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Corresponding author. Department of Gynecological Endocrinology, University Medical Center Hamburg–Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany. Tel.: +49 40 7410 52510; fax: +49 40 863728.
Globally, 14.3% of women of reproductive age use intrauterine contraception (IUC), but the distribution of IUC users is strikingly nonuniform. In some countries, the percentage of women using IUC is <2%, whereas in other countries, it is >40%. Reasons for this large variation are not well documented. The aims of this review are to describe the worldwide variation in IUC utilization and to explore factors that impact utilization rates among women of reproductive age in different continents and countries.
Study Design
Published literature from 1982 to 2012 was reviewed, using Medline and Embase, to identify publications reporting diverse practices of IUC provision, including variation in the types of IUC available. Local experts who are active members of international advisory groups or congresses were also consulted to document variations in practice regulations, published guidelines and cost of IUC in different countries.
Results
Multiple factors appear to contribute to global variability in IUC use, including government policy on family planning, the types of health care providers (HCPs) who are authorized to place and remove IUC, the medicolegal environment, the availability of practical training for HCPs, cost differences and the geographical spread of clinics providing IUC services.
Conclusions
Our review shows that the use of IUC is influenced more by factors such as geographic differences, government policy and the HCP's educational level than by medical eligibility criteria. These factors can be influenced through education of HCPs and greater understanding among policy makers of the effectiveness and cost-effectiveness of IUC methods.
Implications
Globally, 14.3% of women of reproductive age use IUC, but the percentage of women using IUC is in some countries <2%, whereas in other countries, it is >40%. This paper reviews the reasons for this diverse and highlights possible starting points to improve the inclusion of IUC in contraceptive counseling.
]. However, among women who use contraception, the percentage that use IUC varies greatly between continents/regions; from 1.8% in Oceania to 27.0% in Asia (Fig. 1) [
]. The distribution of IUC users is also geographically skewed: more than 80% of the world's IUC users live in Asia, with almost two-thirds (64%) of them living in China (Fig. 2) [
Fig. 2Worldwide distribution of IUC users. Eighty-three percent of the world's IUC users are in Asia. The remaining 8%, 4%, 4%, 1% and 0.03% are in Europe, Latin America/Caribbean, Africa, North America and Oceania, respectively. Data have been calculated from United Nations 2011 data tables based on data from surveys of women aged 15–49 years who are married or in union
International experts in contraception have been suggesting that increasing the very low update rate of long-acting reversible contraception (LARC) may reduce the rate of unintended pregnancy [
National Collaborating Centre for Women's and Children's Health, National Institute for Health and Clinical Excellence. Long-acting reversible contraception: The effective and appropriate use of long-acting reversible contraception. 2005.
]. This fact is also supported by an actual published study comparing different long-acting reversible contraceptives with other commonly prescribed contraceptive methods. The authors could show that the LARCs were superior to the other methods [
]. Although the evidence would suggest that these methods can be offered to most women of reproductive age, regardless of parity, in some countries only a small percentage of contraceptive users take up this method [
]. In this article, we aimed to explore the worldwide diversity of practice with regard to IUC, and the underlying factors that might explain the differences were noted. We aimed to use both the published literature and sought first-hand experience about local practices from experts across the globe.
2. Methods
We undertook a review of published literature using EMBASE, PubMed and Medline between 1982 and 2012 to explore IUC practices in various countries using the search terms “intrauterine contraception,” “IUD” “practices,” and “training.” We also drew on a pool of experts from across the globe to explore disparities that existed but that were not necessarily documented in published studies, especially variations in national guidelines, differences in placement recommendations and nation-specific differences in the costs of various types of IUC and the reimbursement systems in place. We consulted with clinicians in different countries and cross-checked information about prices and country-specific guidance from a number of sources including key professional organizations and national pharmaceutical databases.
