8th Postgraduate Course for Training in Reproductive Medicine and Reproductive Biology

Reproductive Health in Hungary

Zoltàn Borthaiser, Attila Kereszturi
Albert Szent-Györgyi Medical University
Department of Obstetrics and Gynaecology
Szeged, Hungary
Director: Prof. Làszlo Kovàcs

in collaboration with the

Geneva WHO Collaborating Centre for Research in Human Reproduction

Contents

1. Introduction

1.1 History

1.2 Political and economical aspects

2. Background

2.1 Demographic data

2.2 Women’s perspectives and life styles

3. Government strategies

4. Reproductive health services

4.1 Structure

4.2 Definition of reproductive health periods

4.3 Components of reproductive health

5. Reproductive health situation in Hungary

5.1 Maternal health and safe pregnancy

5.2 Family planning

5.3 New-born care

5.4 Screening of genital cancer

5.5 Post-reproductive health

6. Perspectives for the future

List of annexes

Annex 1 - Population in Hungary

Annex 2 - Outcome of pregnancies in Hungary

Annex 3 - Maternal mortality in Hungary

Abbreviations

1. Introduction

1.1 History

The mother and infant health care has an old tradition in Hungary. Igancz Semmelweis was the first well-known physician who strove to defeat puerperal sepsis. The first easy-to-survey obstetrical statistics were initiated by Vilmos Tauffer in 1892. This statistical methods have served as a basis for Hungarian obstetrical statistics for more than one hundred years.

1.2 Political and economical aspects

During the socialist government many laws and programs were created to increase the birth rate, but have only been partially successful. Most of these laws are still valid e.g. :maternity support, child welfare support etc. The unequal socio-economic status within the Hungarian population was more obvious after the break up of the socialist regime and this decreased its influence on reproductive health in Hungary. Nowadays, one part of the population is living in good social conditions,similar to western-Europeans. civil. The other part of Hungarian population lives in low social conditions, mostly in villages.
The women's workforce was very important after the second world war and was strongly supported by the socialist government. Several generations have lived these circumstances since that time. Many divorces and broken up families resulted by the overworked way of life. The educational and FP problems, which established during that time are characteristic for both parts of the population.

2. Background

2.l Demographic data

The number of live births (LB) decreased significantly in the last few years in Hungary. This is probably due to the financial uncertainty of families who formed during the change of the regime. The extensive decrease of LB appears in the population belonging to a higher socioeconomic status. Families with one or two children are common in this group. Big families (6-8 children) are not rare in the lower socioeconomic population group. This is based on the ethnical traditions. This process has just weakened the financial position of these families and the state has been in charge for the up-bringing and education of some of these children.

Nowadays, the number of the Hungarian population is decreasing. In 1990, 10.374.823 inhabitants were reported, in 1997 this number decreased to 10.174.442 (Annex 1). The number of LB decreased in the population, this can be seen in the number of LB per 1.000 inhabitants (Annex1). The percentage of women at reproductive age (WRA: women 15-49 years old) is about 25% of the total population (Annex1 ). The increasing number of elderly people is one of the characteristics of Hungarian population.

2.2 Women’s perspectives and life styles

In Hungary, the female life expectancy at birth was 74.7 yr. and male life expectancy at birth was 66.06 years in 1996 and women are already emancipated in legal, cultural and educational aspects.

The rather unhealthy nourishment and the insufficient physical exercise are important characteristics of Hungarian people. This is valid for the population of WRA as well.

The treatment of diseases which are due to the unhealthy life style (cardiovascular diseases, obesity, diabetes mellitus) are the most serious medical problems in Hungary.

3. Government strategies

The increase population size has been supported by the Hungarian government by introducing laws which tended to increase the population number and financially support families with children, mainly with children less than 14 years old. The place of a professional mother is established: mothers who have three or more children receive a salary. However, we can feel some discrepancy between these laws and the health service. The health establishments are financed from the fund of Health Insurance in Hungary. Only the treatment of diseases is covered by the Health Insurance which excludes pregnancy. Therefore, Hungarian women have to pay for interruption of pregnancy, for sterilisation, contraceptive pills and IUDs. It was discussed that the Health Insurance wants to stop financing prenatal care. This has to be considered a very dangerous process, taking into account that many pregnant women will not be able to cover the expenses for antenatal care and will therefore not attend the clinics.

4. Reproductive health services

4.1 Structure

First level care:

• Prenatal care services
• Public run health centres in rural zones
• General practitioner or family physician
• Mother and child consulting centres in districts
• Private specialists (obstetricians/gynecologists)
• Outpatient clinics for menopausal women

Second level care

District hospitals with obstetric/gynecology and paediatric departments

Third level care

University hospital with obstetrics/gynecology and pediatric departments

4.2 Definition of reproductive health periods

• Period of the pre-reproductive health, which corresponds to adolescent age.
• Period of the reproductive health, which includes:
  maternal period: prenatal, delivery, postnatal, postpartum and breast feeding period.
  intervals between deliveries
• Period of post reproductive health, which corresponds to menopause and andropause.

