. Access
to a wide range of contraceptive methods for all individuals seeking contraception should be
ensured.

Practice points

 contraceptive provision results in substantial cost-savings to the healthcare system

 the potentially high costs of initiation associated with use of some forms of contraception
(mainly male and female sterilization, the subdermal implant and the IUS) should not be
a barrier to their availability, as these methods have been demonstrated to be very cost-
effective
 more consistent and correct use of oral contraceptives, barrier methods and behavioural
methods will substantially improve their relative cost-effectiveness
 besides cost-effectiveness issues, individual needs, preferences and lifestyle should deter-
mine choice of contraceptive method
 offering access and choice to prospective contraceptive users is likely to increase cost-savings
from contraception
 I. Mavranezouli / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 187–198 197

Research agenda

 economic evaluation of contraceptive methods in the developing world

 investigation of factors affecting correct/consistent use of contraception and rates of method
continuation, as well as methods to increase both of these parameters in the population
 validated generation of utility scores associated with contraceptive provision and unintended
pregnancy for use in cost-utility analyses

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