3. Results
3.1 Geographical variability in the prevalence of IUC use
Only 62.7% of women worldwide use any form of contraception, although the use of contraception is more prevalent in more developed areas (72.4% of women) than in less developed areas (61.2% of women) (Table 1) [
]. Globally, 14.3% of women and 22.8% of women using contraception use IUC (Table 1; Fig. 1). However, the use of IUC is more prevalent in the less developed areas of the world (15.1% of women; 24.7% of contraception users) than in the more developed areas (9.2% of women; 12.7% of contraception users) (Fig. 1; Table 1) [
The highest rate of IUC use is in Asia (17.9% and 27.0% of women and contraception users, respectively), followed by Europe (12.4%; 17.1%), Africa (4.4%; 15.4%), Latin America/Caribbean (7.0%; 9.6%), North America (4.8%; 6.1%) and Oceania (1.1%; 1.8%) (Table 1; Fig. 1) [
]. Looking at individual Asian countries, in China, the Democratic Peoples' Republic of Korea and Vietnam, 41%–44% of women use IUC, compared with some other countries in the region that have IUC utilization rates of less than 2% [
]. In addition, data from Chinese national surveys conducted by the National Population and Family Planning Committee have shown that in married women aged 15–49 years, there has been an increase in IUC use from 42.1% in 1988 to 48.0% in 2006 [
The proportion of women using IUC in Europe also shows tremendous variation by region (Table 1) and country. The highest rates of IUC use are in Estonia (35.9% of women), and the rates range between 16% and 28% in countries such as France, Slovenia, Latvia and the Scandinavian countries. In contrast, less than 8% of women use IUC in Ireland, Germany and Romania [
]. In addition, in a survey of randomly selected women aged 18–49 years from five European countries (approximately 200 women per country), the reported prevalence of IUC use was 19.0% in Sweden, 13.4% in France, 10.3% in the UK, 5.0% in Germany and 3.5% in Romania [
There is a clear dichotomization within Africa regarding IUC use: the proportions of women using IUC are very low (<2%) in the sub-Saharan, Eastern, Middle, Southern and Western regions, whereas they are high in Northern Africa (18.1% of women, or 22.3% if Sudan is excluded) (Table 1), with “hot spots” for IUC use in Tunisia and Egypt (27.8% and 36.1% of women, respectively) [
The percentages of women in Latin America who use IUC vary regionally (9.6% in Central America; 5.5% in South America). In the Caribbean, 11.3% of women use IUC. By contrast, less than 2% of women in Oceania use IUC methods (Table 1) [
], a comprehensive summary of the types of intrauterine devices (IUDs) used in each country is not available. In the 1960s and 1970s, inert IUDs were widely available, but issues concerning infection with the Dalkon Shield caused it to be removed from the market in 1975. Since then, most other inert devices have gradually been replaced by other types of devices, typically those containing copper [
]. Most countries have at least one T-framed copper device, but some countries produce and/or dispense up to 15 different varieties of copper IUD; some of these are available only in the country in which they are manufactured, whereas others are exported, imported or reimported and renamed (Table 2). In addition to copper IUC, hormonal IUC has been introduced. The levonorgestrel-intrauterine system (LNG-IUS), Mirena®, was first marketed in Finland in 1990 and is now available in over 120 countries throughout the world, although in many countries, access is limited by the cost [
• Placement is reimbursed up to 65% by public insurance and 35% by private insurance; approximately 90% of the French population receives complementary private insurance
Gynelle 375
30.50 EUR
38.40 EUR
• Placement is reimbursed up to 65% by public insurance and 35% by private insurance; approximately 90% of the French population receives complementary private insurance • For women <18 years of age, IUD cost and the placement procedure can be free in family planning clinics
Mona Lisa Cu375
Mona Lisa Cu 375 SL
Mona Lisa CuT 380A QL
Mona Lisa NT Cu380
Multiload Cu375
Multiload 375 SL
NT 380 standard
NT 380 short
TT380
UT 380 standard
UT 380 short
Germany
Mirena®
195 EUR
155–255 EUR
• Fully reimbursed by public and private insurances for treatment of heavy menstrual bleeding and for contraception in women with certain illnesses that contraindicate use of pills
• Partially or fully reimbursed by public insurance for contraception in women <20 y of age (the percentage reimbursement depends on the woman's age) • Contraception is never covered by private insurance
Flexi-T300
15–30 EUR (GyneFix® 120 EUR)
155–210 EUR
• Fully reimbursed by public insurance for women <20 y of age
Flexi-T + 380
Multiload Cu375
• No reimbursement by public or private insurers for women ≥20 y of age
Multi-safe 375 short stem
T-safe 380A
GyneFix®
The Netherlands
Mirena®
~150 EUR
GP: 60 EUR
• The consultation/placement is totally reimbursed by the woman's health care insurance if she has an upgraded insurance, which is common in the Netherlands.
