Skip directly to site content Skip directly to page options Skip directly to A-Z link Skip directly to A-Z link Skip directly to A-Z link
Volume 23, Number 1—January 2017

Cost-effectiveness of Increasing Access to Contraception during the Zika Virus Outbreak, Puerto Rico, 2016

Rui LiComments to Author , Katharine B. Simmons, Jeanne Bertolli, Brenda Rivera-Garcia, Shanna Cox, Lisa Romero, Lisa M. Koonin, Miguel Valencia-Prado, Nabal Bracero, Denise J. Jamieson, Wanda Barfield, Cynthia A. Moore, Cara T. Mai, Lauren C. Korhonen, Meghan T. Frey, Janice Perez-Padilla, Ricardo Torres-Muñoz, and Scott D. Grosse
Author affiliations: Centers for Disease Control and Prevention, Atlanta, Georgia, USA (R. Li, K.B. Simmons, J. Bertolli, S. Cox, L. Romero, L.M. Koonin, D.J. Jamieson, W. Barfield, C.A. Moore, C.T. Mai, L.C. Korhonen, M.T. Frey, J. Perez-Padilla, S.D. Grosse); Puerto Rico Department of Health, San Juan, Puerto Rico (B. Rivera-Garcia, M. Valenica-Prado, R. Torres-Muñoz); University of Puerto Rico and Puerto Rico Section of the American College of Obstetricians and Gynecologists, San Juan (N. Bracero)

Main Article

Table 3

Sensitivity analyses indicating the number of ZAM cases prevented and Zika virus–associated costs avoided in proposed intervention to increase access to contraception to women during Zika virus outbreak, Puerto Rico, 2016*

Parameter No. ZAM cases prevented Incremental intervention cost, millions Zika virus–associated cost avoided, millions Total incremental cost,† millions Cost per HLY gained Additional cost avoided from UP, millions
Main scenario
% Women receiving contraceptive services from healthcare provider; main scenario, 50% of no method users, 60% of less-effective method users, and 100% of moderately effective method users
30% of no method users‡ 22 $32.4 $55.8 –$23.5 CS $34.6
70% of no method users 29 $34.6 $74.5 –$39.9 CS $46.1
30% of less-effective method users 19 $26.0 $50.0 –$24.0 CS $31.0
80% of less-effective method users
% Women receiving contraceptive services as in NSFG 2011–2013§ 16 $25.2 $40.6 –$15.4 CS $25.1
% Women willing to change to more effective method;¶ main scenario value: 50%
10% 6 $13.0 $15.8 –$2.8 CS $9.7
30% 16 $23.2 $40.5 –$17.3 CS $25.0
80% 39 $48.8 $102.2 –$53.3 CS $63.3
% Women receiving contraceptive services from healthcare provider as in NSFG 2011–2013 with 30% of them willing to change to a new method
Use of highly effective methods among switchers; main value 50%
67% 27 $38.4 $69.9 –$31.5 CS $43.3
Contraception switching pattern reported in Colorado Family Planning Initiative#
Dual-method use; 30% of moderately effective method users in main scenario
20% of moderately effective users 24 33.1 61.3 –$28.2 CS $38.0
50% of moderately effective users
Contraception use distribution at baseline
As reported in 2002 BRFSS survey** 30 33.6 −78.4 –$44.8 CS $48.6
As in Title X clinics in 2014††
Rate of ZAM among all live-born infants; main scenario value 58/10,000
32/10,000 14 $33.5 $37.5 –$4.0 CS $40.4
Lifetime costs for microcephaly; main scenario value $3.8 million
$1.9 million 25 $33.5 $33.5 0 CN‡‡ $40.4
$2.2 million 25 $33.5 $39.5 –$6.1 CS $40.4
$5.5 million
Termination of pregnancy with ZAM
20% 25 $33.5 $72.8 –$39.3 CS $40.4
Cost of the program other than providing the contraception at no cost to patients; main scenario value $39/person
$0/person 25 $27.1 $65.2 –$38.0 CS $40.4
Annualized LARC device cost 25 $17.5 $65.2 –$47.7 CS $40.4
Puerto Rico costs§§
Discount rate
0% 25 $33.5 $105.4 –$72.0 CS $40.4
5% 25 $33.5 $52.9 –$19.4 CS $40.4

