PREVALENCE, PREVALENCE, AVAILABILITY AND AVAILABILITY AND

ACCESSABILITY OF IUD IN ACCESSABILITY OF IUD IN HUNGARYHUNGARY

I. BatárDepartment of Obstetrics and Gynecology

University of Debrecen, Hungary

7th ESC SEMINAR, September 12 - 13, 2003Budapest, Hungary

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SHORT SHORT HISTORY OF IUDHISTORY OF IUDCornerstone international and Hungarian Cornerstone international and Hungarian

eventsevents1909 Dr. Richard Richter (Germany): dried silkworm gut

1923 Dr. Karl Pust (Germany): similar device with tail

1929 Dr. Ernst Gräfenberg (Germany): Gräfenberg ring

1934 Dr. T. A. Ota (Japan): Ota ring

1959 Reconsideration of IUD use (Oppenheimer/IL, Ishihama/J)

1960 Dr. Lazar Margulies (USA): Margulies spiral

1962 Dr. Jack Lippes (USA): Lippes loop (Gold Standard!)

1965 Dr. Ferenc Szontágh (Hungary): Szontágh IUD (plastic)

1972 Szontágh IUD marketed in Hungary after clinical trials

1074 Limited number of TCu 200 IUD for clinical trials

1970s-1980s Clinical trials with new IUDs in designated centers

1990s Wide range of devices became available in Hungary

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PREVALENCEPREVALENCE OF IUD OF IUD USE USE IN IN HUNGARYHUNGARY I. I. 1970s – 1980s: exact figures (all-country reporting system)

50.000 - 60.000 insertions/year

(minus illegal export to Romania?)

1990s – 2000s: no central recording, only estimations• Marketing surveys: 35.000-40.000 insertions/year

(Schering)

• Contraceptive survey/demographic data:

a) IUD use: 14% of married women in reproductive age

b) No of married women in reproductive age (2001): 1.3 M

c) Calculated number of users: 177.000

d) If changed every 5 (?) years: 35.000 insertions/year (?)

(plus non married women)

IUD is the second in the rank of methods next to the pill (33%)

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PREVALENCEPREVALENCE OF IUD OF IUD USE USE WORLDWIDEWORLDWIDE (1998)* (1998)* Country/Region Percentage of women of reproductive ageContraception total IUD

Rank #Hungary 73 14 2WORLD 58 13 3 USA (min) 59 1 6 Finland (max) 80 29 2 Moldova (max) 74 38 1Less developed regions 55 14 2More developed regions 70 6 5CEEC 67 16 2Northern Europe 78 18 3Western Europe 75 9 3Southern Europe 68 4 4

* Source: UN

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AVAILABILITY OF IUD IN HUNGARYAVAILABILITY OF IUD IN HUNGARY I. I.

MLCu 250/375

(Mona Lisa)

x Szontágh IUD TCu 200 TCu 380

GyneFix

Nova T 380 Mirena * = available in three sizesPlastic = no metal content

1. Types of devices

Utering

SilverLily/GoldLilySilverLily-Zn/Plastic*

Alloy IUDs:

Nova T

X = not available anymore (non-medicated)

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AVAILABILITY OF IUD IN HUNGARYAVAILABILITY OF IUD IN HUNGARY IIII..

2. Where to get it?• pharmacies (Mirena is exclusively available here)• company sales (directly or through distributors)• physician’s office (mainly in private praxis)

3. When to insert?• interval (usually on cycle days 1-7)• post abortion (not everywhere accepted)• post partum (6-8 weeks following delivery)• post placental (limited number of cases in clinical trials; no suitable devices are available)• post coital (emergency contraception: not well known)

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AACCESSCCESSABILITY OF IUD IN HUNGARY ABILITY OF IUD IN HUNGARY I.I.

1. Legal restrictions

• nulligravidas (sometimes neglected)

• only gynecologists are allowed to insert

• insertion in centers with lying-in background (?)

(nowadays neglected)

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AACCESSCCESSABILITY OF IUD IN HUNGARY ABILITY OF IUD IN HUNGARY II.II.

2. Medical (ob/gyn) limitations• „optimal for those with completed family size”

• „suggested after the second child”

• side effects/problems are more publicized than benefits

• not widely known as emergency contraception

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AACCESSCCESSABILITY OF IUD IN HUNGARY ABILITY OF IUD IN HUNGARY III.III.

3. Financial limitations

• not subsidized by the health insurance (since 1993)

• high price (compared to salary; the cheapest!)

• not exempted for VAT (12% 25%!) “punishment” instead of support

• indirect effect (IUD use has not been a medical indication for abortion since 1993)

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CONCLUSIONS I.CONCLUSIONS I.

• Hungary was pioneer for IUD use in the Hungary was pioneer for IUD use in the 1960s, and has a good position even 1960s, and has a good position even nowadays as fornowadays as for inventions inventions (see alloy(see alloy devices)devices)

• Prevalence: Prevalence: although acceptablealthough acceptable (14%) (14%), but , but it it could could further be increased throughfurther be increased through eliminatingeliminating oror

decreasing the restrictive and limiting decreasing the restrictive and limiting factorsfactors

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CONCLUSIONS II.CONCLUSIONS II.

• Availability:Availability:

- market has market has a a wide choice of IUDs, but wide choice of IUDs, but newnew types are welcomedtypes are welcomed- devices are easy to getdevices are easy to get ((pharmacies, clinicspharmacies, clinics))

- positive attitude needs to be increased positive attitude needs to be increased (correct information,(correct information, postabortal insertion, postabortal insertion, emergency contraception)emergency contraception)

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CONCLUSIONS III.CONCLUSIONS III.

• Accessibility:Accessibility:

- eliminating legal restrictions eliminating legal restrictions (gravidity(gravidity//parity, who/where to insert)parity, who/where to insert)- decreasing medical barriers through decreasing medical barriers through CMECME- modifying health caremodifying health care, social, social and and taxation policy to reduce prices taxation policy to reduce prices