Gynecologist: 95 EUR
Flexi-T 300
32–69 EUR
GP 60 EUR
Flexi-T plus 300
Gynecologist: 95 EUR
• Hospital costs vary from hospital to hospital in the Netherlands according to the agreement with the insurance companies, but are between 155 and 330 EUR, so placement in total costs between 250 and 425 EUR including the device itself.
T-Safe Cu
Multiload Cu375
GyneFix®
108 EUR
GP 60 EUR Gynecologist:95 EUR
Sweden
Mirena®
1000 SEK (119 EUR)
Placement service is free of charge to women when used for contraception (however, women pay for the device itself)
• Mirena® is subsidized in some regions for younger women (the threshold for “younger” may be 20, 23 or 25 y depending on the region). For example, in Stockholm, women <23 y of age pay 6 EUR for Mirena®
• Mirena® placement is free of charge to women when it is for contraceptive purposes (the government reimburses the provider). However, women pay 20–30 EUR when Mirena® is placed for therapeutic (noncontraceptive) purposes
Nova T (380)
100–200 SEK (12–24 EUR)
Placement service is free of charge
• Provided free of charge to women in most (but not all) regions of Sweden (providers are reimbursed by the regional health services)
Flexi-T 300
Flexi-T plus 300
• In regions where devices are not provided free of charge, women pay between 100 and 200 SEK (12–24 EUR)
• Placement is performed free of charge to women (providers are reimbursed by the government)
UK
Mirena®
Provided to women free of charge by the National Health Service
Placement is free of charge to women on the National Health Service
• Mirena® and copper IUD are provided and placed free of charge to women (the provider is reimbursed by the National Health Service)
Cu-safe T300
Provided to women free of charge by the National Health Service
Placement is free of charge to women on the National Health Service
Flexi-T300
• Private cost of copper devices: 8.52−26.64 GBP (9.97−31.37 EUR)
• Private cost of Mirena®: 88 GBP (103 EUR)
Flexi-T + 380
• Private placement fee for copper devices or Mirena®: 150−500 GBP (176−585 EUR)
Load 375
Mini TT 380
Multiload Cu375
Multi-safe 375
Multi-safe 375 short stem
Neo-safe T30
Nova-T 380
T-safe 380A
TT380 slimline
UT380 short
UT380 standard
GyneFix®
Provided to women free of charge by National Health Service
North America
USA
Mirena®
Up to 875 USD (up to 673 EUR)
Up to 300 USD(up to 231 EUR)
• Depending on a woman's insurance, she may pay nothing or up to 875 USD for Mirena® or ParaGard®
ParaGard®
Up to 875 USD (up to 673 EUR)
Up to 300 USD (up to 231 EUR)
• Some insurance plans cover the cost (or a proportion of the cost) of both the device and its placement. Other plans may cover only the device or only the placement and vice versa.
• Government-funded insurances vary considerably depending on the state the woman lives in
• The new affordable care act in the US aims to provide contraception to all women at no cost to themselves; however, it is not yet clear who will cover these costs.
Canada
Mirena®
Up to 500 CAD(up to 378 EUR)
Placement service is free of charge
• Some publicly funded clinics will provide IUC at no cost to the woman.
• Some public and private insurance plans will cover IUC.
Copper IUDs
Up to 150 CAD (up to 113 EUR)
Placement service is free of charge
• Insurance-plan coverage varies between provinces but usually covers 80%–100% of women.
• If women are not covered by insurance, IUC will be entirely their expense.
Latin America
Argentina
Mirena®
220 USD (169 EUR)
400–1000 USD (308–770 EUR)
• Placement is available in private offices only.
• Women pay for Mirena® and its placement themselves.
• Women pay either the entire cost of the device and placement themselves (if they do not have insurance that covers this form of contraception) or the cost is partially reimbursed by the insurance company.