*BRFSS, Behavioral Risk Factor Surveillance System; CN, cost-neutral; CS, cost-saving; HLY, healthy life years; LARC, long-acting reversible contraceptive; NSFG, National Survey of Family Growth; UP, unwanted pregnancy; ZAM, Zika virus–associated microcephaly.
†Total incremental cost is the additional cost of contraception minus Zika virus–associated cost avoided.
‡30% of no contraception users, 60% of less-effective contraceptive method users, 100% of moderately effective contraceptive method users seeking contraceptive services from healthcare provider during the Zika virus outbreak.
§Based on NSFG 2011–2013, among women of reproductive age who are sexually active, did not intend to become pregnant, and were not using permanent contraceptive methods, 21% of no contraception users, 33% of less-effective contraceptive method users, 97% of moderately effective contraceptive method users, and 94% of dual-method users had at least 1 contraceptive service visit in the last 12 months (in total 50%).
¶Based on Title X Family Planning annual report for 2007–2015 in Colorado, 30% of clients who visited Title X clinics switched to a new method.
#Eighteen percentage points of users of moderately effective methods are assumed to switch to highly effective methods, of whom 21% were dual-method users.
**Contraception distribution in Puerto Rico in 2002 15.9% no method, 41.6% less-effective methods, 40.2% moderately effective methods, and 2.4% highly effective methods.
††In 2014, in Title X clinics in Puerto Rico, 20% of women at risk for unintended pregnancy used less-effective methods, 77% used moderately effective methods, and 2% used highly effective methods.
‡‡Intervention cost equals to the medical savings from ZAM cases prevented.
§§Conversion factor of 0.36 applied to pregnancy and ZAM medical costs based on the ratio of per capita medical expenditure in Puerto Rico and in the United States in 2012 as in Portela et al. 2015 (32); conversion factor of 0.72 applied to costs of supportive care for live-born infants with ZAM, based on the ratio of annual salary for assistant nurses in Puerto Rico and in the United States (33).

