Family planning community medicine lecture

FAMILY PLANNINGFAMILY PLANNING
1] DEFINITION
2] SCOPE
3] HEALTH
ASPECTS
4] Methods

DEFINITION
• “A way of thinking and living that is
adopted voluntarily, upon the basis of
knowledge, attitudes and responsible
decisions by individuals and couples, in
order to promote the health and welfare of
the family group and thus contribute
effectively to the social development of a
country"

• A program to regulate no and spacing of
children in a family through practice of
contraception or other methods of birth control
• Programs or services designed to assist the
family in controlling reproduction by either
improving contraceptive use or by diminishing
fertility there by limiting the no of child born
• A health service that helps couples decide
when to have children n if so how many

FAMILY PLANNING aims at
• Avoid unwanted births
• Bring about wanted births
• Regulate intervals between pregnancies
• Control the time of birth in relation to ages of
parents
• To determine the no of children in the family

CLASSIFICATION
METHODS
SPACING
METODS
TERMINAL
METHODS
MISCELLANEOUS
METHODS

SCOPE OF FAMILY PLANNING
• Proper spacing and limitation of births
• Advice on sterility
• Education for parenthood
• Sex education
• Screening for pathological conditions related to
the reproductive system (Ex. Cervical cancer)

Cont….d
• Genetic counseling
• Premarital consultation and examination
• Carrying out pregnancy tests
• Marriage counseling
• Preparation of couples for the arrival of their 1st
child

Cont ……..d
• Providing services for unmarried mothers
• Teaching home economics and nutrition

HEALTH ASPECTS OF FAMILY
PLANNING
FETAL
HEALTH
INFANTS
AND
CHILD
HEALTH
WOMENS
HEALTH

WOMEN’S HEALTH
• Pregnancy can mean
serious problems for
women
• Health risk is 10-20
times greater in
developing countries
• Risk Increases As:
mother grows old
• With no of children

HEALTH IMPACT OF FAMILY
PLANNING
METHOD
UNWANTED
PREGNANCY
NO OF
BIRTHS
TIMING OF
BIRTH

UNWANTED PREGNANCIES
CRIMINAL
ABORTION
POTENTIAL
THREAT TO
LIFE
UNWANTED
PREGNANCIES
UNSAFE
ABORTION

LIMITING NO OF BIRTHS
• Repeated pregnancies may cause mortality n
morbidity due to
• Rupture of uterus
• Toxemias of pregnancies
• Placenta previa
• Eclampsia
• Severe anemia

TIMING OF BIRTHS
• Great risk of death is
< 20 and >35 years of
age

FETAL HEALTH
• A no of congenital anomalies are associated with advancing
maternal age
• Quality of population can be improved by avoiding
completely unwanted births, compulsory sterilization of all
the adults who r suffering from certain diseases like leprosy
and psychosis

CHILD HEALTH
BENEFITS
DECREASED
CHILD
MORTALITY
CHILD
GROWTH
AND
DEVELOPMENT
INFECTIONS
AND
INTELLIGENCE

WELFARE CONCEPT
TABOOS
CULTURAL
FACTORS
STERILISATION
MIS
CONCEPTIONS

SMALL FAMILY NORM
• Small diff. in family size will make big diff. in birth rate
• Symbolized by inverted red triangle
• In 1970 slogan was “DO YAA TEEN BAS”
• In 1980 it was revised to 2 child norm

THE CURRENT EMPHASIS IS ON
1}SONS OR DAUGHTERS -2 WILL DO
2}2nd
child after 2-3yrs
3}Universal immunization

ELIGIBLE COUPLES
• Currently married couple
• Wife is in reproductive age group[15-45 ]
• Around 150-180 such couples per 1000
population
• Eligible couple register is a basic document for
organizing F.P work

TARGET COUPLES
• In order to pin point the couple who are the
priority groups within the broad definition of
“eligible couples” the term target couple was
coined
• Applies to couples who have had 2-3 living
children and F.P was largely directed to such
couples

COUPLE PROTECTION RATE
• Its an indicator of prevalence of contraceptive
practice in the community
• It is defined as % of eligible couples effectively
protected against child birth by one of the
standard or approved methods of sterilization
• CPR is a dominant factor in reduction Net
reproduction rate

BARRIER METHODS IN
CONTRACEPTION

IDEAL CONTRACEPTIVE

Safe

Effective

Acceptable

Inexpensive

Reversible

Simple to administer

Independent of coitus

Long-lasting

Little or no medical supervision.