4.3 Components of reproductive health

• Improvement of RH education in school
• Increased knowledge of STD and contraception
• Prevention of inadequate sexual behaviours
• Safe abortion

• Pre-conception counselling
• Prevention of abortion
• Post-partum and post-abortion counselling
• Safe abortion
• Information, application and counselling on different contraceptive methods
• Follow-up contraceptive side effects and complications
• Providing of modern contraceptive methods
• Sexuality
• Infertility

• Pre-conception
• Prenatal care
• Decrease of pre-term and low birth weight babies
• Care during labour
• Postnatal care
• Promotion of breast-feeding
• Reduced perinatal mortality
• Reduced maternal mortality
• Reduced obstetric and neonatal complications

• Improving the knowledge and education on nourishment
• Reduced anaemia during pregnancy
• Promotion of breast-feeding

• Reduction of neonatal mortality and morbidity
• Reduction of neonatal infections after delivery
• Improvement of early neonatal intensive care
• Promoting exclusive breast-feeding

• Prevention, treatment and counselling on STD/AIDS
• Reduction of gynaecological disease complications

• Prevention and treatment of menopause disorders

5. Reproductive health situation in Hungary

5.1 Maternal health and safe pregnancy

More than 94% of the pregnant women in Hungary attend antenatal care services. The prenatal care services assessing pregnant women, are found in every big area with mobile services available in smaller villages. Attendency of prenatal care service is not compulsory, but financial support for the mother will be paid if she visits antenatal care clinic. Screening for gestational diabetes, FPH gestosis, IUGR and other risc factors are performed by the Perinatal Care Service and women will be treated by the second level of RH if necessary. Fetal monitoring is a routine task provided by the clinic.

There is close co-operation between this system and the Visiting Nurse Service (VNS) in Hungary. The VNS was founded in 1916. The nurses prepare the pregnant women for their delivery and they instruct the women on infant-care and child welfare.

Maternal mortality ratio, being one of the most sensitive indicators of women’s health, is one of the lowest in Central and Eastern Europe (Annex 3). In 1996, 33% of all maternal deaths were due to abortions.

5.2 Family planning

The modern FP methods are well known and accepted in Hungary. There exist only partial or estimated data because there are no national statistics about the use of contraceptive methods in Hungary. The OC is the most wide-spread method in the whole country. A increase in IUD use has been observed, because the women are often afraid of OC complications. The increased use of condoms is likely due to the AIDS-propaganda and recently the use of traditional or natural methods is more preferred. Oral contraceptives are only available in clinics and pharmacies. IUD insertion is only performed in hospitals, and sterilisation is strictly only permitted for men and women over 40 years of age, for those over 35 years with three children, or over 30 years with four children.

Interruption of pregnancy is legal and performed upon request up to 12 weeks of pregnancy, if there is a risk to the woman’s life, a risk of having a disabled child and in case of an unwanted pregnancy. Abortion is performed up to 24 weeks of pregnancy if there is an acute risk for the woman’s life or intrauterine death or suspected genetic defect. An abortion costs about US $ 60. The law on legal abortion stipulates that abortion is not a family planning method.

77.000 abortions are officially induced during one year. 15 % of all abortions in Hungary are performed in adolescent girls (14-19 years) (Annex 2). The method of interruption of early pregnancies (less than 12 weeks) are dilatation and aspiration.

5.3 New-born care

99% of births are assessed by trained medical staff in Hungary. Recently, there was a claim to family delivery, mainly in big cities. The hospitals and other delivery rooms are prepared also for the presence of the father or other members of family during the birth process. Home-delivery is not widely practised.

The perinatal mortality rate is decreased in the last years (Annex 2). This result is due to a the work of the Prenatal Care Service and delivery rooms. The data of the perinatal mortality rates are not comparable with other countries statistics, because in Hungary the perinatal period was defined as starting from 28 weeks of gestation till the 7th day of life.

The number of new-borns with low birth weight (less than 2500 grams) also decreased in the last few years (Annex 2). The duration of hospital staying for healthy babies is usually 5 days. The babies usually stay inneonatal departments which are in close connection with the delivery rooms. Babies with different pathologies or congenital problems are transferred to the regional perinatal intensive centres.

5.4 Screening of genital cancer

Breast, colon and rectum cancer have the highest morbidity in women in Hungary. All women examined by gynaecologists are also screened for cervical cancer, as the gynaecologist is obliged to take a cytological smear. This has helped to diagnose this malignant pathology at an early stage, even in symptom-free patients. The services that provide screening of genital cancers are placed in specialised polyclinics of some cities of the country, in gynaecological hospitals and in services of gynaecological oncology.

5.5 Post-reproductive health

The care for women after menopause is performed in the outpatient clinics for menopausal women, at the first level of the health care system.

6. Perspectives for the future

Annex 1.

Population in Hungary

Proportion of women in reproductive age (15-49 years)

Life expectancy at birth (in years)

Proportion of live births / 100.000 habitants

Annex 2.

Pregnancy outcomes

Induced abortions in Hungary

Perinatal mortality rate

Low birthweight infants in Hungary

Annex 3

Maternal Mortality in Hungary

Maternal mortality rate = number of maternal deaths/100000 women 15-19

Maternal mortality ratio as obstetric risk = number of maternal deaths/100000 live births

Maternal mortality ratio as risk of pregnancy  =  number of maternal deaths/100000 pregnancies

* deaths caused by complications of pregnancy, abortion, delivery and puerperium.

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Edited by Aldo Campana,