Main Article

  1. Rasmussen  SA, Jamieson  DJ, Honein  MA, Petersen  LR. Zika virus and birth defects—reviewing the evidence for causality. N Engl J Med. 2016;374:19817.DOIPubMedGoogle Scholar
  2. Tepper  NK, Goldberg  HI, Bernal  MI, Rivera  B, Frey  MT, Malave  C, et al. Estimating contraceptive needs and increasing access to contraception in response to the Zika virus disease outbreak—Puerto Rico, 2016. MMWR Morb Mortal Wkly Rep. 2016;65:3114.DOIPubMedGoogle Scholar
  3. Oster  AM, Russell  K, Stryker  JE, Friedman  A, Kachur  RE, Petersen  EE, et al. Update: interim guidance for prevention of sexual transmission of Zika virus—United States, 2016. MMWR Morb Mortal Wkly Rep. 2016;65:3235.DOIPubMedGoogle Scholar
  4. Centers for Disease Control and Prevention. Zika virus disease in the United States, 2015–2016 [cited 2016 May 3].
  5. Ellington  SR, Devine  O, Bertolli  J, Martinez Quiñones  A, Shapiro-Mendoza  CK, Perez-Padilla  J, et al. Estimating the number of pregnant women infected with Zika virus and expected infants with microcephaly following the Zika outbreak in Puerto Rico, 2016. JAMA Pediatr. 2016 Aug 19 [Epub ahead of print]. PubMedGoogle Scholar
  6. Finer  LB, Zolna  MR. Declines in unintended pregnancy in the United States, 2008–2011. N Engl J Med. 2016;374:84352.DOIPubMedGoogle Scholar
  7. Trussell  J. Overstating the cost savings from contraceptive use. Eur J Contracept Reprod Health Care. 2008;13:21921.DOIPubMedGoogle Scholar
  8. Bensyl  DM, Iuliano  DA, Carter  M, Santelli  J, Gilbert  BC. Contraceptive use—United States and territories, Behavioral Risk Factor Surveillance System, 2002. MMWR Surveill Summ. 2005;54:172.PubMedGoogle Scholar
  9. Secura  GM, Allsworth  JE, Madden  T, Mullersman  JL, Peipert  JF. The Contraceptive CHOICE Project: reducing barriers to long-acting reversible contraception. Am J Obstet Gynecol. 2010;203:115.e17.DOIPubMedGoogle Scholar
  10. Trussell  J. Contraceptive failure in the United States. Contraception. 2011;83:397404.DOIPubMedGoogle Scholar
  11. Sedgh  G, Singh  S, Henshaw  SK, Bankole  A. Legal abortion worldwide in 2008: levels and recent trends. Int Perspect Sex Reprod Health. 2011;37:8494.DOIPubMedGoogle Scholar
  12. Singh  S, Sedgh  G, Hussain  R. Unintended pregnancy: worldwide levels, trends, and outcomes. Stud Fam Plann. 2010;41:24150.DOIPubMedGoogle Scholar
  13. Cragan  JD, Gilboa  SM. Including prenatal diagnoses in birth defects monitoring: Experience of the Metropolitan Atlanta Congenital Defects Program. Birth Defects Res A Clin Mol Teratol. 2009;85:209.DOIPubMedGoogle Scholar
  14. Centers for Disease Control and Prevention. Outcomes of pregnancies with laboratory evidence of possible Zika virus infection in the United States, 2016 [cited 2016 Jul 26].
  15. Grosse  SD, Ouyang  L, Collins  JS, Green  D, Dean  JH, Stevenson  RE. Economic evaluation of a neural tube defect recurrence-prevention program. Am J Prev Med. 2008;35:5727.DOIPubMedGoogle Scholar
  16. Trussell  J, Hassan  F, Lowin  J, Law  A, Filonenko  A. Achieving cost-neutrality with long-acting reversible contraceptive methods. Contraception. 2015;91:4956.DOIPubMedGoogle Scholar
  17. Truven Health Analytics. The cost of having a baby in the United States [cited 2016 May 16].
  18. Biggio  JR Jr, Morris  TC, Owen  J, Stringer  JS. An outcomes analysis of five prenatal screening strategies for trisomy 21 in women younger than 35 years. Am J Obstet Gynecol. 2004;190:7219.DOIPubMedGoogle Scholar
  19. Santelli  JS, Lindberg  LD, Finer  LB, Singh  S. Explaining recent declines in adolescent pregnancy in the United States: the contribution of abstinence and improved contraceptive use. Am J Public Health. 2007;97:1506.DOIPubMedGoogle Scholar
  20. Oduyebo  T, Petersen  EE, Rasmussen  SA, Mead  PS, Meaney-Delman  D, Renquist  CM, et al. Update: interim guidelines for health care providers caring for pregnant women and women of reproductive age with possible Zika virus exposure—United States, 2016. MMWR Morb Mortal Wkly Rep. 2016;65:1227.DOIPubMedGoogle Scholar