CAFETERIA CHOICE :
THE PRESENT APPROACH IN
FAMILY PLANNING PROGRAMMES
IS
TO OFFER ALL METHODS FROM
WHICH AN INDIVIDUAL CAN
CHOOSE
ACCORDING TO HIS NEEDS AND
WISHES AND TO PROMOTE
FAMILY
PLANNING AS A WAY OF LIFE.

CONVENTIONAL CONTRACEPTIVES
DENOTE METHODS USED THAT
REQUIRE ACTION AT THE TIME
OF COITUS.
E.g. : Condoms , spermicides , etc .
SUCCESS OF ANY CONTRACEPTIVE
DEPENDS ON ITS EFFECTIVENESS
AND RATE OF CONTINUATION .

CONTRACEPTIVE METHODS
SPACING METHODSSPACING METHODS TERMINAL METHODSTERMINAL METHODS

SPACING METHODS
BARRIER METHODS
a) PHYSICAL METHODS
b) CHEMICAL METHODS
c) COMBINED METHODS
INTRA-UTERINE DEVICES
HORMONAL METHODS
POST-CONCEPTIONAL METHODS
MISCELLANEOUS

TERMINAL METHODS
MALE STERILISATION
FEMALE STERILISATION

BARRIER METHODS
OCCLUSIVE METHODS:
THE AIM OF THESE METHODS IS
TO PREVENT SPERM FROM MEETING
OVUM.
ADVANTAGES :
 FREE FROM SIDE EFFECTS
ASSOCIATED WITH PILLS & IUD.
 PROTECTION FROM STD’S , PELVIC
INFLAMMATORY DISEASES &
CANCER
CERVIX.

DISADVANTAGES :
HIGH DEGREE OF MOTIVATION
LESS EFFECTIVE THAN PILL OR
LOOP
THEY SHOULD BE USED
CONSISTENTLY & CAREFULLY.

PHYSICAL METHODS
CONDOMS :
MOST WIDELY USED METHOD BY MALES.
NIRODH-TRADE NAME-MEANS PREVENTION.
CONDOM IS FITTED OVER ERECT PENIS.
AIR MUST BE EXPELLED FROM TEAT TO MAKE
ROOM FOR EJACULATE.
CONDOM PREVENTS DEPOSITION OF SEMEN IN
VAGINA.
IT SHOULD BE CAREFULLY WITHDRAWN TO AVOID
SPILLAGE.

EFECTIVENESS CAN BE INCREASED BY
APPLYING SPERMICIDAL JELLY .
PREGNANCY RATE VARIES FROM 2-3PER
1OOO OT >14 IN TYPICAL USERS.
ADVANTAGES :
 EASILY AVAILABLE
 SAFE & INEXPENSIVE
 EASY TO USE
 LIGHT,COMPACT & DISPOSABLE
 PROTECTS AGAINST PREGNANCY &
STD’S.

DISADVANTAGES :
 INCORRECT USE.
 IT MAY SLIP OFF OR
TEAR DUE TO
 INTERFERES WITH SEX
SENSATION
MANUFACTURED IN
INDIA AT
HINDUSTAN LATEX IN
TRIVANDRUM &
LONDON RUBBER
FACTORIES IN
CHENNAI.

FEMALE CONDOM :
POUCH MADE OF
POLYURETHRANE
WHICH LINES VAGINA.
INTERNAL RING COVERS
CERVIX ,
EXTERNAL RING REMAINS
OUTSIDE
VAGINA.
PRELUBRICATED WITH SILICON
HIGH COST & ACCEPTABILITY
ARE
MAJOR PROBLEMS .

DIAPHRAGM
VAGINAL BARRIER , DUTCH CAP
SYNTHETIC RUBBER OR
PLASTIC MATERIAL.
IT HAS A FLEXIBLE RIM OF IT IS
INSERTED BEFORE
INTERCOURSE & KEPT
IN PLACE FOR UPTO 6hrs AFTER
COITUS.
SPERMICIDAL JELLY SIDE EFFECTS
ARE NILL.
FAILURE RATE IS 6 TO 12 PER
100 WOMEN
YEARS .

