17% 2% USA India Bangladesh 5% Other Countries Indonesia ...

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Family planning

Dr. Shweta Mangal Professor,

Community Medicine

Demographic Trends of The World

• World Population in the Year 1800 → 1 Billion

• 2nd Billion Added in just 130 years

• 3rd in 30 years

• 4th in 15 years

• 5th & 6th in 12 Years

• Projected 8 billion in year 2025

10 Most Popular Countries of The World

China

21%

India

17%

USA

5%

Indonesia

3%

Brazil

3%

Pakistan

3%

Russia

2%

Bangladesh

2%

Japan

2%

Nigeria

2%

Other Countries

40%

China

India

USA

Indonesia

Brazil

Pakistan

Russia

Bangladesh

Japan

Nigeria

Other Countries

Demographic Trends In India

➢Crossed 1 billion mark on 11th May 2000

➢2nd most populous country next to China

➢Has 16.87% of the world population; but <3% of land

➢India’s Population currently Increasing @ 16 million/ year

➢Projected Population By The Year 2050 → 1.53 Billion

➢Expected to exceed China’s population by year 2030

➢Last century growth - world 3 times; but India 5 times

➢Population Distribution in India is not Homogenous

Fertility

• Fertility means the actual bearing of children by women

in reproductive age group.

• Average Indian woman gives birth to an average of six

to seven children if her married life is uninterrupted.

• The level of fertility in India is beginning to decline.

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Fertility

This high fertility rate in India is due to following:

➢ Marriage: Universality of marriage; Lower age of marriage –

Sarada/Child marriage restrain act; Duration of married life

➢ Illiteracy; Low economic status

➢ Caste, Religion and customs

➢ Inadequate nutrition

➢ Limited use of family planning measures

➢ Other like place of women in society, value of children in

society, breast feeding, customs and beliefs, health

condition & housing, industrialization & urbanization

Fertility indicators

• Birth rate: no. of live birth per 1000 mid year population

• Death rate: no. of deaths per 1000 mid year population

• Gen. fertility rate: no. of live birth per 1000 WRA in a yr

• Gen. marital fertility rate: per 1000 MWRA in a yr

• Age specific marital fertility rate:

• Total fertility rate: average no. of children a woman would have if she was to pass through her reproductive years bearing children at the same rate as the women in each group

• Total marital fertility rate:

• Gross reproduction rate: average no. of girls a woman would have if she experience the current fertility pattern throughout her reproductive age assuming no mortality

• Net reproductive rate:

Small Family Norm

• The currant emphasis is on three themes

– ‘Sons or daughters - two will do’

– Second child after 3 years and

– Universal immunization .

• Fertility Rate has declined from 6.4 in 1950 to 3.1 in 2002

• Current NRR – 1.48 (2001)

• NRR <1 means reproduction below replacement level

• To reach the National Goal of NRR =1 the “Two Child

Family” norm is to be achieved.

Family Planning

WHO Definition

• A way of thinking & living that is adopted voluntarily

upon the basis of knowledge, attitudes & responsible

decision by individuals & couples in order to promote

the health & welfare of family group and thus contribute

effectively to the social development of the country.

History of family planning

• 1951: Family planning programme – clinic approach

• 1976: forcible sterilization approach

• 1977: Family welfare approach – no compulsion

• Target free approach

• Community need assessment approach in RCH

• Cafeteria approach

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The Welfare Concept

• Previous belief – family planning is all about sterilization

or birth control; because of injudicious Govt policies &

their strict implementation.

• But its name changed to Family Welfare programme

• Aims at achieving a higher end that is to improve the

quality of life of the people.

• The United Nations Conference on Human Rights at

Teheran in 1968 - Family Planning a basic Human Right.

Objectives of family planning

➢ To Avoid unwanted births

➢ To bring about wanted births

➢ To regulate the intervals between pregnancy

➢ To control time at which births occur in relation to

the ages of the parents

➢ To determine the no. of the children in the family

Scope of Family Planning Services

➢ Birth Control

➢ Proper Spacing of Birth

➢ Advise on Sterility

➢ Education For Parenthood

➢ Sex Education

➢ Screening For Diseases

➢ Genetic Counseling

Target couple v/s Eligible couples

• Target couples : Couples who have had 2-3 living

children; family planning largely directed to such couple

• Eligible couple: Currently married couple wherein the

wife is in the reproductive age group of 15 to 45 years.