  21. Fleming-Dutra  KE, Nelson  JM, Fischer  M, Staples  JE, Karwowski  MP, Mead  P, et al. Update: interim guidelines for health care providers caring for infants and children with possible Zika virus infection—United States, February 2016. MMWR Morb Mortal Wkly Rep. 2016;65:1827.DOIPubMedGoogle Scholar
  22. Martines  RB, Bhatnagar  J, Keating  MK, Silva-Flannery  L, Muehlenbachs  A, Gary  J, et al. Notes from the field: evidence of Zika virus infection in brain and placental tissues from two congenitally infected newborns and two fetal losses—Brazil, 2015. MMWR Morb Mortal Wkly Rep. 2016;65:15960.DOIPubMedGoogle Scholar
  23. Hamilton  BE, Martin  JA, Osterman  MJ, Curtin  SC, Matthews  TJ. Births: Final Data for 2014. Natl Vital Stat Rep. 2015;64:164.PubMedGoogle Scholar
  24. Martin  JA, Hamilton  BE, Sutton  PD, Ventura  SJ, Menacker  F, Munson  ML. Births: final data for 2002. Natl Vital Stat Rep. 2003;52:1113.PubMedGoogle Scholar
  25. Riehman  KS, Sly  DF, Soler  H, Eberstein  IW, Quadagno  D, Harrison  DF. Dual-method use among an ethnically diverse group of women at risk of HIV infection. Fam Plann Perspect. 1998;30:2127.DOIPubMedGoogle Scholar
  26. Besnard  M, Eyrolle-Guignot  D, Guillemette-Artur  P, Lastère  S, Bost-Bezeaud  F, Marcelis  L, et al. Congenital cerebral malformations and dysfunction in fetuses and newborns following the 2013 to 2014 Zika virus epidemic in French Polynesia. Euro Surveill. 2016;21:30181.DOIPubMedGoogle Scholar
  27. Alfaro-Murillo  JA, Parpia  AS, Fitzpatrick  MC, Tamagnan  JA, Medlock  J, Ndeffo-Mbah  ML, et al. A cost-effectiveness tool for informing policies on Zika virus control. PLoS Negl Trop Dis. 2016;10:e0004743.DOIPubMedGoogle Scholar
  28. Broyles  RS, Tyson  JE, Swint  JM. Have Medicaid reimbursements been a credible measure of the cost of pediatric care? Pediatrics. 1997;99:E8.DOIPubMedGoogle Scholar
  29. Trussell  J, Lalla  AM, Doan  QV, Reyes  E, Pinto  L, Gricar  J. Cost effectiveness of contraceptives in the United States. Contraception. 2009;79:514.DOIPubMedGoogle Scholar
  30. Arroyo  MP. Contraceptive access due to Zika threat. Elnuevodia [cited 2016 Aug 4].
  31. Fowler  C, Gable  J, Wang  J, Lasater  B. Title X family planning annual report: 2014 national summary. Research Triangle Park (NC): RTI International; 2015.
  32. Portela  M, Sommers  BD. On the Outskirts of national health reform: a comparative assessment of health insurance and access to care in Puerto Rico and the United States. Milbank Q. 2015;93:584608.DOIPubMedGoogle Scholar
  33. Bureau of Labor Statistics. May 2015 state occupational employment and wage estimates: Puerto Rico [cited 2016 Jul 20].
  34. Bureau of Economic Analysis. Table 2.5.4. Price indexes for personal consumption expenditures by function [cited 2016 Aug 5].
  35. Grosse  SD. Assessing cost-effectiveness in healthcare: history of the $50,000 per QALY threshold. Expert Rev Pharmacoecon Outcomes Res. 2008;8:16578.DOIPubMedGoogle Scholar
  36. McGann  PT, Grosse  SD, Santos  B, de Oliveira  V, Bernardino  L, Kassebaum  NJ, et al. A cost-effectiveness analysis of a pilot neonatal screening program for sickle cell anemia in the Republic of Angola. J Pediatr. 2015;167:13149.DOIPubMedGoogle Scholar
  37. Burlone  S, Edelman  AB, Caughey  AB, Trussell  J, Dantas  S, Rodriguez  MI. Extending contraceptive coverage under the Affordable Care Act saves public funds. Contraception. 2013;87:1438.DOIPubMedGoogle Scholar
  38. Frost  JJ, Sonfield  A, Zolna  MR, Finer  LB. Return on investment: a fuller assessment of the benefits and cost savings of the US publicly funded family planning program. Milbank Q. 2014;92:696749.DOIPubMedGoogle Scholar
  39. Center for Work Force Studies. 2015 state physician workforce data book. Washington: Association of American Medical Colleges; 2015.
  40. Bishaw  A, Fontenot  K. Poverty: 2012 and 2013 [cited 2016 May 20].

Main Article

Page created: December 14, 2016
Page updated: December 14, 2016
Page reviewed: December 14, 2016
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.