The Cost of Unintended Pregnancies (CoUP) in Canada: Estimating Direct Cost, Role of Imperfect Adherence, and the Potential Impact of Increased Use of Long-Acting Reversible Contraceptives

Amanda Y Black; Edith Guilbert; Fareen Hassan; Ismini Chatziheofilou; Julia Lowin; Mark Jeddi; Anna Filonenko; James Trussell

doi:10.1016/s1701-2163(16)30074-3

J Obstet Gynaecol Can. Author manuscript; available in PMC 2017 Jul 26.

Published in final edited form as:

J Obstet Gynaecol Can. 2015 Dec; 37(12): 1086–1097.

doi: 10.1016/s1701-2163(16)30074-3

PMCID: PMC5527291

NIHMSID: NIHMS880334

PMID: 26637081

The Cost of Unintended Pregnancies (CoUP) in Canada: Estimating Direct Cost, Role of Imperfect Adherence, and the Potential Impact of Increased Use of Long-Acting Reversible Contraceptives

Amanda Y Black, MD, MPH,^1,² Edith Guilbert, MD, MSc,^3,⁴ Fareen Hassan,⁵ Ismini Chatziheofilou,⁵ Julia Lowin,⁵ Mark Jeddi,⁶ Anna Filonenko,⁷ and James Trussell, BS, B.Phil, PhD^8,⁹

Author information Copyright and License information Disclaimer

Abstract

Objective

Unintended pregnancies (UP) are associated with a significant cost burden but the full cost burden in Canada is not known. The objectives were to quantify the direct cost of UPs in Canada, the proportion of UPs and cost attributable to imperfect contraceptive adherence, and the potential cost-savings with increased uptake of long-acting reversible contraceptives (LARCs).

Methods

A cost model was constructed to estimate the annual number and direct costs of UP in women aged 18–44 years. Adherence-associated UP rates were estimated using perfect- and typical-use contraceptive failure rates. Change in annual number of UPs and impact on cost-burden were projected in 3 scenarios of increased LARC usage. One-way sensitivity analyses were conducted to assess the impact of key variables on scenarios of increased LARC use.

Results

There are over 180,700 UPs annually in Canada. The associated direct cost was over $320 million. Fifty-eight percent (58%) of UPs occurred in women aged 20–29 years at an annual cost of $175 million; 82% of this cost ($143 million) was attributable to contraceptive non-adherence. Increased LARC uptake produced cost savings of over $34 million in all three switching scenarios; the largest savings ($35 million) occurred when 10% of oral contraceptive users switched to LARCs. The minimum duration of LARC usage required before cost savings was realized was 12 months.

Conclusions

The cost of UPs in Canada is significant and much of it can be attributed to imperfect contraceptive adherence. Increased LARC uptake may reduce contraceptive non-adherence thereby reducing rates of UP and generating significant cost savings, particularly in women aged 20–29.

Keywords: Unintended pregnancy, cost savings, contraceptive efficacy, contraceptive adherence, intrauterine device, intrauterine system, long-acting reversible contraceptive, LARC

INTRODUCTION

Unintended pregnancies (UPs) are associated with a substantial, and potentially avoidable, cost burden.¹ In the United States, half of all pregnancies are unintended and the rates of unintended pregnancies appear to be increasing.^2,3 Women in the 15–19 year-old age group have the highest proportion of unintended pregnancies⁴ with 82% of pregnancies being unintended;³ however, women in the 20–24 year old age group have the highest rate of unintended pregnancy (104/1000 women aged 15–44 years).³ The annual medical costs of UP in the United States is approximately $4.6 billion USD.¹ Data on UP in Canada are more limited but suggest that up to 40% of pregnancies in Canada are unintended.⁵ Surprisingly, there are no studies of the full cost burden of UP in the Canadian setting.

