Biomedical Sciences ETDs

Publication Date



Objectives: To compare the cost per quality of life (QALY) between immediate postpartum and interval initiation of intrauterine devices (IUDs) and contraceptive implants from the societal perspective. Cost per unintended pregnancy prevented between timing strategies was also compared. Methods: Two decision analytic models were created using TreeAge Pro 2015 software for TCu380A IUD and levonorgestrel IUD and for the contraceptive implant. Each model compared immediate postpartum versus interval contraceptive provision to determine the occurrence of pregnancy events over time and their impact on costs and QALYs, using a time horizon of 1 to 5 years. The probabilities of insertion, expulsion/removal, pregnancy and the utility values with having an unintended pregnancy were estimated from a literature review. Costs were adjusted to 2014 and included all direct medical and non-medical expenses such as transportation and infant care for the first year of life. Indirect costs were estimated using the human capital method. Sub-analysis using different payer perspectives and adjustments due to mistimed pregnancies were also done. Univariate and probabilistic sensitivity analyses (PSAs) were performed to determine robustness of the model. Results: The strategy of immediate insertion for all three contraceptive devices dominated interval initiation. For each delivery, interval (versus immediate) insertion results in an additional average cost of $1,549, loss of 0.015 QALY, and an additional incremental cost of $2,249 for each unintended pregnancy prevented. Regardless of perspective used and after adjustments for mistimed pregnancy, immediate insertion remains the strategy of choice. Extending the time horizon to 5 years increases the additional average cost with interval insertion to $2,600, loss of 0.024 QALY, and an additional incremental cost of $4,923 for each unintended pregnancy prevented. The models were most sensitive to the probabilities of actual insertion or postpartum loss to follow up, pregnancy rates from use of IUDs and implants, and cost of immediate insertion. PSA, using Monte Carlo simulation, show that immediate insertion is less costly and more effective 95% of the time. Conclusion: Immediate postpartum IUD and implant initiation is the dominant strategy compared to interval insertion, which support expansion of long acting reversible contraception (LARC) coverage.


"cost utility, long acting reversible contraception, intrauterine device, etonogestrel implant"



Document Type




Degree Name

Clinical Research

Level of Degree


Department Name

Biomedical Sciences Graduate Program

First Committee Member (Chair)

Raisch, Dennis

Second Committee Member


Third Committee Member