title: Timing of postpartum intrauterine device placement: a cost-effectiveness analysis.
abstract: OBJECTIVE
  To determine if immediate postpartum (PP) intrauterine device (IUD) placement prevents pregnancy and is cost-effective compared with routine placement.
  
  
  METHODS
  We developed a decision-analysis model to determine the number of pregnancies prevented and the cost-effectiveness of immediate PP IUD placement defined as within the first 10 minutes of placental expulsion compared with routine placement at the PP visit. Associated costs and probability estimates for adherence to PP follow-up, IUD placement, expulsion, and pregnancy were determined from the literature.
  
  
  METHODS
  Hospital and outpatient facility.
  
  
  METHODS
  Women desiring PP IUDs.
  
  
  METHODS
  IUD placement.
  
  
  METHODS
  The main outcome measure was the number of pregnancies prevented per 1,000 women. The secondary outcome was an incremental cost-effectiveness ratio (ICER) defined as the marginal cost per quality-adjusted life-year (QALY) gained. An ICER of <$50,000/QALY gained was considered to be cost-effective.
  
  
  RESULTS
  Immediate PP IUD placement prevented 88 unintended pregnancies per 1,000 women over a 2-year time horizon. Immediate PP IUD placement was the dominant strategy. For every 1,000 women who desired a PP IUD, attempted immediate PP placement resulted in a cost savings of $282,540 and a gain of 10 QALYs. The model is most sensitive to the cost of an undesired pregnancy. When the cost of a live birth is <$6,000, immediate placement is no longer cost-saving but remains cost-effective. Monte Carlo simulation demonstrates that immediate PP IUD placement is cost-effective in 99% of simulations.
  
  
  CONCLUSIONS
  Immediate PP IUD placement is a dominant strategy that prevents unintended pregnancy.
authors.affiliation: Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland. Electronic address: cwashi19@jhmi.edu.
authors.forename: Chantel I
authors.initials: CI
authors.lastname: Washington
authors.affiliation: Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Roxanne
authors.initials: R
authors.lastname: Jamshidi
authors.affiliation: Obstetrics and Gynecology, Ohio State University Medical School, Columbus, Ohio.
authors.forename: Stephen F
authors.initials: SF
authors.lastname: Thung
authors.affiliation: Obstetrics and Gynecology, State Universities of New York Upstate Medical University, Syracuse, New York.
authors.forename: Unzila A
authors.initials: UA
authors.lastname: Nayeri
authors.affiliation: Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon.
authors.forename: Aaron B
authors.initials: AB
authors.lastname: Caughey
authors.affiliation: Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland; Obstetrics and Gynecology, Alpert Medical School at Brown University, Providence, Rhode Island.
authors.forename: Erika F
authors.initials: EF
authors.lastname: Werner
mesh_terms: D000328:Adult; D003362:Cost-Benefit Analysis / Q000191:economics* / Q000706:statistics & numerical data; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D007433:Intrauterine Device Expulsion; D007434:Intrauterine Devices / Q000191:economics* / Q000706:statistics & numerical data*; D008875:Middle Aged; D010349:Patient Compliance / Q000706:statistics & numerical data; D049590:Postpartum Period; D011247:Pregnancy; D049168:Pregnancy, Unplanned; D019057:Quality-Adjusted Life Years; D013997:Time Factors; D014481:United States / Q000453:epidemiology; D055815:Young Adult
keywords: Contraception; QALY; expulsion; pregnancy; utility