Copper T375
• In publicly funded clinics the cost of copper IUDs and their placement is free to women
Brazil
Mirena®
300 USD (231 EUR)
Private office: 500 USD (385 EUR)
• Women pay either the entire cost of Mirena® and its placement themselves (if they do not have insurance that covers Mirena®) or the cost is partially reimbursed by the insurance company.
Insurance plan: 50 USD (38 EUR)
• Insurance covers Mirena® for contraception and treatment of heavy menstrual bleeding.
Copper T380
20 USD (15 EUR)
Private office: 500 USD (385 EUR)
• Women pay either the entire cost of the device and its placement themselves (if they do not have insurance that covers this form of contraception) or the cost is partially reimbursed by the insurance company.
Copper T375
Insurance plan: 50 USD (38 EUR)
Colombia
Mirena®
240–350 USD (185–269 EUR)
Private office: 190 USD (146 EUR) (Mirena is not provided by publicly funded clinics.)
• Women pay for Mirena® and its placement themselves
• Insurance covers Mirena® strictly for treatment of heavy menstrual bleeding, not for contraception.
Copper T380
3–10 USD (2–8 EUR)
Private office: 100 USD (77 EUR) (cost of placement and device)
• Women in private office must pay for the device and its placement.
• Copper IUDs and their placement are fully reimbursed by some insurances.
• Women without insurance that covers copper IUDs pay the full cost of the device and its placement themselves.
• In public clinics and hospitals, cost is covered by the government, so it is free for women.
Insurance plan: 20–80 USD (15–62 EUR)
Mexico
Mirena®
150 USD (115 EUR)
Private office: 150 USD (115 EUR)
• In private office, women must pay for Mirena® and for placement.
• Insurance companies do not cover the cost for contraception or treatment of heavy menstrual bleeding.
• In some publicly
funded clinics, Mirena® is provided to women free of charge (the cost is reimbursed by the government).
Copper T380
7 USD (5 EUR)
Private office: 150 USD (115 EUR)
• In private office, women must pay for copper IUDs and for placement.
Copper T375
Insurance plan: placement is not covered
• Insurance companies do not cover the cost of copper IUDs.
• Women are provided with copper IUDs free of charge in public clinics (providers are reimbursed by the government).
Public clinic: free of charge to women
Asia-Pacific
China
Stainless steel rings
Free of charge to women
Free of charge to women
• All copper and stainless steel IUDs are provided free of charge to women (providers are reimbursed by the government).
Copper devices
Australia
Mirena®
Public script: up to 35.40 AUD (28.55 EUR)
0–200+ AUD(0–161+ EUR)
• Mirena® is subsidized, i.e., the women and the government share the cost.
• Some hospital and sexual health clinics do not charge for fitting or only charge Medicare rebate, and others charge a flat fee of 100–175 AUD (81–141 EUR). Other practices may charge beyond this. This is the placement fee only, not the consultation fee.
• Insurance plans cover the cost of the placement procedure, but not the cost of the device.
• Some hospital and sexual health clinics do not charge for placement or only charge Medicare rebate, and others a flat fee of between 100 and 175 AUD (81–141 EUR). Other practices may charge beyond this. This is the fitting fee only, not the consultation fee.
New Zealand
Mirena®
350–400 AUD (282–323 EUR)
28–600 AUD (23–484 EUR)
• Mirena® is not subsidized, and women must pay 350–400 AUD (282–323 EUR) for the device.
• However, Mirena®is free of charge to women when it is for the treatment of heavy menstrual bleeding.
• Insurance plans cover the cost of the placement procedure, but not the cost of IUC.
Copper IUD
0 AUD
28 AUD (23 EUR)
• Copper IUDs are free to women, the retail cost of 39.50 AUD (32 EUR) is fully funded.
Currency conversions to Euros correct as of March 25, 2013.
Differences in the range of IUC options available may affect access for numerous reasons. However, the most obvious factor that influences access is cost [
Depending on the country, the cost of IUC and its placement might be charged to the health care system, insurance companies, nonprofit organizations or to women themselves. Medical insurance plans vary in the types of device covered and whether or not the cost of placement is included. Furthermore, in low-resource settings, where foreign aid is received for family planning, the methods of contraception provided may reflect donor preferences or may limit the contraceptive options available [
]. Obtaining information on both the cost of manufacturing and the costs to consumers is difficult, but costs are clearly not uniform around the world. In the UK, T-framed, U-framed and frameless copper devices and the LNG-IUS are available to women free of charge through the National Health Service; however, there is, of course, a cost to the health care system (Table 2).