ADVANTAGES :
NO SIDE EFFECTS .
DISADVANTAGES :
NEEDS DEMONSTRATION
AFTER DELIVERY , IT CAN BE USED
ONLY AFTER COMPLETE
INVOLUTION
TOXIC SHOCK SYNDROME
NOT RECOMMENDED IN FAMILY
WELFARE PROGRAMME .

VAGINAL SPONGE
SPONGE SOAKED IN VINEGAR OR
OLIVE OIL .
TRADE NAME - TODAY.
SMALL POLYURETHRANE SPONGE
SATURATED WITH SPERMICIDE ,
NONOXYNOL-9.
LESS EFFECTIVE , FAILURE RATE IN
PAROUS WOMEN IS 20 TO 40 FOR 100
WOMEN YEARS.
IN NULLIPAROUS WOMEN IT IS 9 TO 2PER
100 WOMEN YEARS.

CHEMICAL METHODS
SPERMICIDES - 4 CATEGORIES
 FOAMS : FOAM TABLETS & AEROSOLS
 CREAMS , JELLIES & PASTES
 SUPPOSITORIES–INSERTED MANUALLY
 SOLUBLE FILMS – C FILM
SPERMICIDES CONTAIN A BASE IN TO
WHICH SPERMICIDE IS INCORPORATED .
MODERN SPERMICIDES ARE SURFACE
ACTIVE AGENTS . THEY ATTACH TO
SPERMS AND INHIBIT OXYGEN UPTAKE.

DRAWBACKS OF SPERMICIDES
 HIGH FAILURE RATE.
 MUST BE USED IMMEDIATELY BEFORE
COITUS & REPEATED EVERY TIME.
 MUST BE INTRODUCED INTO AREAS
WHERE SPERMS ARE DEPOSITED.
 MILD BURNING , IRRITATION BESIDES
MESSINESS.
NOT RECOMMENDED BY PROFESSIONALS.

INTRA UTERINE DEVICES
2 types of IUDs
Nonmedicated Medicated
Cu IUDs Hormone Releasing
• .

Non medicated/ Inert/ First generation IUDs :
• These IUDs are available in different shapes and sizes
• Loops, spirals, coils, rings, bows etc.
LIPPES LOOP
• Double ‘S’ shaped device
• It contains small amount of Baso4
• Loop has attached threads or tail
• Tail made up of nylon
• Importance of tail
easy to remove
• Loop exists 4 sizes A,B,C & D

MEDICATED IUDs
Importance of medicated IUDs :
• Reduce incidence of side effects
• To increase contraceptive effective ness
DISADVANTAGE :
• More expensive
SECOND GENERATION IUDs :
• Metallic copper had a strong antifertility effect
• Number of cu bearing devices are available
• These are a. Copper – 7
b. copper – T- 200 B

2. Newer devices
a. variants of the T devices
i. T cu – 220C
ii. T cu – 380 A or Ag
b. Nova T
c. Multi load devices
i. ML – Cu -250
ii. ML – Cu- 375
Numbers represents the surface area of
the copper on the device (in. sq mm).

• ADVANTAGES OF COPPER DEVICES :
1. Low expulsion rate
2. Low incidents of side effects
3. High anti fertility effect
4. easier to fit even in nulliparous women
5. Post coital contraceptives

THIRD GENERATION IUD
• Most widely used hormonal devices are
1.Progestasert
• T shape device filled with 38 mg of
progesterone
• It has direct effect on uterine lining, cervical
mucus and sperms
• 2. Levonorgestrel (LNG – 20)
• T shaped device
• It has 1. low pregnancy rate
2. less number of ectopic pregnancies
3. Lower menstrual blood loss
4. Fewer days of bleeding

MECHANISM
• Foreign body reaction.
• Cellular and biochemical changes.
• Impair the viability of the gamete.
• Reduce the chances of fertilization
rather than implantation.
• Copper enhances the
Cellular response in the endometrium.
Affects the enzymes in the uterus.
Alter biochemical composition of
cervical mucus.
• Hormonal devices increase viscosity of the
cervical mucus.

