Contraceptive Practice
in Europe: Differences in Availability and Accessibility
7th Seminar of the European Society
of Contraception, Hungarian Session
Budapest, 13 September 2003
Nine lectures were presented in the Hungarian Session. The survey by the Central
Bureau of Statistics (CBS) provided an insight into the contraceptive practice
of Hungarian couples. In addition to hormonal contraception, the program paid
special attention to emergency contraception and the current approach to STIs
in Hungary. Lectures looked at questions concerning intrauterine contraceptive
devices (IUDs) and the structure of providing services for adolescents
(particularly girls) in this country. Last but not least, highly informative
and thought-provoking data were listed about the costs of contraception and
abortion. This clearly highlighted the
need for change and subsidy to an acceptable level by the National Health
Insurance (NHI).
In a brief summary of the lectures presented
and, also, as a message relating to Hungary, the following can be concluded:
- When
compared to international data, the current Hungarian contraceptive
prevalence is good. Cross-sectional studies, between 1958 and 1993 showed
it increased from 59% to 73% among women of fertile age living with a
partner. However, the figure (72%)
has not changed since 1977. A longitudinal study on marriage conducted
between 1988 and 2001 yielded somewhat better results: the proportion of
women relying on contraception 6, 16 and 10 years after getting married
was seen at 67%, 68% and 73% in 1989, 1990 and 2001, respectively.
However, there is no new
cross-sectional data from the past ten years, nor any regular studies, repeated
at least every 5-10 years, which cover the whole fertile population (including
single women as well).
- Despite
the high contraceptive prevalence the proportion of induced abortions is felt to be unacceptably high in Hungary.
On the one hand, lack of information on the appropriate use of
contraceptives (the method is known but not used correctly, or less
effective methods are used) plays a role in high abortion rates. On the
other, as revealed in group discussions, the high price of contraceptives
is also a powerful limiting factor.
- A
variety of hormonal (principally oral) contraceptives are available, but
owing to steadily rising prices (with no NHI subsidy to reduce them) many
find this method inaccessible. This is especially true of the young
population.
- Hungary
has played a pioneering part in emergency
contraception as, for over twenty years, we have had experience with
Postinor (known as Rigesoft today), a drug containing levornorgestrel
(LNG). International comparative studies conducted in the meantime have
proved that this method is more effective than the Yuzpe method, in which
combined estrogen/gestogen-containing drugs are used. However many
countries (especially the western ones) have overtaken us in everyday
practice. The proportion of users, for instance, is closely associated
with the approach by doctors, pharmacists and the lay public alike.
Evidence-based studies have demonstrated that there is no practical
contraindication to LNG emergency contraception. In the view of that, more
and more (western) countries have ensured over-the-counter access to these
preparations. This may cause professional debate but after objective
judgment of the pros and cons it can be concluded that there is no valid
reason for refusing emergency contraceptives without a prescription, over
the counter.
- “Medical abortion” using
Mifepristone (RU486) is established and accepted practice in a number of
western countries and is favorably received by service providers and the
lay public alike. In France, most abortions are performed with this
non-surgical technique and, more recently, successfully done so on an outpatient
basis. Unfortunately, Hungary is still far from this stage. A few years
ago, attempts were made to present the method in the Journal of Hungarian
Gynecologists but soon after that, still in the phase of preparation, we
had to give up the idea – and not for professional reasons.
- All
over Europe, the rise in STI
incidence has posed a problem. This has been especially obvious in the
former Soviet Union, but can also be observed in some western countries.
Special emphasis has been given to Chlamydia trachomatis, a disease not
frequently identified or treated in Hungary previously. According to
surveys based on the latest observations by several centers, its incidence
rate is 5.4%. However, screening is often made difficult because of the
high costs of detection using up-to-date techniques. Since NHI finances
the cheap but less effective method of detection, “screened” (but
undetected) infections only worsen the situation.
- Owing
to the above, it is imperative that the lay public is correctly, objectively, responsibly and fully
informed (education in family life, information at school, counseling
about reproductive health at FP centers/polyclinics, etc.). To achieve
that goal, the training and retraining of professionals (teachers, health care workers, and doctors) is
required, and the media, as well
as the decision-makers
(politicians) should be involved in giving publicity to the topic.
- Cost is a crucial point here. Since
1993, contraceptives have not been subsidized in Hungary. This applies to hormonal, intrauterine
and other methods alike, including sterilization. Those in want of
contraception have to pay full price, which may amount to tens of
thousands of Hungarian Forint (HUF) at a time (USD 1 = HUF 225). It is not
only that the prices increase year on year but also, starting from 2002,
the VAT on IUDs, for example, has been risen from 12% to 25%. (Thus,
instead of subsidizing, the government penalizes and withholds money for
its own profit.) There are legal conditions for sterilization (3 live, biological
children or 35 years of age). No one would seriously expect that these
conditions make parents want more children thus contributing to the rise
in birth rates in Hungary. At the same time, this group of people is far
from being able to easily cover the cost of the operation. The result
usually is: there is no contraception; consequently there is unwanted
conception and subsequent abortion. Restrictions, i.e. withholding subsidy
will thus have an adverse effect.
In terms of financial subsidy of
contraception, the internationally recommended “1 CYP”-price (1 Couple-Years of
Protection) is the most useful. This is the so-called “acceptable price”
(which, based on experience, is worth paying for contraceptives, and, also,
many among the poor can afford to pay). It is worth 1% of the per capita GNI
(gross national income), but not higher than 0.25% of PPC (purchase power
capacity). (For Hungary the figures in 2002 were: GNI = 5,280 USD and PPC =
13,300 USD.) Based on the above, the price for 1 CYP in Hungary related to GNI
is less than 12,000 HUF, while it is not more than 7,600 HUF if PPC is
considered. In an effective family planning campaign, no higher contribution to
purchasing contraceptives can be expected on behalf of poor couples. In other
words, the aforementioned annual prices should be achieved by subsidy in
Hungary today.
Dr
István Batár