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The cost of improving care: a multisite economic analysis of hospital resource use for implementing recommended postpartum contraception programmes
  1. Vivian B Ling1,
  2. Erika E Levi2,
  3. Amy R Harrington3,
  4. Nikki B Zite4,
  5. Saul D Rivas5,
  6. Vanessa K Dalton6,
  7. Roger Smith6,
  8. Michelle H Moniz6
  1. 1School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
  2. 2Obstetrics & Gynecology and Women's Health, Yeshiva University Albert Einstein College of Medicine, Bronx, New York, USA
  3. 3Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, New York, USA
  4. 4Obstetrics & Gynecology, University of Tennessee Knoxville Graduate School of Medicine, Knoxville, Tennessee, USA
  5. 5Obstetrics and Gynecology, University of Texas Rio Grande Valley, Brownsville, Texas, USA
  6. 6Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
  1. Correspondence to Dr Michelle H Moniz, Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 48109-5276, USA; mmoniz{at}


Background The costs of quality improvement efforts in real-world settings are often unquantified. Better understanding could guide appropriate resource utilisation and drive efficiency. Immediate postpartum contraceptive care (ie, placement of an intrauterine device or contraceptive implant during hospitalisation for childbirth) represents an excellent case study for examining costs, because recommended services are largely unavailable and adoption requires significant effort. We therefore evaluated the cost of implementing immediate postpartum contraceptive services at four academic centres and one private hospital in USA.

Methods In this mixed-methods cost analysis, implementation activities were retrospectively identified using standardised data collection. Activities were categorised as preimplementation activities (infrastructure building, tool creation and stakeholder engagement) or execution activities (workforce training and process refinement). Costs were assigned based on national median salaries for the roles of individuals involved. Cross-case comparison and rapid qualitative analysis guided by the Consolidated Framework for Implementation Research were used to identify factors driving cost variation observed across sites.

Results On average, implementation activities required 204 hours (range 119–368), with this time costing $14 433.94 (range $9955.61–$23 690.49), and involving 9 (range 7–11) key team members per site. Preimplementation activities required more resources than execution activities (preimplementation: average 173 hours, $11 573.25; execution: average 31 hours, $2860.67). Sites that used lower-cost employees (eg, shifting tasks from a physician to a project manager) observed lower costs per hour for implementation activities. Implementation activities and costs were associated with local contextual factors, including stakeholder acceptance, integration of employees and infrastructure readiness for the change effort.

Conclusions Our findings provide the first estimates of health system costs for adopting recommended contraceptive care in maternity units in USA. More broadly, our findings suggest that the budget impact of improvement efforts may vary widely depending on local context.

  • implementation science
  • quality improvement
  • cost-effectiveness
  • obstetrics and gynecology

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  • Funding MHM is supported by the Agency for Healthcare Research and Quality grant #K08 HS025465. VKD is supported by the Agency for Healthcare Research and Quality grant #R01 HS023784 and has served as a paid expert witness for Bayer Corporation and a consultant for Bind.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. De-identified data, including standardised data collection forms and spreadsheet matrices with raw quantitative and qualitative data, are available upon request from MHM (

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