• “Target couple” older concept; while “Eligible couple”

is newer concept

• 150-180 eligible couple per 1000 population

• 20% of eligible couples are in the age gr of 15-24 yrs

• 170 million at present + 2.5 millions are added per year

Couple Protection Rate

• Definition : Percentage of eligible couples protected

effectively against child birth by one or the other

approved method of family planning viz, sterilization,

IUD, Condoms or oral pills.

• An indicator of the prevalence of contraceptive practices

in the community.

• Goal is to achieve 60% of CPR as a mean of achieving

NRR=1 or TFR=2.1 or completed family size of 2

• Present CPR in India 46.2% (2002)

Types of contraceptives

I. Spacing methods:

1. Barrier methods

a) Physical methods

b) Chemical methods

c) Combined methods

2. Intra-uterine devices

3. Hormonal contraceptives

4. Post conceptional methods

5. Miscellaneous

II. Terminal methods:

1. Male sterilization.

2. Female sterilization.

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Various contraceptive methods Some terms related to contraception

• Conventional contraceptives: methods that require

action at the time of sexual intercourse. e.g. condom,

spermicides etc.

• Traditional methods: for example withdrawal and

rhythm method etc.

• Modern methods: for example sterilization, OCP, IUD,

injectables, condoms, emergency contraceptives etc

Current use of contraceptive methods

• Current use of contraceptives by women in India:

– All India: 56.3%; Rural: 53.0%; Urban: 64.0%

– Modern methods: 86%; Traditional methods: 14%

– Permanent methods: 68%, Spacing methods: 32%

– Spacing method highest (14%) in 25-29 yrs age group

Barrier methods

• The aim of this method

is to prevent live sperm

from meeting the ovum.

• Requires high degree of

motivation

• Less effective than either

pill or the loop.

Barrier methods

Physical methods:

• Condom:

– Most widely known & used barrier

device by males around the world.

– Known as NIRODH

– Deluxe NIRODH & Super Deluxe

NIRODH

– Failure rate from 2-3% to >14%.

Advantages of condoms

1. Easily available.

2. Safe & inexpensive.

3. Easy to use, do not require medical supervision.

4. No side effect

5. Light, compact & disposable.

6. Provides protection not only against pregnancy but

also against STDs.

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Disadvantage of condoms

1. Slip off or tear during coitus due

to incorrect use.

2. Interferes with sex sensation.

3. Low compliance rate

4. Only for single use

5. High chance of incorrect use

Barrier methods

Physical method:

• Female condoms:

– A pouch made of polyurethane which lines the vagina

– Failure rate may very from 5 -21 % .

Barrier methods

Physical method:

• Diaphragm:

– Shallow cup made of synthetic rubber or plastic

– It is a vaginal barrier.

– Invented by German Physician in 1982 also known as

“DUTCH CAP”.

– Failure rates:

• 18-28% when used alone

• 6 -12% when used consistently and along spermicide

Advantages:

• Total absence of risk & medical contraindication.

Disadvantages:

• Initially a physician or trained person will be needed to demonstrate the technique

• After delivery it can be used only after involution of the uterus i.e. up to 6 weeks.

• It should be washed and stored carefully.

• Not suited for rural women, privacy required

• Failure to remove after use – toxic shock syndrome

Diaphragm

Vaginal sponge

• Small polyurethane foam sponge measuring 5 cm × 2.5

cm saturated with spermicide nonoxynol – 9 .

• Commercially marketed as “TODAY”.

• Failure rate is 20 – 40 % in multiparous & 9 - 20 % in

nulliparous.

Chemical methods

• In 1960s before the advent

of IUDs & OC, spermicides

were used widely.

• They comprises 4 categories

1. Foams : foam tablets &

foam aerosols.

