A Mobile Phone-Based Support Intervention to Increase Use of Postabortion Family Planning in Cambodia: Cost-Effectiveness Evaluation

Abstract

Background: Despite progress over the last decade, there is a continuing unmet need for contraception in Cambodia. Interventions delivered by mobile phone could help increase uptake and continuation of contraception, particularly among hard-to-reach populations, by providing interactive personalized support inexpensively wherever the person is located and whenever needed.

Objective: The objective of this study was to evaluate the cost-effectiveness of mobile phone-based support added to standard postabortion family planning care in Cambodia, according to the results of the MOTIF (MObile Technology for Improved Family planning) trial.

Methods: A model was created to estimate the costs and effects of the intervention versus standard care. We adopted a societal perspective when estimating costs, including direct and indirect costs for users. The incremental cost-effectiveness ratio was calculated for the base case, as well as a deterministic and probabilistic sensitivity analysis, which we compared against a range of likely cost-effectiveness thresholds.

Results: The incremental cost of mobile phone-based support was estimated to be an additional US $8160.49 per 1000 clients, leading to an estimated 518 couple-years of protection (CYPs) gained per 1000 clients and 99 disability-adjusted life-years (DALYs) averted. The incremental cost-effectiveness ratio was US $15.75 per additional CYP and US $82.57 per DALY averted. The model was most sensitive to personnel and mobile service costs. Assuming a range of cost-effectiveness thresholds from US $58 to US $176 for Cambodia, the probability of the intervention being cost-effective ranged from 11% to 95%.

Conclusions: This study demonstrates that the cost-effectiveness of the intervention delivered by mobile phone assessed in the MOTIF trial lies within the estimated range of the cost-effectiveness threshold for Cambodia. When assessing value in interventions to improve the uptake and adherence of family planning services, the use of interactive mobile phone messaging and counselling for women who have had an abortion should be considered as an option by policy makers.

Trial registration: ClinicalTrials.gov NCT01823861; https://clinicaltrials.gov/ct2/show/NCT01823861.

Keywords: Cambodia; contraception; cost-effectiveness; digital health; mHealth; postabortion contraception; postabortion family planning.

Figure 1

Conceptual framework for the service provision model based on the MOTIF trial. Inputs from the MOTIF trial are shown in green. Models used to derive costs and effects are shown in yellow. IUD: intrauterine device; MOTIF: MObile Technology for Improved Family planning; OCP: oral contraceptive pill.

Figure 2

Marie Stopes International Impact2 model framework. Inputs, outputs, and processes used in the Impact2 model are illustrated, as they apply to this study. Green: inputs to the model from the MOTIF trial. Yellow: effects reported in this study. Adapted from Weinberger et al [21]. CYPs: couple-years of protection; DALYs: disability-adjusted life-years; LAM: long-acting method; MOTIF: MObile Technology for Improved Family planning.

Figure 3

Tornado plot of deterministic sensitivity analysis using MOTIF intervention model parameters. For each parameter, the ICER was recalculated taking the upper and then lower deterministic range value. ICER ranges are centered on the ICER point estimate of US $82.57 per DALY averted. DALYs: disability-adjusted life-years; ICER: incremental cost-effectiveness ratio; IUD: intrauterine device; MOTIF: MObile Technology for Improved Family planning; MSIC: Marie Stopes International Cambodia; OC: oral contraceptive.

Figure 4

Monte-Carlo simulation results plotted on the cost-effectiveness plane, with effects measured in DALYs averted. Linear demarcations of the upper and lower bounds for the cost-effectiveness threshold for DALYs averted are included for comparison. DALYs: disability-adjusted life-years; MOTIF: MObile Technology for Improved Family planning.

Figure 5

Monte-Carlo simulation results plotted on the cost-effectiveness plane, with effects measured in CYPs. CYPs: couple-years of protection.

Figure 6

Cost-effectiveness acceptability curve derived from Monte-Carlo simulations of MOTIF intervention results, with effects measured in DALYs averted. DALYs: disability-adjusted life-years; MOTIF: MObile Technology for Improved Family planning.

Figure 7

Cost-effectiveness acceptability curve derived from Monte-Carlo simulations of MOTIF intervention results, with effects measured in CYPs averted. CYPs: couple-years of protection; MOTIF: MObile Technology for Improved Family planning.