In the US, the available IUC options include one 10-year T-shaped copper device (ParaGard®) and two LNG-IUSs (Mirena® and Skyla®). Depending on a woman's insurance plan, she could pay nothing or up to $875 for any of the devices and up to $300 for the placement of the device. Currently, women who have government-funded insurance in the US have variable access to IUC depending on the state in which they live. In 2014, the Patient Protection and Affordable Care Act in the US (commonly known as “ObamaCare”) will come into effect. Although it is unclear how this act will impact the cost of IUC, the intention is for all women to have access to contraception at no cost to women themselves. However, there is considerable debate over who would be responsible for covering this financial burden and not all contraceptive methods have to be covered in any given State's plan.
In China, stainless steel rings (Fig. 3) continue to be placed despite the government's commitment to discontinue this option and switch to the use of more effective devices containing copper (Fig. 3) [
]. Whatever device a region chooses is provided free of charge to the women there. However, because stainless steel rings are less expensive for the family planning clinics to buy, for many years, these rings were the devices that were provided, despite their higher expulsion and failure rates [
In some countries, one IUC device may be provided or subsidized, whereas other devices are not. In Mexico and in most parts of Sweden, copper IUDs are provided to women free of charge, whereas women must pay for the LNG-IUS themselves if it is the method they desire. In New Zealand, the copper IUD is subsidized and is used more widely than the LNG-IUS [
Australian Government Department for Health and Aging. Pharmaceutical Benefits Scheme (PBS). 2013. Available at: http://www.pbs.gov.au/medicine/item/8633J. Accessed February 20, 2013.
3.3.1 Types of health care providers authorized to provide IUC services
Through practitioners working in different countries, we obtained information about both the types of health care providers (HCPs) that provide IUC and the settings in which this provision occurs. One of the key variations is whether countries train and permit placement by nurses and/or midwives (Table 3). In Germany, IUC services are provided only by obstetrician-gynecologists. In the neighboring Netherlands, IUC services are provided by a wider range of HCPs, including family practice physicians and general practitioners. In Sweden, midwives provide most contraceptive services.
Differences in the types of HCP that are authorized to provide IUC services have a marked influence on IUC uptake rates. This is particularly evident in countries with geographically isolated rural populations who are unable to travel to clinics offering IUC services. For example, in Turkey, initial attempts to extend access to IUC in rural areas via physician-run mobile clinics were less successful than anticipated owing to difficulties in providing adequate postplacement follow-up care [
]. Initial research undertaken to assess whether IUC placements and removals could be performed safely by local midwives who could provide both immediate and follow-up care at a location accessible to women living in rural villages [
]. The study demonstrated that nurses were at least as careful as physicians in performing IUC placements and, based on these findings, the Turkish Government authorized midwives to provide IUC services. A similar approach has been studied in Sudan in the late 90s when midwives undertook a 3-week training course for the insertion of IUDs. The rate of incorrect insertions was evaluated in 520 patients, and just 6 (1.2%) IUDs were found to have been incorrectly placed [
]. In contrast, one study has shown a higher failure rate when IUC was inserted by nurses compared to physicians. This fact was discussed as the result of an insufficient training in nurses [
The provision of IUC services in Egypt used to be the sole prerogative of obstetrician-gynecologists. However, since the mid-1980s, a steady increase in IUC use has been achieved, in part by allowing general practitioners to place and remove devices, with careful attention given to the training and certification of these providers [
An important factor-limiting access to IUC is the availability of providers who have the skills, time and support to train other HCPs. In the UK, a shortage of trainers has led to waiting lists for training program opportunities and hence a delay in physicians gaining the Letter of Competence in Intrauterine Techniques qualification [
The locations at which women can access IUC services also vary between countries (Table 3). For example, in Germany, IUC services are provided only in obstetrician-gynecologists' offices. However, in many other countries, IUC services can be accessed at a choice of locations, including HCPs' offices, sexual health clinics, contraception or youth clinics, abortion clinics and hospital-based community clinics.