2. Creams, jellies, & pastes.

3. Suppositories – inserted

manually.

4. Soluble films –c films

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• Insert before sex (up to 1 hour before)

• Insert deep into vagina using applicator or fingers

• Do not wash vagina for at least 6 hours after sex

• If possible, store in a cool, dry place

• They have high failure rate.

Disadvantages:

• They must be used immediately before intercourse & repeated before each act.

• Must be introduced into those region of vagina where sperms are likely to be deposited

• They may cause mild burning or irritation.

Chemical methods INTRA-UTERINE DEVICES:

• Two basic types:

1. Non medicated

2. Medicated

First generation IUDs:

• Comprise the inert or non medicated devices usually

made of polyethylene or other polymers.

• Appeared in different sizes & shapes – loops, spirals,

coils, rings, & bows.

• LIPPES LOOP:

– Exists in 4 sizes , A , B , C , & D .

Second generation IUDs:

• In 1970s , a new approach was tried by adding copper to IUDs.

• Copper has strong anti – fertility effect.

• Newer devices:

-T cu -220 c

-T cu -380A or Ag

-Nova –T

-ML –cu – 250

-ML -375

• Earlier devices-

-Copper – 7

-Copper T – 200

Advantages of copper devices:

1. Low expulsion rate.

2. Low incidence of side effects eg. Pain & bleeding.

3. Easier to fit in nulliparous women .

4. Better tolerated by nullipara.

5. Increased contraceptive effectiveness.

6. Effective as post coital contraceptive if inserted

within 3 – 5 days of unprotected intercourse.

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Third generation IUDs:

• It contain another principle i.e release of a hormone.

• Most widely used device is progestasert which is T

shaped device filled with 38 mg of progesteron.

• Hormone is released slowly in the uterus at the rate of

65 micro gms daily.

Mechanism of action of IUDs:

• IUD causes a foreign body reaction in the uterus

causing cellular & biochemical changes in the

endometrium & uterine fluids – these changes may

impair the viability of gametes & thus reduces its

chances of fertilization rather than its implantation.

• Copper seems to enhance the cellular response in the

endometrium, it also affects the enzymes in the uterus.

• By altering the biochemical composition of cervical

mucus, copper ions may affect sperm motility,

capicitation, & survival .

• Hormone releasing devices increases the viscosity of

cervical mucus & there by prevent sperm from entering

the cervix.

• They also maintain high level of progesterone in the

endometrium.

Mechanism of action of IUDs:Insertion of Speculum

Grasping of cervix with Volsellum

Sounding the uterus (length)

Insertion of loaded intra-uterine device

Withdrawal to release IUD

Advantages

1. Simplicity.

2. Insertion takes only few minutes

3. Once inserted IUDs stays in place as long as required.

4. Inexpensive.

5. Contraceptive effect is reversible by removal of

IUDs.

6. Free of systemic side effects associated with

hormonal pills.

7. Highest continuation rate

8. Only one act of motivation is required.

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Contraindication:

Absolute:

1. Suspected pregnancy.

2. PID

3. Vaginal bleeding of undiagnosed aetiology.

4. Ca cervix, uterus , or adenexia & other pelvic

tumours.

5. Previous ectopic pregnancy.

Contraindications:

Relative:

1. Anaemia

2. Menorrhagia

3. h/o of PID since last pregnancy.

4. Purulent vaginal discharge.

5. Distortion of uterus due to congenital malformation

or fibroids.

6. Unmotivated person.

Timing of insertion

• Most ideal time of insertion – during menstruation or

within 10 days of beginning of menses

• Post puerperal insertion – 6-8 wks after delivery

• Concurrently with 1st trimester MTP

• After 1st menses following spont./med./2nd trimester ab

• Within 5 days of unprotected sex as an emerg. Contra.

