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