Despite the wide range of contraceptive options available in Canada, research has found that only 65% of Canadian women who are at risk of pregnancy and not trying to conceive “always” use a method of contraception.⁶ Conversely, 35% either never use a method of contraception (15%) or use contraception inconsistently (20%).⁶ With many contraceptive methods, contraceptive effectiveness is high with perfect use but imperfect adherence during typical use contributes to contraceptive failures.⁷ In fact, half of UPs in the United States occur in women using contraception.² In addition, 17.6% of Canadian women are using contraceptive methods that are associated with higher failure rates such as coitus interruptus, natural family planning, and rhythm methods.^6,7

Contraceptive methods that are less dependent on the user are associated with typical-use failure rates that are closer to perfect-use failure rates.⁷ The most effective methods of reversible contraception during typical use are long-acting reversible contraceptives (LARCs), including intrauterine contraceptives (IUCs) and subdermal implants, because they do not rely on user adherence.⁷ However, subdermal implants are not available in Canada and use of IUCs by Canadian women is low (<5%).⁶ Increasing IUC use may help to decrease the rates of adherence-related UP and the cost burden associated with these pregnancies. Studies in the USA¹ and Norway⁸ have found that increasing LARC uptake may result in reduced rates of UP and hence a significant cost savings. To date, there is no study that has quantified the direct cost of UP in Canada or the proportion of this cost that can be attributed to imperfect contraceptive adherence.

The objectives of this study were to quantify the direct cost burden of UPs in Canada, to determine the proportion of UPs and cost attributable to imperfect contraceptive adherence, and to estimate the potential cost-savings that could be realized with increased usage of LARCs in Canada. IUCs are the only LARCs available in Canada, thus the cost savings and timeframe within which the savings could be achieved were calculated in three scenarios of increased IUC usage.

METHODS

Model and Population

Using a framework that followed the structure of previous analyses in the United States,^{1, 9} a cost-burden model was constructed. Using this model, the annual number and cost of UPs in Canada were estimated. Next, the proportion of UPs attributable to imperfect adherence and the associated direct cost was calculated. Utilization and associated cost of contraceptive methods in Canada were evaluated and used to derive the change in number of UPs and cost impact that might result from increased use of intrauterine contraceptives (IUCs). Cost impact was calculated in three separate switching scenarios of increased IUC use. The analysis was performed from the public payer perspective, therefore only direct costs were considered.

The model considered women aged 18–44 years who were sexually active and were not trying to conceive. The base case analysis was conducted in Canadian women aged 20–29 years because the abortion rate is higher in this population,⁵ as is the use of less effective and/or more adherence-demanding methods of contraception.⁶ In order to allow comparability between short-acting reversible contraceptives (SARCs) and IUCs, an average one-year period of use was used in the analyses.

Unintended Pregnancies

Four possible pregnancy outcomes were considered: birth (live and still), induced abortion, spontaneous abortion, and ectopic pregnancy. The annual number of these outcomes (resulting from both intended and unintended pregnancy) was obtained from Statistics Canada.¹⁰ Ectopic pregnancy rates were taken from the Canadian Perinatal Health Report¹¹ and applied to the total number of pregnancies reported by Statistics Canada¹⁰ to determine the number of ectopic pregnancies.

The proportion of births resulting from UPs was estimated from The Maternity Experiences Survey¹² based on women who reported either a mistimed pregnancy (“wanted to be pregnant later”) or a truly unwanted pregnancy (“did not want to be pregnant at all”). Data on the proportion of induced abortions from UP are not available for Canada; therefore, estimates from a US study were used.² There are also no data on the proportion of ectopic pregnancies and spontaneous abortions resulting from an UP. For this analysis, it was assumed that if these pregnancies had not resulted in those outcomes, they would have resulted in births or induced abortions; therefore, the proportion of ectopic pregnancies and spontaneous abortions assumed to be unintended was calculated as the weighted average of unintended births and induced abortions (Table 1).

Table 1

Probability of pregnancy intendedness by outcome

Pregnancy outcome	Probability of unintended pregnancy	Probability of intended pregnancy
Births	34%^a	66% ^b
Induced abortion	92%^c	8% ^b
Spontaneous abortion	48%	52% ^b
Ectopic pregnancy	48%	52% ^d

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Source:

^acalculated as sum of “% wanted to be pregnant later” (i.e. mistimed) and “% did not want to be pregnancy at all” (i.e. truly unwanted) from Public Health Agency of Canada, 2009 for women aged 20–29 years¹²;

^bcalculated as difference from 100%;

^cFiner and Henshaw, 2006²;

^dweighted average of probability unintended births and induced abortions.

