Elsevier

Contraception

Volume 98, Issue 5, November 2018, Pages 396-404
Contraception

Original research article
Is contraceptive self-injection cost-effective compared to contraceptive injections from facility-based health workers? Evidence from Uganda,☆☆

https://doi.org/10.1016/j.contraception.2018.07.137Get rights and content
Under a Creative Commons license
open access

Abstract

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.

Keywords

Cost-effectiveness
Economic evaluation
DMPA-SC
Injectable contraception
Self-injection
Family planning

Cited by (0)

Acknowledgment of funding: This work was supported by the Bill & Melinda Gates Foundation, Seattle, WA, USA (grant number OPP1060986). The funder did not play a role in study design; the collection, analysis and interpretation of data; the writing of the report or the decision to submit the article for publication.

☆☆

Declaration of interest: N/A.