• Insertion is done by withdrawal method

• IUD need to change every 4-5 yrs

• An IUD should be checked after her “first menstrual

period” and thereafter every 6 months or 1 year interval

Side effects & Complication:

1. Bleeding

2. Pain

3. Uterine perforation

4. Pelvic infection

5. Pregnancy

6. Ectopic pregnancy

7. Expulsion

8. Fertility after removal

9. Cancer & teratoginicity

10. Mortality

Hormonal Contraceptives:

• More than 65 millions in the world are estimated to be taking the “pill” of which 10 millions from India.

• Classification

A. Oral pills

1. Combined pills

2. Progestogen only pills

3. Post –coital pills

4. Once a month pills

5. Male pill

B. Depot (slow release) formulation

• Injectables

• Subcutaneous implants

• Vaginal rings

ORAL PILLs

1. Combined pills:

• Entered in market in1960s contained 100 -200 micro gms of synthetic oestrogen & 10 mg of progesteron.

• At present 30 – 35 µg of synthetic oestrogen & 0.5 – 1 mg of progesteron .

• Types of pills:

• MALA-N & MALA-D: Contain norgesterol 0.3 mg & ethinil oestrodiol 0.03 mg

• MALA-N: Free supply

• MALD-D: 2 Rs per cycle

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Combined oral contraceptive pills

Price (MRP) of OC pills under Social Marketing Prog.:

1. Apsara - 1/3 - 4.00/10.00

2. Choice - 1 - 7.00

3. Julie - 1 - 5.00

4. Mala D - 1 - 2.00

5. Pearl – 1/3 - 5.00/10.00

6. Suvidha – 1/3 - 7.00/20.00

7. Khushi - 1 - 5.00

8. Hamjoli – 1/3 – 5.00/10.00

2. Progestogen only pills :

• “Mini pills” or “Micro pills”’ .

• Contains only progestogen which is given in small doses thorought the cycle

Advantages:

• Prescribed to older women for whom combined pill is contraindicated due to CVS risks.

• Prescribed to young women with risk factors for neoplasia.

3. Post –coital contraception:

• “Morning after” contraception recommended within 48 hrs of unprotected intercourse.

• Two methods: IUDs & Hormonal

• In past high doses of oestrogen (DES 50 mg daily)

• Yuzpe & Lancee method : Give a double dose of std combined pill when most pill contained 50 µg oestrogen, the recommended regimen was 2 pills immediately followed by another 2 pills 12 hrs later.

• Today's pill contain 30 – 35 µg oestrogen so given 4 tab immediately followed by 4 tab. Failure rate is <1% .

• Can insert a Cu IUD within 48-72 hrs

• LNG only pills 1.5 mg within 72 hrs

4. Once a month (long acting) pill:

• Quinestrol, a long acting oestrogen is given in

combination with a short acting progestogen.

• Pregnancy rate is too high & bleeding tends to be

irregular.

5. Male pill:

• Made of gossypol – a cotton seed oil .

• Is effective by producing azospermia or severe

oligospermia

• But as many as 10 % of men may be permanently

azoospermic after taking it for 6 months.

Mode of action of oral pills:

• Combined pill act by preventing the release of ovum from ovary by blocking pituitary gonodotropin secretion

• Renders the cervical mucus thick & scanty & thus preventing sperm penetration

• Progestogen also inhibits tubal motility & delay the transport of sperm & of the ovum to uterine cavity

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•Effectiveness :

• Taken according to present regimen OC of combined

type are almost 100 % effective

• In India the pregnancy rate is less than 1 %

• Effectiveness may also affected by certain drugs like

rifampicin, phenobarbiton, & ampicillin.

Adverse effects:

1) Cardiovascular effects:

• Mortality is due to myocardial infarction , cerebral

thrombosis , & venous thrombosis.

• Risk increased with age & cigarette smoking.

• Associated with oestrogen

2) Carcinogenesis :

• Increased risk of cervical cancer with increased

duration of oral contraceptives.

3) Metabolic effect :

a. Elevation of BP, decrease HDL, blood clotting &

ability to modify carbohydrates metabolism with

resultant elevation of blood glucose & plasma insulin.

Related to progestogen.