3.5 The medicolegal environment
The medicolegal environment can impact IUC provision, and fear of liability has frequently been cited by US-based physicians as a barrier to more liberal prescribing of these methods [
]. This may include fear of liability for uterine perforation and, in particular, the fear that if the woman at any point experiences pelvic inflammatory disease or infertility, she may blame it on the LNG-IUS/copper IUD and the provider who placed it. In a survey of Fellows of the American College of Obstetricians and Gynecologists (ACOG) conducted in 2002, a significant correlation (p < .001) was found between physicians' fear of litigation and a lower number of IUC placements performed the previous year [
]. However, outside the US, fear of litigation is much less of a barrier to HCPs offering IUC services.
3.6 Factors at the HCP level
HCPs' attitudes have a strong influence on rates of IUC use. The likelihood that an HCP will prescribe IUC depends on many factors, including the providers' knowledge base, and whether they have received appropriate training on placement/removal techniques and patient counseling [
The degree to which these misperceptions curtail IUC use in individual countries may depend on the persistence of these misperceptions and the success that educational programs have had in dispelling them. Family planning experts in the US for example are actively addressing the misperceptions among women and HCPs regarding the safety of IUC and the unsuitability of these methods for certain groups of women (e.g., nulliparous women and adolescents) [
3.7 Factors at the end-user level: religious and cultural influences
Cultural and religious influences in different countries create environments that are more or less favorable to IUC use. For example, in Muslim countries, bleeding disturbances associated with IUC interfere with women's religious and social activities [
], exist to guide contraceptive practice throughout the world. Individual countries also produce their own guidelines such as US Center for Disease Control and Prevention MEC [
Centers for Disease Control and Prevention. MMWR early release: U.S. medical eligibility criteria for contraceptive use. 59. 2010. Available at: http://www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf. Accessed May 23, 2013.
Faculty of the Royal College of Obstetricians and Gynaecologists. UK medical eligibility for contraceptive use. 2009. Available at: http://www.fsrh.org/pdfs/UKMEC2009.pdf. Accessed January 21, 2013.
Family Planning New South Wales. Family Planning New South Wales. Family Planning Queensland Family Planning Victoria, Contraception: an Australian clinical practice handbook. 3rd edn. Queensland: 2012.
], which are broadly based on the WHO recommendations. All of these have relaxed recommendations regarding IUC use in nulliparous women and adolescents and after first- or second-trimester abortions. However, some national guidelines have been slow to acknowledge the evidence supporting use of IUC in nulliparous women; for example, the German guidelines continue to regard IUC as a second choice for nulliparous women [
Gemeinsamen Bundesausschusses. Richtlinie des Gemeinsamen Bundesausschusses zur Empfängnisregelung und zum Schwangerschaftsabbruch. Bundesanzeiger Nr. 60a. 1985. Available at: http://www.g-ba.de/informationen/richtlinien/9/.
There are also variations between countries in the package inserts for different intrauterine contraceptives. For example, in the US, although the package insert for the copper IUD (ParaGard®) was revised significantly in 2005 (the restrictive “recommended patient profile” was removed entirely), the current package insert for the LNG-IUS (Mirena®) does not support use in nulliparous women; the insert recommends use in “women who have had at least one child” [
There are between-country divergences in preplacement screening practices that are not always evidence based but are driven by local recommendations. One example of such a divergence is the use of preplacement screening for sexually transmitted infections (STIs). In the US, the ACOG guidelines state that for a woman at high risk of STIs (e.g., aged ≤25 years or with multiple sexual partners), it is reasonable to screen for STIs and then place the IUC on the same day (and subsequently treat the infection if the results are positive) or alternatively wait until the test results are available before placing IUC [
]. In the UK, National Institute for Health and Clinical Excellence guidance recommends that women “at risk of STIs” should be tested for chlamydia and gonorrhea (if the woman lives in an area where gonorrhea is prevalent) before placement of IUC and, if STI screening is not possible, antibiotic prophylaxis should be given before IUC placement [
National Collaborating Centre for Women's and Children's Health, National Institute for Health and Clinical Excellence. Long-acting reversible contraception: The effective and appropriate use of long-acting reversible contraception. 2005.