The various proportions associated with “unintendedness” described above were applied to the respective annual number of each pregnancy outcome in order to estimate the annual number of unintended pregnancies for each pregnancy outcome. These adjusted numbers were used to estimate the weighted cost of unintended pregnancy.

The Cost of Events Related to Unintended Pregnancy

The costs associated with each of the 4 possible pregnancy outcomes in Canada were taken from a Canadian Institute of Health Information (CIHI) report¹³ and the Ontario Case Costing Initiative¹⁴ and inflated to 2013 Canadian dollars using the Health and Personal Care CPI¹⁵ (Table 2). Mistimed births that resulted from UP would have occurred later; therefore, the cost of mistimed births was adjusted downward as in prior work.⁹ The cost per unintended pregnancy is a weighted average cost of the four possible outcomes, with the weights determined by the annual number of each outcome. The weighted-average cost of UP was estimated to be $2,129 per UP.

Table 2

Cost of pregnancy outcomes in women aged 20–29 years

	Births	Induced abortion	Spontaneous abortion	Ectopic pregnancy	Total
Number of Pregnancies (Unadjusted)	160,884^a	51,778^a	3,543^a	2,228^b	218,433
Percentage of Pregnancies (Unadjusted)^c	74%	24%	2%	1%	100%
Number of Unintended Pregnancies (Adjusted)^d	160,884 × 34% = 54,544	51,778 × 92% = 47,636	3,543 × 48% = 1,702	2,228 × 48% = 1,070	104,952
Percentage of Unintended Pregnancies (Adjusted)	52%	45%	2%	1%	100%
Unit Cost ($)	$3,492^e	$609 ^f	$626 ^g	$2,619 ^h	$2,129 ⁱ

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Source:

^aStatistics Canada, 2005¹⁰;

^bEctopic pregnancy rate from Public Health Agency of Canada, 2008 applied to the total number of pregnancies¹¹;

^cWeights have been rounded off and therefore do not add to 100%;

^dRefer to Table 1 for adjustment factor accounting for probability of ‘intendedness’;

^eCanadian Institute for Health Information, 2006¹³;

^fOCCI Day Surgery 2010/2011 – CACS Grouper code 2530: Termination of Pregnancy¹⁴;

^gOCCI Day Surgery 2010/2011 – Procedure code 5CA89GD: Surg terminate preg D & E¹⁴;

^hCanadian Institute for Health Information, 2006¹³ inflated to 2013;

ⁱweighted average cost of UP applied in analysis.

Unintended pregnancies and the proportion attributable to imperfect adherence

To estimate the total number of contraceptive failures, results from the Canadian Contraception Study were used to determine the percent use of each contraceptive method.⁶ The number of UPs associated with each contraceptive method was estimated by factoring the typical-use failure rates found in the literature⁷ by the number of Canadian women on each respective method. The total number of UPs in Canada attributable to contraceptive failure was then calculated as the sum of all the UPs associated with contraceptive failure of each method. To calculate the total cost of contraceptive failures, the total number of UPs was multiplied by the weighted cost of UP.

The total number of failures attributable to imperfect adherence was then calculated. For each contraceptive method, the difference in failure rates during perfect-use and typical-use⁷ was assumed to represent the failure rate attributable to imperfect adherence (Table 3). The number of UPs associated with imperfect adherence of each method was subsequently estimated by multiplying this difference by the number of Canadian women aged 20–29 years using that method of contraception.

