Outcomes and economic burden of hormonal contraceptive failure in developing countries: A case for improving effectiveness?
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PURPOSE- Unintended pregnancies (UP) result from contraception non-use or inconsistent and incorrect use leading to negative maternal and child health outcomes. The burden of healthcare spending on the consequences of UP and associated opportunity costs are substantial in resource-scarce developing regions. Among users of hormonal contraceptives (HC) which include IUDs, implants, injectables and pills, contraception failure can occur from non-compliance or drug-drug interactions (DDI) with co-medications. The objective of this study is to evaluate the prevalence of use, outcomes and cost burdens of HC failure in developing regions. METHODS- Country, region-wise contraceptive prevalence, distribution of contraceptive use by marital status and pregnancy intention, outcomes of UP and costs were taken from the “Adding It Up, 2017” dataset published from Guttmacher Institute. The developing countries were divided into sub-regions by UNDP classifications and included Africa, Asia, Latin America and the Caribbean. Number of UP were calculated by multiplying contraceptive method specific failure rates and number of users of each of the ten methods. Outcomes of UP were estimated by multiplying proportions of each outcome with total number of UP. Only costs of UP resulting in abortion are reported. Descriptive analysis and visualization was done using R (v. 3.5.1). RESULTS- The lowest hormonal contraceptive coverage was seen in Middle Africa (3.8%) while the highest is seen in Eastern Asia (35%). In developing countries, 44% of all pregnancies were unintended. Of the 885 million women who wish to avoid a pregnancy, 24% of women have an unmet need of contraception relying on traditional methods or no method. These women contribute to around 70 million (84%) of unintended pregnancies. However, users of HCs contribute to around 6.6 million (8%) of the unintended pregnancies. Of these, 2 million result in unplanned births, 1.8 million result in safe abortions and 1.9 million result in unsafe abortions. UP results in 98% of total abortions costs ($1.7 billion) with HC failure estimated to account for 8% ($144 million). CONCLUSIONS- Hormonal contraceptives are known to be highly cost-effective, consequently increasing their access in developing countries is imperative. Apart from an emphasis on using long acting contraceptives whose efficacy does not rely on patient adherence, healthcare providers must be sensitized about potential pregnancy risk due to DDI’s in the subset of women taking HCs and interacting co-medications.