Contraceptive Practice in Europe: Differences in Availability and Accessibility

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:

  1. 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).

  1. 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.

  1. 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


  1. 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.

  1. 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.

  1. 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.

  1. 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.

  1. 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.


István Batár

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