Table 3

Contraceptive method failure rates: Perfect-use and typical-use failure rates and proportion of failures attributable to imperfect adherence

Method	Perfect-Use Failure (A)	Typical-Use Failure (B)	Proportion of UP attributable to imperfect adherence^a (B-A/B)
SARC methods
OC	0.3%	9.0%	0.97
Ring	0.3%	9.0%	0.97
Patch	0.3%	9.0%	0.97
Injection (DMPA)	0.2%	6.0%	0.97
Intrauterine contraceptives
IUD	0.6%	0.8%	0.25
IUS	0.2%	0.2%	0.00
Other methods
Male Condom	2.0%	18.0%	0.89
Female Condom	5.0%	21.0%	0.76
Emergency Pill ^b	5.1%	5.1%	0.00
Cervical Cap ^c	18.0%	28.0%	0.36
Diaphragm	6.0%	12.0%	0.50
Sponge	9.0%	12.0%	0.25
Film	18.0%	28.0%	0.36
Withdrawal	4.0%	22.0%	0.82
Rhythm	5.0%	5.0%	0.00
Natural Family Planning	0.4%	24.0%	0.98
No method ^d	46.0%	46.0%	Not applicable

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Source: Trussell et al, 2011⁷, unless otherwise noted;

^aCalculated as (typical-use rate – perfect-use rate)/typical-use rate i.e., using OC as example: (0.09–0.0033)/0.09 = 0.963;

^bGaffield et al, 2011²⁶;

^cassumption – set to spermicide as a proxy from Trussell et al, 2011⁷;

^dVaughan et al, 2008²⁷.

To calculate the direct cost of unintended pregnancy associated with imperfect contraceptive adherence, the estimated number of UPs associated with imperfect adherence was multiplied by the weighted cost of UP. The analysis was also performed on two additional populations: all women (aged 18–44 years) and women under the age of 30 (aged 18–30 years).

Cost of Contraception

The costs of contraception provision include the costs of the product and health care resources. Product costs were estimated from the RAMQ formulary¹⁶ in conjunction with Ontario pharmacies and healthcare provider costs were obtained from the Ontario Schedule of Benefits for Physician Services (Appendix A).¹⁷ The product costs incurred over an average one-year period were determined for each method in order to permit comparability between contraceptives with different durations of use. This analysis assumed that a $10 dispensing fee was incurred each time a prescription was filled and a 10% mark-up was applied to all product costs. Cost inputs and assumptions used to estimate the annual total cost of the various methods are summarized in Table 4. To permit comparability between contraceptives with different durations of use, the total contraceptive costs were annualized. For SARC methods (pills, patches, rings, and injectables), the annual product cost was calculated by multiplying the cost per cycle (or injection) by the number of cycles/injections per year. Health care resource costs were calculated as the sum of the fee for one initial consultation and any subsequent follow-up visits. Long acting reversible contraceptives, including IUCs, can be used for longer than one year. The annual costs were determined by summing the cost per unit with the costs of the fees for one initial consultation, one insertion visit, follow-up visits, and one removal visit and then dividing by the maximum duration of use of the method (the annualization factor) to estimate the average one-year cost.

Table 4

Costs of contraceptive methods in Canada

Unit	Cost per units	Units per year	Dispensing fees per year	Follow-up consultations	Annualisation coefficients
OC^a^,^d^,^g^,^j	$10.98	13	4	1 per year	1.00
Ring^b^, ^d^, ^g^, ^j	$44.16	4.33	4	1 per year	1.00
Patch^b^, ^d^, ^g^, ^j	$14.95	13	4	1 per year	1.00
Injection (DMPA)^b^, ^d^, ^g^, ^j	$26.98	4	4	4 per year	1.00
LNG-IUS 20^b^,^d^,^h^,ⁱ^,^k	$318.45	1	1	1 per 5 years	0.20
IUD^c^, ^d^, ^h^, ⁱ^, ^k	$60.00	1	1	1 per 5 years	0.20
Male Condom^c^, ^e^, ^j	$1.00	83	0	0	1.00
Female Condom^c^, ^e^, ^j	$4.00	83	0	0	1.00
Diaphragm^c^, ^m	$30.00	1	0	0	0.33
Cervical cap^c^, ^j	$60.00	1	0	0	1.00
Sponge^c^, ^e^, ^j	$9.00	83	0	0	1.00
Film^c^, ^e^, ^j	$8.00	83	0	0	1.00
Withdrawal^e^, ^l	$0.00	83	0	0	1.00
Rhythm^e^, ^l	$0.00	83	0	0	1.00
Natural Family Planning^e^, ^l	$0.00	83	0	0	1.00
Emergency contraceptive pill^b^, ^f^, ^j	$16.24	1	0	0	1.00
No method ^e^, ^l	$0.00	83	0	0	1.00

