1. Series 1 Diversity of practice: provision and uptake of intrauterine contraception (IUC) worldwide

2. INTRA group: Intrauterine coNtraception: Translating Research into Action  A panel of independent physicians with expert interest in intrauterine contraception –Formation of the INTRA group and its ongoing work is supported by Bayer Pharma  Purpose: –To encourage more widespread use of IUC methods in a broad range of women through medical education

3. Core Slide Kit: Terms of use  If any adjustments are made to the originals, neither Bayer Pharma nor the INTRA Group can accept responsibility whatsoever for their content. –If you make changes you should not use the INTRA slide template.  When using any of these slides, even if you modify them in some way, please acknowledge to your audience that the original slides were provided by the INTRA Group: –“The global INTRA group is a panel of independent physicians with expert interest in intrauterine contraception. Formation of the INTRA group and its ongoing work is supported by Bayer Pharma”.  You may select any combination of slides to present on to others; however, the context of the slides should be maintained wherever possible.  Please be aware that recommendations and regulations around communications on contraception as well as product labels vary globally, and ensure that the content and recommendations included in the slides are aligned to the local regulations and product labels of the country where you are presenting.

4. In this series:  Variation in prevalence of IUC use  Practitioner variation  Variation in the numbers of providers with the appropriate skill set  Local variation in practices

5. VARIATION IN PREVALENCE OF IUC USE

6. Wide global variation in prevalence of IUC use Women (%) 1.United Nations, 2011 2.Bühling et al 2014 Prevalence of IUC use among women aged 15–49 years, married or in union*: variation between continents 1,2 Contraceptors: women using any form of contraception *Prevalence of IUC use among women aged 15−49 years, married or in union. IUC is also suitable for single women, but this group of users is not captured in available data.

7. Variation in prevalence of IUC use* within Africa 1 Area of AfricaWomen aged 15–49 years, married or in union (%) Using any method of contraception Using any modern method of contraception Using IUC Sub-Saharan21.815.70.5 Northern (excl. Sudan)60.554.022.3 Eastern28.422.90.5 Middle18.66.60.2 Northern50.444.818.1 Southern58.458.11.1 Western14.48.70.7 *Prevalence of IUC use among women aged 15−49 years, married or in union. IUC is also suitable for single women, but this group of users is not captured in available data. 1.Bühling et al 2014

8. Prevalence of IUC use* within Asia  Extremely wide regional variation in prevalence of IUC use: –Lowest prevalence in Southern Asia (2.0%) 1 –Highest prevalence in Central Asia (41.5%) 1  With regard to individual Asian countries 2 : –Highest prevalence: China (40.6%), Democratic People’s Republic of Korea (42.8%) and Vietnam (43.7%) –Lowest prevalence: Nepal (0.7%), the Maldives (0.8%), Bangladesh (0.9%), Afghanistan (1.0%), Myanmar (1.8%) and Cambodia (1.8%) *Prevalence of IUC use among women aged 15−49 years, married or in union. IUC is also suitable for single women, but this group of users is not captured in available data. 1.Bühling et al 2014 2.United Nations, 2011

9. Variation in prevalence of IUC use* within Europe 1,2 Area of EuropeWomen aged 15–49 years, married or in union (%) Using any method of contraception Using any modern method of contraception Using IUC Eastern74.954.316.3 Northern80.177.211.9 Southern63.846.35.7 Western71.968.611.4 *Prevalence of IUC use among women aged 15−49 years, married or in union. IUC is also suitable for single women, but this group of users is not captured in available data. 1.Bühling et al 2014 2.United Nations, 2011

10. Prevalence of IUC use* within Europe 1 France 22.7% Northern Europe Germany 5.3% Estonia 35.9% Latvia 28.0% Finland 25.8% Norway 23.3% Sweden 16.2% Ireland 8.4% Belarus 25.7% Moldova 25.2% Romania 6.7% Slovenia 22.9% Macedonia 0.4% Eastern Europe Southern Europe Western Europe Netherlands 8.0% Switzerland 6.0% Portugal 7.3% Spain 6.4% Italy 5.8% Greece 3.6% UK 10.0% Poland 8.4% Czech Republic 13.9% Highest prevalence: Eastern Europe (16.3%) Lowest prevalence: Southern Europe (5.7%) *Prevalence of IUC use among women aged 15−49 years, married or in union. IUC is also suitable for single women, but this group of users is not captured in available data. 1.United Nations, 2011

11. Prevalence of IUC use* within North America  Prevalence of IUC use has increased over recent years 1 –5.3% in the US –1.0% in Canada  Rates of IUC use in the US are influenced by ethnicity –Hispanic women are more likely to use IUC than Caucasians 2 1.United Nations, 2011; 2.Mosher, 2010 *Prevalence of IUC use among women aged 15−49 years, married or in union. IUC is also suitable for single women, but this group of users is not captured in available data.