TIMING OF INSERTION
• Loop can be inserted any time during a women's
reproductive age group except during pregnancy
• Most propitus time for loop insertion
During menstruation
With in 10 days of begining of menstrual
period
After delivery
• Immediate postpartum insertion (during 1st
week)
• Post puerperal insertion (after 6-8 weeks )

FOLLOW UP
• Follow up is most important aspect of IUD insertion
Objectives :
1.To provide motivational and
emotional support for the women
2.To confirm the presence of the IUD
3.Diagnose and treat any side effects
Time of Examination :
1.After her first menstrual period
2.After 3rd
menstrual period
3.There after at 6 months or 1 year

EFFECTIVE NESS
• Theoretical effective ness of IUD is Less than that of
oral and injectable hormonal contraceptives
• Table shows

DEVICE PREGNANCY
RATE(%)
EXPULSION
RATE (%)
REMOVAL
RATE(%)
Lippes loop 3 12-20 12-15
Cu-7 2-3 6 11
Tcu-200 3 8 11
Tcu-380A 0.5-0.8 5 14
Progesterone 1.3-1.6 2.7 9.3
Levonorgestrel 0.2 6 17

ADVANTAGES OF IUDs
• 1. Simplicity
• 2. Insertion takes few minutes
• 3. Once inserted IUD stays in place as long as
required
• 4. Reversible
• 5. In expensive
• 6. High continuation rates
• 7. Single act of motivation
• 8. Free of systemic side effects

Absolute contra indications
• i. Suspected pregnancy
• ii. Pelvic inflammatory disease
• iii. Vaginal bleeding
• iv. Cancer of cervix and uterus
• V. Previous H/o ectopic pregnancy

• i. Anaemia
• ii. Menorrhagia
• iii. History of pelvic inflammatory disease
• Iv. Purulent cervical discharge
RELATIVE CONTRA INDICATIONS

INTRA UTERINE COTRACEPTIVE DEVICE
SIDE EFFECTS AND COMPLICATIONS

• IMMEDIATE
•  Difficulty in insertion.
•  Vasovagal shock.
•  Uterine cramps.
• EARLY
• Expulsion.
• Perforation.
• Spotting Menorrhagia.
• Dysmenorrhoea.
• Vaginal infection.
• Actinomycosis.

• LATE
• Pelvic inflammatory disease.
• HIV/AIDS.
• Ectopic pregnancy.
• Perforation.
• Memorrhagia.
• Dysmenorrhoea.
• OTHERS
• FERTILITY.
• LATE,TERATOGENELITY.
• MORTALITY.

EXPULSION RATE TYPE OF IUCD GENERATION
12-20 % Lippes Loop Ist gen
6%
8%
5%
Cu 7
Tcu-200
Tcu-380
II gen
2.7%
6%
Progesterone IUCD
Levonorgestrel
IUCD
III gen

EXPULSION• C/F:-
• Complete
• Partial.
• Complete: As seen by person.
• Partial:- Diagnosed by speculum examination.
• FACTORS:
  skill.
  Timing of insertion: postpartum.
  Age: nulliparity, young women.
  Main Problem: pregnancy.

V) Perforation
• Early and late complication.
• Incidence: 1:150 – 1:9000.
• FACTORS:-
• Time of insertion: 48weeks – 60 weeks past partum.
• Design of IUCD:
• Skill:
• Operators experience:
• C/F:-
• pain intestinal destruction.
• Asymptomatic.
• MISPLACED IUCD:-
• Confirmed by pelvic X-ray
• Treatment:-
• Laparatomy & removal.

VI) Bleeding or Menorrhagia
DYSMENNORHOEA:-
  late or early.
  inert or medicated IUCD- commonest complaint
• C/F:-
• 1) greater volume.
• 2) longer periods
• 3) mid cycle bleed.
• Complications:
• Personal inconvenience.
• Iron deficiency anemia.
• Treatment:-
• Generally settles within 1-2 months.
• Ferrous sulphate 20mg tid.

• CAUSE OF REMOVAL.
• RETURN OF NORMAL CYCLE
• If not –full GYNAEC EXAM.
• VAGINAL INFECTION/ACTINOMYCOSIS.
Non medicated Max
Copper T Less average
Hormonal Lower

• VII) PELVIC INFLAMATORY DISEASE(PID):
• sub acute, chronic, conditions of ovaries, tubes, uterus,
connective tissue and pelvic peritoneum following
infection.
• Incidence:- 2-8 times more than non IUCD users.
• Risk:- polygamies, STD’s like HIV / AIDS, syphilis.
• Etiology;_ Ascent OF INFECTION with the IUCD.
• C/F:-
• Vaginal discharge.
• Pelvic pain.
• Tenderness.
• Abnormal bleeding.
• Chills.
• Fever.
• In many cases
• Asymptomatic.
• Low grade.
• Complications:- infertility.