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Source for cost per unit: assumption unless otherwise indicated;

^aweighted average cost of all OCs available on the Canadian market, data on file from Bayer Canada, based on RAMQ database;

^bRAMQ Formulary¹⁶;

^cassumption, based on local Ontario pharmacy.

Source for units per year: assumption unless otherwise indicated;

^dbased on a 52-week year, a 28-day (4-week) cycle and respective product monographs (in the case of the ring the assumption was based on: one pack covers 12 weeks which implies 4.33 packs are required to cover the 52-week year)^28–33;

^erequired per act of intercourse therefore, it was assumed that 83 units would be required per year³⁴;

^ffor the emergency contraceptive, once per year on average³⁵. Source for dispensing fees per year: assumption unless otherwise indicated;

^gassumed to be dispensed for 3 months at a time and therefore, 4 (=12/3) dispensing fees are applied per year in addition to the unit cost;

^honce in year of acquisition.

Source for number of follow-up consultations required: assumption (to renew prescription) unless otherwise indicated;

ⁱto check placement^{32, 33}.

Source for annualisation coefficients:

^jNone required as each unit (pack) lasts for less than one year;

^kOne unit lasts for 5 years (assuming 5-year IUD) and therefore the coefficient is 1/5 = 0.20;

^lNone required;

^mOne unit lasts for 3 years and therefore the coefficient is 1/3 = 0.33.

Contraceptive method use rates in Canada were taken from the Canadian Contraception Study.⁶ In that study, women who were sexually active but not using any method of contraception were not included in the denominator for calculation of rates of method use. For this study, the data were recalibrated including down-adjusting for male condom use on the assumption that among women who reported using more than one method, condoms were being used for additional STI protection (rather than strictly for contraceptive purposes). The original and the recalibrated uptake data for the 20–29 year age group are presented in Appendix B.

The total annual cost of contraception was calculated by multiplying the annual cost of each method by the number of women using the method and summing.

Cost impact of increased use of IUCs

The potential impact of increased IUC uptake in women aged 20–29 years was estimated. Three separate scenarios with different populations of switchers were explored:

10% of women who are currently using oral contraceptives (OCs) switched to IUCs
10% of women who are currently using any SARC method switched to IUCs
10% of women who are currently using either a SARC or no method switched to IUCs.

The projected costs of UP and contraceptive use were estimated in each scenario and compared to the current estimated costs. If there was a cost savings, the minimum duration of time that an IUC would need to be used in order to generate a true cost savings was also determined.

All key parameters were varied between plausible limits through one-way sensitivity analysis (OWSA) to assess their respective impact on the three scenarios of increased IUC use.

RESULTS

Number and Cost of Unintended Pregnancy-Related Events

The estimated annual number of UPs in Canada is 180,733 with an associated direct cost of approximately $320 million (Table 5). In Canadian women aged 20–29 years who are sexually active and not pregnant or trying to conceive, the estimated annual number of UPs was 104,952. This represented over half (58%) of UPs in Canada and a direct annual cost of approximately $175 million (Table 5).

Table 5

Annual number and cost of UP and proportion attributable to imperfect adherence in Canada

Outcome	20–29 years-old	18–44 years-old	<30 years old
Number of UPs	104,952	180,733	117,388
Number of UPs due to imperfect adherence	86,125	124,024	95,443
Cost of UP ($)	$174,760,867	$320,344,481	$180,585,969
Cost of UP due to imperfect adherence ($)	$143,410,089	$219,829,158	$147,282,438
% of cost burden due to imperfect adherence	82%	69%	80%

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Cost of Contraception and Contraceptive Effectiveness

Based on current estimates of contraceptive use, the annual cost of contraception in Canada is $261 million among women aged 20–29 years (Table 6). The lowest annual cost was for the diaphragm at $25.63 per year (data not shown). Pregnancy rates for perfect use and typical use are presented in Table 3. SARCs are associated with higher typical use failure rates compared to IUCs, and thus a higher proportion of UPs associated with their use are attributable to imperfect adherence.