Guidelines regarding cervical cancer screening requirements before IUC placement also vary between countries. For example, in Germany, a Pap smear within 6 months of placement is mandatory [
Gemeinsamen Bundesausschusses. Richtlinie des Gemeinsamen Bundesausschusses zur Empfängnisregelung und zum Schwangerschaftsabbruch. Bundesanzeiger Nr. 60a. 1985. Available at: http://www.g-ba.de/informationen/richtlinien/9/.
National Collaborating Centre for Women's and Children's Health, National Institute for Health and Clinical Excellence. Long-acting reversible contraception: The effective and appropriate use of long-acting reversible contraception. 2005.
]. These examples should give an impression how national guidelines as well as country-specific labeling are likely to contribute to diversity of practice.
3.9 Limitations
Unfortunately, we could not explore all barriers and country-specific reasons, as there are very complicated and sometimes not well-documented factors related to political, religious or other beliefs.
4. Conclusions
There is considerable variation between continents and countries in the rates of IUC use and the types of device that are used. Multiple factors contribute to this variability, including government policy, funding for contraception, types of HCP involved in IUC placement and types of clinics that provide IUC services. In addition, the geographic distribution of clinics providing IUC services (e.g., lack of access in rural areas), differences in how IUC services are funded and misperceptions regarding the unsuitability of IUC for certain groups of women appear to have a substantial impact on IUC use. The religious and sociocultural sensitivities in different countries also create environments that are more or less favorable to IUC use.
Our review shows that in practice the use of IUC is influenced more by factors including geographic differences, government policy and the HCP's educational level than by medical eligibility criteria. In order to increase the use of IUC methods, which are both highly effective and highly cost-effective, a program of HCP education and health policy changes will need to occur in those countries where low rates of IUC uptake are documented. The US and the UK have already recognized a need to increase IUC use and have developed national evidence-based guidelines [
National Collaborating Centre for Women's and Children's Health, National Institute for Health and Clinical Excellence. Long-acting reversible contraception: The effective and appropriate use of long-acting reversible contraception. 2005.
]. Globally, a compelling reason for governments and health care systems to reduce the diversity in access to IUC is to make them aware that IUC is among the most cost-effective methods available [
LARC Guideline Development Group The cost-effectiveness of long-acting reversible contraceptive methods in the UK: analysis based on a decision-analytic model developed for a National Institute for Health and Clinical Excellence (NICE) clinical practice guideline.
National Collaborating Centre for Women's and Children's Health, National Institute for Health and Clinical Excellence. Long-acting reversible contraception: The effective and appropriate use of long-acting reversible contraception. 2005.
Australian Government Department for Health and Aging. Pharmaceutical Benefits Scheme (PBS). 2013. Available at: http://www.pbs.gov.au/medicine/item/8633J. Accessed February 20, 2013.
Centers for Disease Control and Prevention. MMWR early release: U.S. medical eligibility criteria for contraceptive use. 59. 2010. Available at: http://www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf. Accessed May 23, 2013.
Faculty of the Royal College of Obstetricians and Gynaecologists. UK medical eligibility for contraceptive use. 2009. Available at: http://www.fsrh.org/pdfs/UKMEC2009.pdf. Accessed January 21, 2013.
Family Planning New South Wales. Family Planning New South Wales. Family Planning Queensland Family Planning Victoria, Contraception: an Australian clinical practice handbook. 3rd edn. Queensland: 2012.
Gemeinsamen Bundesausschusses. Richtlinie des Gemeinsamen Bundesausschusses zur Empfängnisregelung und zum Schwangerschaftsabbruch. Bundesanzeiger Nr. 60a. 1985. Available at: http://www.g-ba.de/informationen/richtlinien/9/.
The cost-effectiveness of long-acting reversible contraceptive methods in the UK: analysis based on a decision-analytic model developed for a National Institute for Health and Clinical Excellence (NICE) clinical practice guideline.
☆☆Declaration of interest: All authors are members of the INTRA group, an independent panel of physicians with expert interest in intrauterine contraception, the formation of which was facilitated by Bayer HealthCare. This publication and its content were solely the responsibility of the authors. They received editorial support, which was paid for by Bayer HealthCare. In addition, all authors had acted as consultants to Bayer HealthCare and received consultancy honoraria.
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