12. Variation in prevalence of IUC use* within Latin America and Caribbean Area of Latin America and Caribbean Women aged 15–49 years, married or in union (%) Using any method of contraception Using any modern method of contraception Using IUC Caribbean61.657.011.3 Central America68.263.09.6 South America76.169.65.5 *Prevalence of IUC use among women aged 15−49 years, married or in union. IUC is also suitable for single women, but this group of users is not captured in available data. 1.Bühling et al 2014

13. Variation in prevalence of IUC use* within Latin America *Prevalence of IUC use among women aged 15−49 years, married or in union. IUC is also suitable for single women, but this group of users is not captured in available data. Argentina 9.5% Bolivia 8.4% Brazil 1.9% Chile 18.9% Colombia 11.2% Ecuador 10.1% Guyana 7.3% Paraguay 12.3% Uruguay 12.3% Peru 3.8% Suriname 1.5% Venezuela 9.5% Mexico 11.6% 1.United Nations, 2011

14. Prevalence of IUC use* within Latin America  Higher prevalence in Central America (9.6%) versus South America (5.5%)  Central America –Highest prevalence: Mexico (11.6%), Costa Rica (6.9%), Honduras (6.6%) and Panama (6.0%) –Lowest prevalence: El Salvador (0.8%), Guatemala (1.9%) and Nicaragua (3.4%)  South America –Highest prevalence: Chile (18.9%), Paraguay (12.3%) and Uruguay (12.3%) –Lowest prevalence: Suriname (1.5%), Brazil (1.9%) and Peru (3.8%) *Prevalence of IUC use among women aged 15−49 years, married or in union. IUC is also suitable for single women, but this group of users is not captured in available data. 1.United Nations, 2011

15. Worldwide distribution of IUC users is not uniform 1  83% of the world’s users of IUC are in Asia 1,2  Almost two-thirds (64%) of the world’s IUC users are in China alone 1 –The majority of women in Asia use non- hormonal methods (stainless steel and copper IUDs) 3 Europe 8% Africa 4% Oceania 0.03% North America 1% Asia 83% Latin America & Caribbean 4% 1.Bühling et al 2014 2.United Nations, 2011 3.Cheung, 2010

16. Reasons for geographical variation in IUC use 1 Positive or negative influence on IUC uptake Types of providers authorised and the locations at which women can access IUC Funding models and variation in cost (to women) Medico-legal environment Differences in clinical practices Availability of HCPs with the appropriate skill set (availability of practical training for HCPs) The types of devices that are available in different countries 1.Bühling et al 2014

17. PRACTITIONER VARIATION

18. Providers of IUC services, by country 1 Provider CountryOB/GYN FP physician or GP Nurse, midwife or other provider Europe Germany UK France Sweden The Netherlands North America USA Canada 1.Bühling et al 2014

19. Providers of IUC services, by country 1 Provider CountryOB/GYN FP physician or GP Nurse, midwife or other provider Latin America Mexico Costa Rica Colombia Argentina Brazil Asia/Asia-Pacific China India Australia 1.Bühling et al 2014

20. Locations for IUC services, by country 1 Location Country Provider’s office Sexual health, contraception or youth clinic Abortion clinic Hospital- based community clinic Europe Germany UK France Sweden The Netherlands North America USA Canada 1.Bühling et al 2014

21. Locations for IUC services, by country 1 Location Country Provider’s office Sexual health, contraception or youth clinic Abortion clinic Hospital- based community clinic Latin America Mexico Costa Rica Colombia Argentina Brazil Asia/Asia-Pacific China India Australia 1.Bühling et al 2014

22. Providers and locations of IUC services influence uptake GermanyFrance Providers: OB/GYN only 1 Locations: Providers office only 1 Providers: OB/GYN, FP physicians, GPs, nurses, midwives 1 Locations: Providers office, sexual health, contraception or youth clinic, abortion clinic, hospital-based community clinic 1 IUC utilisation: 5.3% 2 IUC utilisation: 22.7% 2 Expanding the types of HCPs and range of locations increases utilisation 1.Bühling et al 2014 2.United Nations, 2011

23. Case study 1: impact of authorising midwives on IUC uptake in Turkey 1 Initial attempts to extend access to IUC to rural areas via mobile clinics failed owing to difficulties in providing adequate post-placement follow-up care Turkish government conducted a study to assess whether local midwives could safely place and remove IUC devices Based on the results of this study, local midwives were authorised to offer IUC services A steady and sustained increase in IUC uptake was achieved over the following decade 1.d’Arcangues, 2007