Table 6

Annual impact of increasing use of IUCs on the cost burden of unintended pregnancy (UP) in Canada (women aged 20–29)

	Number of UPs	Cost of UP	Cost of contraception	Total cost impact

Current contraceptive uptake practice

Estimates of current practice	104,952	$174,760,867	$260,823,349	$435,584,215

Scenario: 10% of women on OC use IUCs instead

Estimates of new practice	97,868	$162,965,128	$237,978,413	$400,943,541
Difference (vs. current practice)	−7,084	−$11,795,739	−$22,844,936	−$34,640,674

Duration of time to achieve cost neutrality	12.14 months

Scenario: 10% of women on any SARC use IUCs instead

Estimates of new practice	96,990	$161,502,483	$240,015,679	$401,518,162
Difference (vs. current practice)	−7,962	−$13,258,384	$20,807,670	−$34,066,054

Duration of time to achieve cost neutrality	12.30 months

Scenario: 10% of women on any SARC or condom or no method use IUCs instead

Estimates of new practice	96,442	$160,589,461	$240,462,869	$401,052,330
Difference (vs. current practice)	−8,511	−$14,171,406	$20,360,480	−$34,531,886
Duration of time to achieve cost neutrality	12.17 months

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Implications of Imperfect Contraceptive Adherence

Imperfect contraceptive adherence was estimated to account for 124,024 of the 180,733 UPs that occur annually in women age 18–44 years (Table 5). The total cost of UP due to imperfect adherence was approximately $220 million, representing 69% of the total cost of UP. In the base-case group of women aged 20–29 years, 86,125 UPs were attributed to imperfect adherence. The estimated direct cost due to imperfect adherence in this base-case group of women was $143 million which represents 82% of the total cost burden of UPs in this group (Table 5). Similar patterns of cost and burden attributable to imperfect adherence were observed when the analysis was conducted for women under the age of 30 years.

Impact of increased IUC utilization

In all three postulated switching scenarios in women aged 20–29 years, higher IUC uptake generated cost savings (Table 6). When considering both the cost of UP and the cost of contraception, the largest total savings ($35 million) were found when 10% of the cohort using an oral contraceptive (OC) pill switched to an IUC. In this scenario, there were 7,084 fewer UPs. A similar decrease in the direct cost of UP ($35 million and 8,511 fewer UPs) was seen in the scenario where 10% of women using either no method of contraception or a short acting-reversible contraceptive (SARC) were switched to an IUC.

One-way sensitivity analyses (OWSA) suggested that the cost-model was most sensitive to the number of follow-up visits required for OCs and IUCs, the cost used for births, and the cost of OCs (Figure 1). However, regardless of any variations in the inputs, the model consistently estimated cost savings from a switch to IUCs in all three switching scenarios.

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Figure 1

One-way sensitivity analysis results for cost savings post-10% switch from oral contraceptive pills to intrauterine contraceptives

In all three switching scenarios, the minimum duration of IUC usage required before cost-neutrality would be realized was just over 12 months (Table 6). Among women aged 20–29, cost neutrality was achieved after 12.1 months if 10% of OC users switched to an IUC; after 12.2 months when 10% of women using no method/any SARC method switched to IUCs; and after 12.3 months after 10% of women using any SARC switched an IUC.