• Treatment:-
• Broad spectrum Antibiotics.
• Prescribe the removal if not responding in 24-48
hrs
• IIIV ) RISK REDUCTION:
• 1)Washing hands & putting on gloves.
• 2)Cleaning cervix & vagina water based iodophore
betadine or chlorhexidine.
• 3)using “no touch instrument technique”
• 4)Washing hands again and processing
• instruments.
• Processing for reuse:-
• Decontamination:- 5% chlorine(10 min)
• HIGH LEVEL DISINFECTON:-
• Instruments & Gloves 30% in Activated
• 2% glutaroldehyde
• 8% formaldehyde
• Washing thoroughly in boiled water or sterile water.

• LOW LEVEL DISINFECTANS:-
• Zephiran(Benzalleonium
chloride)
• Savlan(Cetrimole chlorhexioline)
• Should never be used.
• Costly Autoclave Sterilization not
required.
• STORED DRY FOR WEEK IN
CONTAINER WITH A TIGHT FITTING
LID.

IX) PREGNACY:
3% Lippes Loop
2-3% Copper T
3% Tcu-200
0.5 – 0.8% Tcu-380
1.3-1.6% Progesterone-IUCD
0.2% Levonorgestrel-IUCD

• 50% of pregnancies spontaneous Abortion
• Early removal 30% resolution of
abortions.
• Increase of “premature births”  by
continuing pregnancy
• Complications:-
• Infection & spontaneous abortions
• Prevention:-
• legal induced abortion
• Removal.

X) ECTOPIC PREGNANCY.
• Ectopic pregnancy ratio/100 woman year 0.2
for levonorgestrel IUCD & Copper T 380 A
• compared to 3-4.5 for non contraceptive.
• Reason:-
Mode of action for levonorgestrel
differs from progesterone.

DANGER SIGNALS :-
• lower abdominal pain.
• Dark and scanty virginal bleeding and
amenorrhea.
• Risk Persons:-
• Previous pelvic inflammatory disease.
• Other ectopic pregnancy.

XI):- Others
 Fertility after removal
70% conceive.
 No cancer or teratogenicity.
 Mortality
Extremely rare.
1death /1,00,000 women years of
septic
abortion as ectopic pregnancy.

HORMONAL CONTRACEPTIVES
• Hormonal contraceptives when properly used
are the most effective methods of contraception
• They provide the best means of ensuring
spacing between one childbirth and another
• GONADAL STEROIDES:
a. synthetic steroids: eg ethinyl oestradiol and
mestranol.
b. synthetic progestogens: they are pregnanes ,
oestranes and gonanes.

CLASSIFICATION
a) ORAL PILLS
1.Combined pills
2.Progestogen only pill
3.Post coital pill
4.Once a month pill
5.Male pill
b) DEPOT FORMULATIONS
1. Injectables
2. Subcutaneous implants
3. vaginal rings

ORAL PILLS
1. Combined pill:
It is one of the major spacing methods of
contraception.It contains 30-35 mcg of a synthetic
oestrogen and 0.5 to 1 mcg of a progesterone.
The pill should be taken at a fixed time everyday.

Cont.,
• The pill is given orally for 21 days starting
on the 5th
day of menstrual cycle followed
by a break of 7 days during which
menstruation occurs.
• This is called withdrawal bleeding.
• The department of family welfare , in the Ministry
of Health and Family Welfare Govt. of India has
made available low dose of oral pills – MALA-N
and MALA-D.

2. Progesterone only pill
• It is called as minipill or micropill .it contains only
progesterone which is given in small doses
through out the cycle.
• These pills have an increased pregnancy rate so
not being used , but can be used for women with
cardiovascular problem and for those with the
risk factors for neoplasia.