24. Case study 2: impact of authorising GPs on IUC uptake in Egypt 1  IUC services used to be provided only by OB/GYNs  Since the mid-1980s, a steady increase in IUC use has been achieved  This was in part due to the following: –Authorising GPs to perform placements and removals –Careful attention to the training and certification of the new providers 1.d’Arcangues, 2007

25. VARIATION IN THE NUMBERS OF PROVIDERS WITH THE APPROPRIATE SKILL SET

26. A paucity of adequately trained providers limits IUC uptake 1 Not enough expert providers offer placement training (long waiting lists for training places in some countries) Insufficient providers with the necessary skill set to offer an IUC placement service Women may face long waiting lists for IUC placements Women who would otherwise have chosen IUC opt for other more immediately available methods 1.Black et al. 2012

27. Factors limiting the number of trained providers Both scenarios lead to shortages of providers with the necessary skills to perform IUC placements Scenario 1: paucity of trainers: experienced providers may be reluctant to offer training to others for fear that they may lose an important source of income 1 Scenario 2: some healthcare systems indirectly discourage HCPs from developing IUC placement skills: referral systems may make it advantageous for providers to refer rather than provide a placement service themselves 1 1.Black et al. 2012

28. VARIATION IN THE DEVICES AVAILABLE AND THE COST TO WOMEN

29. Types of devices available globally CountryLNG-IUS Copper IUDs (number of devices) Stainless steel IUD 12–1010+ Argentina Australia Brazil Canada China Colombia France Germany Mexico The Netherlands New Zealand Sweden UK USA 1.Bühling et al 2014

30. Reimbursement for IUC varies globally (1)  Reimbursement for IUC either by government or private insurance varies between countries –In some countries, for example the UK, both copper IUDs and Mirena are fully reimbursed and are free to women –In some countries, only copper IUDs are free to women  In Colombia and Mexico, copper IUDs are free of charge in public clinics 1  In New Zealand, copper IUDs are free to women but Mirena is not 1,2 –In some countries, Mirena is reimbursed and is free to women  In Australia, Mirena is partially subsidised by the government 1,2 –In some countries, certain subsets of women receive reimbursement for IUC  In France, for women <18 years of age, IUD cost and the placement procedure can be free in family planning clinics 2  In Germany, IUC is reimbursed by public and private insurances for women with HMB and those with certain illnesses that contraindicate use of COCs and POPs 2  In Sweden, Mirena can be subsidised for young women and in two counties all contraceptive methods are free for women under the age of 23 or 25 years 2 1.Black et al 2012; 2.Bühling et al 2014

31. Reimbursement for IUC varies globally (2)  Reimbursement for the IUC placement procedure either by government or private insurance varies between countries –In some countries, women do not have to pay for the IUC placement procedure  In France, IUC placement is reimbursed up to 65% by public insurance and 35% by private insurance (approximately 90% of the French population receive complementary private insurance) 1.Bühling et al 2014

32. Other intrauterine devices available in Asia 1 Frameless copper device GyneFix Combined stainless steel and copper devices Uterine-shaped IUD Gamma Cu 380 IUD Framed copper devices Flexi T Cu AiMu Mcu Stainless steel rings Single ring Double ring 1.Cheung 2010

33. LOCAL VARIATION IN CLINICAL PRACTICES

34. Product labelling in certain countries is more restrictive than international Medical Eligibility Criteria 1–4 The Mirena package insert is more restrictive than supported by evidence German product labelling is as a ‘second choice for nulliparae’ Recommended patient profile: a parous woman in a stable, long-term relationship Extensive list of contraindications HCPs infrequently recommend IUC to women, particularly those who are nulliparous or adolescent 1.WHO MEC, 2010; 2.US MEC, 2010; 3.UK MEC, 2009 4.Lyus, 2009;

35. Guidelines: variation in pre-insertion screening requirements may influence IUC uptake accordingly STI screening Cervical cancer screening UK Pre-placement Pap smears are not mandated 1 US Can screen for STIs and place IUC on the same day and treat any positive result in situ 4 UK High-risk women should be tested for STIs prior to placement, but if not possible, antibiotic prophylaxis should be given 1 Australia Screening recommended in higher risk groups e.g sexually active women younger than 25 years old 3 Germany Pap smear within 6 months of placement is mandatory 2 1.NICE 2005 2.German guidelines 1985 3.Family Planning NSW 2011 4.ACOG 2011

36. Conclusion  There is a wide variation in continental, regional and global IUC use –Global distribution of use is uneven with highest use in Asia (83%)  EU (8%), Africa (4%), Oceania (0.03%), North America (1%), Latin America and Carribean (4%) –Factors influencing this wide variation includes:  The types of devices available  Access to treatment  Differences in funding methods  Differences in clinical practice and lack of skillset  Medico-legal environment –Subsequently, there is a local variation in product labelling and pre-insertion screening recommendations which might influence IUC uptake accordingly