DISCUSSION

Unintended pregnancies are a public health concern that account for substantial costs to healthcare systems. Based on our model, the total direct cost of UP in Canada in women aged 20–29 years is $175 million per year, with 82% of this cost ($143 million) attributable to imperfect contraceptive adherence. When the analysis was run for all women aged 18–44 years, the total direct cost was $320 million and the cost burden attributable to imperfect adherence reached $220 million. The annual costs of UP in Canada could be decreased by as much as $35 million with an increase in IUC use, with cost-savings being realized after just over one year of use. These savings are in line with findings of similar studies conducted in the United States¹ and Norway.⁸

It is difficult to determine the annual number of unintended pregnancies in Canada. The most recent Canadian data indicates that there were 92,524 induced abortions in 2011.¹⁸ Although this number may appear low compared to other developed countries,⁵ it likely underestimates the true number of abortions that are performed in Canada and does not take into account the unmet need for abortion services. Many Canadian women do not have access to abortion services in their community or province so the abortion statistics are not necessarily representative of the need for services or the number of women who have experienced an UP. Regardless, the fact that induced abortions occur in Canada despite the availability of a wide range of contraceptive options indicates that there is a financial, emotional, and reproductive health cost associated with UP that public health initiatives must strive to address. Although some unintended pregnancies end in abortion, many do not and therefore have additional costs beyond the direct costs associated with the pregnancy itself.

Unintended pregnancies may occur when contraception is not used, when contraception is not used consistently and correctly (typical-use failure), or when the contraceptive method itself fails despite consistent and correct use (perfect-use failure). Contraceptive methods that are less adherence-demanding generally have typical use failure rates that more closely approximate perfect use failure rates.⁷ For this reason, a number of international societies have advocated for increasing the use of long acting reversible contraceptives such as intrauterine contraceptives,^19,20 including in adolescent women,^{21, 22} in order to decrease the rates of unintended pregnancy. Despite this, rates of IUC use in Canada are low.⁶ Increasing the uptake of IUCs may be a viable option to decrease the rates of unintended pregnancy and alleviate the cost burden on the Canadian healthcare system and the individual. Previous studies from other countries have demonstrated health system savings of over seven dollars for every dollar invested in contraception and contraceptive counselling²³ as well as significant cost savings to the health system as the result of LARC promotion efforts.²⁴ Using a conservative switch rate of 10% to IUCs in our analysis, the number of unintended pregnancies decreased and the estimated annual cost savings was up to $35 million. Higher switch rates may result in even greater cost savings. Even when the cost of contraception is factored in, the cost savings is as high as $35 million. Although IUCs have higher upfront costs, the cost neutrality analysis indicates that cost savings are realized in just over one year.

There were limitations to our analysis. Only first-year failure rates were used to estimate the number of UPs attributable to imperfect adherence. Although failure rates were assumed to be the same for each successive year of use, first-year failure rates may be higher than in subsequent years because users who are less compliant stop using that method leaving a group of users who are increasingly compliant. As a consequence, the number of UPs attributed to imperfect adherence and the cost savings realized from switching to IUCs may be overestimated. In terms of costs used in this analysis, only the direct costs of delivery were included for births; prenatal costs, long-term economic costs, and social costs were not considered. Thus the cost of UP and potential cost savings from switching to IUCs are likely to be underestimated. Another limitation in this analysis is variability in direct product cost. Dispensing fees vary between provinces and pharmacies and the individual may pay a varying proportion of the dispensing and product fee. We took a conservative approach to dispensing fees; with higher frequencies of prescription refills, the cost of SARCs would be higher and hence the potential cost savings of switching from a SARC to a LARC would have been underestimated. A conservative approach was also taken in the switching analyses. With improved education and access to IUCs, it is conceivable that switching rates from SARC to IUCs may be higher than 10% and thus cost savings could be further increased. Lastly, discontinuation was not considered in this analysis. One-year continuation rates with SARC methods are between 43 and 68% depending on the method, while continuation rates with IUCs are much higher (78 to 80%).²⁵ The impact of discontinuation and switching contraceptive methods warrants additional research.

Despite these limitations, this analysis has several strengths. This is the first study that has attempted to quantify the direct cost burden of UP in Canada. Using established methodology, this analysis highlights the significant, and potentially avoidable, cost burden associated with contraceptive non-adherence and unintended pregnancies in Canada. By increasing the number of women who use IUCs, the number of UPs may be reduced and thus a notable cost savings may be realized, particularly in the 20–29 year age group.