4) Other adverse effects :

a. Liver disorders: Hepatocellular adenoma & gall bladder disease

b. Lactation: High oestrogen affect quantity, constituent

of milk & causes premature cessation of lactation

Adverse effects:

4) Other adverse effects :

c. Subsequent fertility: Cause slight delay in conception.

d. Ectopic pregnancies: More common.

e. Foetal development: OC pills taken during may

increase the incidence of birth defects of foetus.

5) Common unwanted effects:

• Breast tenderness, weight gain, headache & migraine,

& bleeding disturbances .

Adverse effects: Beneficial effect :

• 100 % effectiveness in preventing pregnancy .

• Gives protection against 6 diseases:

– Benign breast disorders including fibrocystic disease

& fibroadenoma,

– Ovarian cysts,

– Iron deficiency anaemia ,

– PIDs,

– Ectopic pregnancy &

– Ovarian cancer.

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Contraindication of oral pills:

• Absolute :

1) Ca breast & genitals

2) Liver diseases

3) Thromboembolism

4) Cardiac abnormalities

5) Congenital hyperlipidaemia

6) Undiagnosed uterine bleeding

1) Age > 35 yrs

2) Mild hypertension & diabetes

3) Age > 40 yrs

4) Smoking Chronic renal disease

5) Migraine

6) Nursing mother in first 6 months

7) Epilepsy

8) Gall bladder disease

9) Infrequent bleeding

10) Amenorrhea

Relative:

Depot formulations:

• Three types

1. Injectable contraceptives

2. Subdermal implantss

3. Vaginal rings

Injectable contraceptives:

Two types

a) Progestogen only injectables

b) Combined injectables

DMPA (depot medroxyprogestrone acetate)

• Dose is 150 mg i. m. every three months

• Gives protection in 99% for at least 3 months

• Action is by suppression of ovulation

• Side effects: wt gain, irregular bleed, prolonged infertility

NET-EN (norethisterone enantate)

• Dose is 200 mg i.m. every 60 days.

C . I. of injectables: ca breast, all genital ca, undiagnosed abnormal uterine bleeding, suspected malignancy.

Injectable contraceptives:

Combined injectables:

• Contains both progestogen & oestrogen

• Action is by suppression of ovulation

• Gives at monthly intervals plus or minus 3 days.

• C.I. : confirmed or suspected pregnancy,

thromboembolism, cerebrovascular or CAD, focal

migraine, Ca breast, DM with vascular complication.

Subdermal implants

• “Norplant”.

• Consists of 6 silastic capsules

containing 35 mg (each) of

levonorgestrel.

• Silastic capsules are implanted

beneath the skin

• 3 year pregnancy rate is 0.7%

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Vaginal ring

• Contains levonorgestrel which is absorbed through the

vaginal mucosa

• The ring is worn in the vagina for 3 wks of the cycle &

removed for the fourth .

Miscellaneous :

1. Abstinence:

2. Coitus interruptus:

3. Safe period or Rhythm method: shortest cycle minus

18 days to longest cycle minus 10 days is fertile period.

4. Natural family planning methods :

• Basal body temperature (BBT)

• Cervical mucus method

• Symptothermic method: BBT+CMM+Rhythm

5. Breast feeding:

6. Birth control vaccine: HCG vaccine trials

Terminal methods:

• Male sterilization

– NSV fund provided by UNFPA

• Female sterilization

– Laparoscopy

– Minilap: No Gynaecologist, No anaesthtist, No pneumoperitoneum, Less post op stress

Male sterilization

• Simple surgical procedure

• Permanent.

• Men who will not want more children.

• Very effective

• Very safe

• No effect on sexual ability

• No protection against STIs or HIV/AIDS

• Afterwards:

– Take rest for 2 days

– Avoid heavy work for a few days

– Important! Use condoms for next 3 months

Female sterilization

• A surgical procedure

• Womb is NOT removed.

• Will still have menstrual period

• Permanent

• Women who will not want more children

• Very effective; Very safe

• No long-term side-effects

• No protection against STIs or HIV/AIDS

• Afterwards:

– Take rest for 2 or 3 days

– Avoid heavy lifting for a week

– No sex for at least 1 week

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Comparing contraceptive methods