Economic Evaluation of Provision of Postpartum Intrauterine Device Services in Bangladesh and Tanzania

Figures & Tables

TABLE 1.

Country Demographic and Health Data^a

	Bangladesh³⁸	Tanzania³⁹
2018 population, millions⁴⁰	161.4	56.3
2018 population density, people/km² of land area⁴⁰	1,240	64
Total fertility rate, births per woman	2.3	5.2
Use of modern method of contraception,^b %	51.9	32
Family planning uptake at 1–2 months postpartum, %⁴¹	13.2	9.2^c
Unmet need for family planning,^b %	12.0	22.1
Use of intrauterine device,^b %	0.6	0.9
Received antenatal care at least once from a medically trained provider,^d,^e %	81.9	98.0
Delivered at a health facility,^d,^e %	49.4	62.6
Deliveries attended by a skilled provider,^d %⁴²	52.7	63.6

↵a Source: Demographic and Health Survey, unless otherwise stated.
↵b Among currently married women aged 15–49 years.
↵c Tabulations based on use of family planning obtained from the reproductive calendar (average of use in time span postpartum), births 12–23 months preceding the interview, based on Bangladesh DHS 2011 and Tanzania DHS 2010.
↵d Among women aged 15–49 years who had a live birth within 3 years of the survey.
↵e Medically trained providers include qualified doctor, nurse, midwife, family welfare visitor, and community skilled birth attendant. For antenatal care, medically trained providers also include paramedics, medical assistants, or subassistant community medical officer.

TABLE 2.

Results of Costing Analysis in Bangladesh and Tanzania

	Bangladesh		Tanzania
	PPIUD Initiative	National Scale-Up Model	PPIUD Initiative	National Scale-Up Model
Program design
Number of facilities^a	6	36	6	28
Setup period, months	4	4	4	4
Implementation period, months	36	36	27	36
Number of PPIUDs inserted	8,031	26,507	7,448	43,928
Costing analysis
Estimated total cost	US$539,285	US$1,979,140	US$1,869,507	US$6,910,494
Estimated cost of direct PPIUD service provision^b	US$1.71	US$1.71	US$2.05	US$2.05
Cost per facility per year	US$27,986	US$17,373	US$130,697	US$79,223
Main cost driver	Facility staff^c (58% total cost)	Facility staff^c (53% total cost)	Training (76% total cost)	Training (80% total cost)
Estimated direct health care costs saved (Impact 2)	US$802,368	US$2,648,284	US$1,348,744	US$7,954,649
Estimated total costs after including estimated health care costs saved (Impact 2)	−US$263,083	−US$669,144	US$520,763	−US$1,044,156

Abbreviation: PPIUD, postpartum intrauterine device.
↵a Note the facilities included in the national scale-up model include the facilities in the PPIUD initiative plus additional facilities at the equivalent level of the public health care system. For Tanzania, each hospital in the scale-up model is assumed to have 4–6 associated satellite facilities that are trained in postpartum family planning counseling and given IEC materials to distribute and that refer clients to the hospitals, as was done in the PPIUD initiative.
↵b Includes cost of initial insertion, follow-up visit, and eventual removal using weighted averages. Cost of counseling is included for Tanzania but not for Bangladesh (cost of counselors in Bangladesh is included in staff costs, not direct service costs). Government reimbursements paid in Bangladesh are not included here.
↵c Facility staff in Bangladesh include counselors and honorariums in the PPIUD initiative. Counselors only are included in the national scale-up model.

TABLE 3.

Cost-Effectiveness of PPIUD Initiative

Outcome of interest^a	Bangladesh			Tanzania
Outcome of interest^a	Estimated Number	ICER Without Cost Offset^b	ICER With Cost Offset	Estimated Number	ICER Without Cost Offset^b	ICER With Cost Offset^c
PPIUDs inserted	8,031	67.2	PPIUD dominates	7,448	251.1	69.9
CYPs	36,943	14.6	PPIUD dominates	34,261	54.6	15.2
Unintended pregnancies averted	16,683	32.3	PPIUD dominates	15,471	120.8	33.7
Maternal deaths averted	11	50,731.0	PPIUD dominates	30	62,316.9	17,358.8
Child deaths averted	63	8,613.0	PPIUD dominates	306	6,109.5	1,701.8
Total DALYs averted (maternal + child DALYs)	5,918	91.1	PPIUD dominates	27,626	67.7	18.9

Abbreviations: CYP, couple-years of protection; DALYs, disability-adjusted life years; ICER, incremental cost-effectiveness ratio; PPIUD, postpartum intrauterine device.
↵a Outcomes are the estimated service lifespan impacts from the Impact 2 tool.
↵b The ICER without cost offset is equivalent to the cost per outcome because the cost of standard practice is estimated as zero cost in both study groups without any impact on the ICER.
↵c When neither the intervention nor standard care “dominates,” the ICER should be used to decide whether or not to invest (see Figure 2).

TABLE 4.

Cost-Effectiveness of National Scale-Up Model

Outcome of Interest^a	Bangladesh			Tanzania
Outcome of Interest^a	Estimated Number	ICER Without Cost Offset^b	ICER With Cost Offset	Estimated Number	ICER Without Cost Offset^b	ICER With Cost Offset
PPIUDs inserted	26,507	74.7	PPIUD dominates	43,928	157.31	PPIUD dominates
CYPs	121,932	16.2	PPIUD dominates	206,064	34.2	PPIUD dominates
Unintended pregnancies averted	55,062	35.9	PPIUD dominates	91,248	75.73	PPIUD dominates
Maternal deaths averted	18	107,057.9	PPIUD dominates	120	57,587.45	PPIUD dominates
Child deaths averted	207	9,576.2	PPIUD dominates	1,804	3,830.65	PPIUD dominates
Total DALYs averted (maternal + child DALYs)	18,558	106.6	PPIUD dominates	159,561	43.31	PPIUD dominates

Abbreviations: CYP, couple-years of protection; DALYs, disability-adjusted life years; ICER, incremental cost-effectiveness ratio; PPIUD, postpartum intrauterine device.
↵a Outcomes are the estimated service lifespan impacts from the Impact 2 tool.
↵b The ICER without cost offset is equivalent to the cost per outcome because the cost of standard practice is estimated as zero cost in both study groups without any impact on the ICER.