CONCLUSION

Consideration should be given to increasing awareness of and access to long acting methods of reversible contraception and encouraging women of reproductive age to utilize IUCs. Governmental authorities should enable health care providers to provide IUCs and support the development and approval of other safe and effective LARCs such as contraceptive implants. This could result in significant cost savings by reducing unintended pregnancies and associated health care expenditures and would have a tremendous impact on the reproductive health of Canadian women. Given the high direct cost of UP in Canada, funding and reimbursement for all methods of contraception, including IUCs, should be supported.

Acknowledgments

The authors would like to thank Peter McMahon (IMS Health) and Chrisoula Gianneris (Bayer Inc) for their editorial support and Dimitra Lambrelli (Evidera) for reviewing the manuscript and providing useful comments.

Funding Statement

IMS Health, funded by Bayer Pharma AG, developed the economic model based on input from the authors. This work was supported in part by the Eunice Kennedy Shriver National Institute of Child Health and Human Development grant for Infrastructure for Population Research at Princeton University, Grant R24HD047879 (JT).

Appendix A: Cost of health care provider visits associated with contraceptive provision

Consultation	Setting of care and cost code	Cost

Physician consultation	GP: A007 Intermediate Assessment	$33.70

	Oby/Gyn: A205 Consultation	$101.70

Insertion consultation (Incurred only in year of insertion)	GP:
	A001 Minor Assessment +	$21.70
	G378 Insertion of intrauterine contraceptive device + E542 (Tray Fee)	$25.50 $11.15

	Oby/Gyn:
	A203 Specific Assessment +	$47.45
	G378 Insertion of intrauterine contraceptive device	$25.50
	+ E542 (Tray Fee)	$11.15

Follow-up visit	GP: A007 Intermediate Assessment	$33.70

	Oby/Gyn: A204 Minor Assessment	$26.35

Visit for removal (Incurred only in year of discontinuation or at end of method life span)	GP: A007 Intermediate Assessment	$33.70

	Oby/Gyn: A203 Specific Assessment	$47.45

Injection administration (Assuming injection is sole reason for visit)	GP and Ob/Gyn: G373 Intramuscular injection (sole reason)	$6.75

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Source: Ontario Schedule of Benefits for Physician Services¹⁷

Note: Consultation costs applied in the model were weighted under the assumption that 85% of women would attend these consultations under General Practitioner (GP) care and 15% would attend Obstetrics and Gynaecology (Ob/Gyn) specialist care.

APPENDIX B. RATES OF CONTRACEPTIVE METHOD USE IN CANADA (WOMEN AGED 20 TO 29 YEARS)

Method	Percent using contraceptive method	Recalibrated data: condom down-adjusted and “no method” added, %
Condom, male	55.5	9.76
OC	58.3	57.50
Withdrawal	12.0	11 83
Sterilization, male	14	0 00
Sterilization, female	0.7	0.00
Rhythm	2.8	2.76
Film	2.1	2.07
Natural family planning	1.3	1 28
Injection (DMPA)	3.4	3.35
IUD	1.8	1 78
IUS 20	1.5	1.48
Emergency pill	1.7	1.68
Patch	2.3	2.27
Hysterectomy	0.0	0.00
Sponge	1.0	0.99
Ring	1.2	1.18
Condom, female	0.2	0.20
Diaphragm	0.5	0.49
Implant	0.2	0.00
Cervical cap	0.0	0.00
Total	147.9	98.62
No method	7.3	1.38
Total including no method	155.2	100.00

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DMPA: depot medroxyprogesterone acetate; IUS: intrauterine system

Footnotes

Author Disclosures

Fareen Hassan and Ismini Chatzitheofilou, who developed the economic model based on input from all authors, were full-time employees of IMS Health and served as paid consultants to Bayer Healthcare Pharmaceuticals Inc. During the conception and development of the economic model, Mark Jeddi was a full-time employee of Bayer Inc. Amanda Black, Edith Guilbert, and James Trussell have received honoraria for consultancy work done for Bayer Pharma AG. All authors provided input to the model concept and input data, reviewed the data analysis, and have reviewed and contributed to the manuscript.

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