3. Post coital contraception:
It is used within 48 hrs of unprotected
intercourse.
Two methods are available.
a) IUD: e.g. copper device
b) Hormonal: combine oc pill is used. It
contains double dose of the standard combined
pill. 2 pills immediately followed by 2 pills 12
hours later.
For emergency contraception a women must
take four instead of 2 in each dose.

4. Once a month long acting pill
• Quniestrol , a long acting estrogen is given
in combination with a short acting
progesterone.
• Disadvantage: high pregnancy rate and
irregular bleeding.

5. Male pill:
The approach is
• a) preventing spermatogenesis.
b)
interfering with sperm storage.
c) preventing sperm transport.
d) affecting the seminal fluid constitution.
• An ideal male contraceptive will decrease the
sperm count while leaving testosterone at
normal values.

Mode of action of oral pill:
• Combined only pill prevents the release of ova
from the ovary by blocking the pituitary
secretion of gonadotropin.
• Progesterone only pills render the cervical
mucus thick and scanty and inhibit the sperm
penetration.

Effectiveness :
• If taken according to the prescribed regimen
oral contraceptives of the combined type are
100% effective.
• It is also influenced by drugs – rifampicin,
phenobarbital, ampicillin.

BENEFICIAL EFFECTS Contraceptive benefits- prevention of unwanted
pregnancy (failure rate- 0.1per 100 women year).
 Non contraceptive benefits-
a. relief of:
menorrhagia (50% ),
dysmenorrhoea (40% ),
premenstrual tension syndrome,
mittleschmerz syndrome.
b. improvement of:
iron def. anemia,hirsutism,
acne, endometriosis, autoimmune disorders of
thyroid, rheumatoid arthritis.

c. marked reduction in: pelvic inflammatory
disease, benign breast cancer, ectopic
pregnancy, fibroid uterus, functional
ovarian cysts, carcinoma of ovary (40% )
carcinoma of endometrium (50% ),
protection against osteoporosis.

b) DEPOT FORMULATIONS
• Injectable contraceptives, sub dermal
implants and vaginal rings come in this
category.
1. Injectable contraceptives:
There are two types:
PROGESTAGEN ONLY INJECTABLES:
• (a) DMPA: Depot medroxy -
progesterone acetate.
• Dose is i.m injection of 150mg every
3months.

• Dose is i.m injection of 150mg every
3months.
• Action is by suppression of ovulation.

• It is safe effective and an
acceptable contraceptive.
• Acceptable in the
postpartum period as a
means of spacing.
• Side effects: weight
increase, irregular
menstrual bleeding.

(b) NET-EN
• Norethisterone enantate is given as i.m
injection dose of 200mg. every 60 days.
• Contraceptive action is by inhibiting
ovulation and progesterogenic effects on
cervical mucus.
ADMINISTRATION:
• Both DMPA ,NET-EN should be given
during first five days of menstrual period.

• The injection site should never be
massaged following injections.
SIDE-EFFECTS:
• Unpredictable bleeding
• Amenorrhea
CONTRAINDICATIONS:
• Breast cancers, all genital cancers.

B. COMBINED INJECTABLE :
• They contain a progestogen and an oestrogen.
• Given at monthly intervals.
• Act by suppressing ovulation ,cervical mucus is
affected mainly by progestogen and inhibits
sperm penetration.
• CONTRAINDICATIONS: confirmed or suspected
pregnancy; past or present evidence of
thromboembolic disorders; cerebrovascular or
coronary artery disease; focal migraine;
malignancy of breast and diabetes with vascular
complications.

2. SUBDERMAL IMPLANTS:
• Norplant : it consists of 6 silastic capsules
containing 35mg of levonorgesterel.
• The capsules are implanted beneath the
skin of forearm or upper arm.
• Effective contraception is provided for 5
years.

• The contraceptive effect of Norplant is
reversible on removal of capsules.
• DISADVANTAES: irregularities of
menstrual bleeding and surgical
procedures for inserting and removal of
implants.

3. VAGINAL RINGS
Vaginal rings containing levonorgesterel
are highly effective.
• The hormone is slowly absorbed through
the vaginal mucosa , bypassing the
digestive tract and liver and allowing a
potentially lower dose.
• The ring is worn in the vagina for 3 weeks
and removed for the 4th
week.

Post Conceptional Methods
These are the methods employed for the
termination of the pregnancy.
It includes
Menstrual regulation
Menstrual induction
Abortion

Menstrual regulation
• It consists of aspiration of uterine contents 6-14
days of a missed period but before most
pregnancy tests can accurately determine
whether or not a woman is pregnant.
• Complications :
IMMEDIATE - Uterine perforation, Trauma
LATE - Tendency to abortion, Infertility
Menstrual disorders
Increase in ectopic pregnancy
Rh immunization

Menstrual regulation differs from abortion
in the following respects :
• Lack of certainty if pregnancy is being
terminated.
• Lack of legal restrictions.
• Increased safety of early procedures.

Menstrual Induction
• Intrauterine application of 1-5 mg of PGF2
solution disturbs the normal progesterone
prostaglandin balance.
• The uterus responds with a sustained
contraction lasting about 7 minutes,
followed by cyclic contractions continuing
for 3-4 hours.

Abortion
• Definition : Termination of pregnancy
before the foetus becomes viable (28wks).
• Types  Spontaneous
Induced
• Spontaneous- Nature’s method of birth
Control
• Induced- Legal - MTP
Illegal - Hazardous
• In India, about 6 million abortions takes
place every year.

• Abortion Hazards :
Maternal morbidity and mortality
• Complications :
Early Late
Hemorrhage Infertility
Shock Ectopic gestation
Sepsis Spontaneous abortion
Uterine perforation Reduced birth weight
Cervical injury
Thrombo embolism

Legislation of abortion
• MTP act was passed by Indian parliament
in 1971. It came into force in April 1st
1972.
• It is a health care measure to reduce
maternal morbidity and mortality resulting
from illegal abortions.

Medical termination of Pregnancy Act
• Conditions under which the pregnancy can be
terminated :
Medical
Eugenic
Humanitarian
Socio economic
Failure of contraceptives
•

Person who can perform
abortion:
RMP having experience in OBG can
perform abortion when the length of
pregnancy does not exceed 12 weeks.
 when the pregnancy is from 12-20 wks
opinion of two RMP’s is necessary.
• Place where abortion can be done
Govt. hospital or place approved for
purpose of this act.

MTP Rules 1975
• Initial rules and regulations are altered to
eliminate time consuming procedure in MTP
• Approval by board: CMO of the district is
empowered to certify a doctor to do abortion
• Qualification: If the doctor has assisted a RMP in
performing 25 cases of MTP in a approved
institution
• Place: Non Govt. institutions may also taken up
abortions provided they obtain a license from
CMO, District

• Illegal abortions are still rife although it is
now more than 30 yrs MTP has been
promulgated
“If abortion is considered as a disease,
health education is the vaccine.”

Natural Methods of
faMily PlaNNiNg

Miscellaneous Methods
• Abstinence
• Coitus interruptus
• Safe periods
• Natural family planning
– basal body temperature
– cervical mucus method
– symptothermic method
• Breast feeding
• Birth control vaccine

Abstinence
• The only method of birth
control which is
completely effective is
complete
sexual abstinence

Coitus Interruptus
• This is the oldest method of voluntary
fertility controls.
• Widely practiced method.
• Preventing the deposition of the
semen into
the vagina.
• Disadvantages
–The pre-coital secretions of the male
may contain sperms.

Safe Periods
• It is also called
‘rhythm method’ or
‘calendar method’
• It is based on the
fact that ovulation
occurs from 12 to
16 days before the
onset of
menstruation.

Safe Periods (cont’d)
• The first day of the fertile phase is found by
subtracting 18 days from the length of the
shortest cycle.
• To find the last day of the fertile phase, subtract
11 days from the longest cycle.
• Sample
– In this sample, the shortest menstrual cycle in
the past 6 months was 25 days. The longest
menstrual cycle in the past 6 months was 35
days.

Coitus Interruptus (cont’d)
• To calculate the fertile phase
–Subtract 18 from the shortest cycle
(25 days) = 7
–Subtract 11 from the longest cycle
(35 days) = 24
–This means the first day of the fertile
phase is Day 7. The last day of the
fertile phase is Day 24. If a couple is
using this method to avoid intercourse
during the fertile phase.

• Disadvantages
– Women’s menstrual cycles are not always
regular.
– It is only possible for this method to be used
by educated and responsible couples with
high degree of motivation and co operation.
– Compulsory abstinence of sexual intercourse
for nearly one half of every month.

– This method is not applicable during the
post-natal period.
– A high failure rate of 9 per 100 women
years.
– Failures due to wrong calculations.
• Medical complications
– Ectopic pregnancy

Natural Family Planning
Methods
• Variety of methods used to plan or prevent
pregnancy, based on identifying the
women’s fertile days.
• The term” natural family planning” is
applied to three methods, they are …
– basal body temperature method (BBT)
– cervical mucus method
– symtothermic method

Basal Body Temperature Method
(BBT)• The BBT method depends
upon the identification of a
specific physiological event –
the rise of BBT at the time of
ovulation, as a result of
increase in the production of
progesterone.
• The rise of temperature is
very small, 0.3–0.5
degree C.
• When no ovulation occur the
body temperature does not
rise.
• The temperature is preferably
measured before getting out
of the bed in the morning.

Basal Body Temperature Method
(BBT)
• This method is reliable if the
intercourse is restricted to the
post-ovulatory infertile period,
commencing 3 days after the
ovulatory temperature rise
and continuing up to the
beginning of menstruation.
• Drawbacks—abstinence is
necessary for the entire
pre-ovulatory phase.
• The failure rate is as high
as 15%.

Cervical Mucus Method
• This also known as “billings method” or “ovulation
method”.
• This method is based on the observation of changes in
the characteristics of cervical mucus.
• Cervical Mucus has regular, cyclic pattern changes. The
cycle starts with the beginning of period and ends at the
beginning of the next period.
• At the time of ovulation, cervical mucus becomes watery
clear resembling raw egg white, smooth, slippery and
profuse.
• After ovulation ,under the influence of progesterone, the
mucus thickens and lessens in quantity.
• From the beginning of the change in your mucus pattern
until it disappears or changes (four days after the
greatest volume) are the unsafe days.

Symtothermic Method
• This method
combines the
temperature,
cervical mucus and
calendar techniques
for identifying the
fertile period.
• This is more
effective.

Other Methods
Post ovulation method
• Ovulation always occurs
12–16 days before your
period (Usually 14 days).
• Based on the average of
14 days, the ovulation
day can be predicted.
• This is not an absolute
prediction of the
ovulation day.

The Two Day Method
• The Two Day Method relies on a simple
algorithm, based upon the presence or
absence of cervical secretions.
• If the woman notices any secretions on the
current or previous day, then she is
probably fertile today.
• If she notices no secretions today and
yesterday (two days in a row without
secretions), then she is not fertile today.

Breast-Feeding
• Lactation prolongs postpartum amenorrhoea.
• This is because levels of a certain hormone,
prolactin are increased.
• However, once menstruation returns,
continued lactation no longer offers any
protection against pregnancy.
• This method is most effective during the first 6
months of exclusive breastfeeding.
• Women using this method have a 2% chance
of getting pregnant in the first 6 months.

Birth Control Vaccine
• The most advanced research involves
immunization with a vaccine prepared from beta
sub-unit of human chorionic gonadotropin
(hCG).
• Immunization with hCG would block continuation
of pregnancy.
• Antibodies appeared in about 4–6 weeks and
reached maximum after about 5 months and
slowly declined reaching zero levels after a
period ranging from 6–11 months.
• The immunity can be boosted by a second dose.
• But there are many uncertainties.

Terminal Methods of Sterilization
1. Male sterilization – Vasectomy (10-15%)
2. Female sterilization – Tubectomy (85%)

Guidelines for family planning
 Age of the husband should not be less than
25yrs or more than 50yrs
 Age of the wife should not be less than 20yrs
or more than 45 yrs
 Couple must have 2 living children at the time
of operation
 If more than 3 children then the lower limit of
age can be shortened
 Informed consent required

Advantages of Terminal methods of
Family Planning
• Most effective method
• One time method
• Cost effective
• Does not require motivation

Male sterilization
(VASECTOMY)
• First used in 1897 (experiments from 1785).
• Permanent sterilization in which the vasa
deferentia of a man are cut and the cut ends
are ligated.
• It is a minor surgical procedure.
• Can be performed by a trained MBBS
doctor.

• NORMAL VASECTOMY- typically seals both
ends of the vas deferens with stitches, heat, or
both, after cutting.
• OPEN ENDED VASECTOMY- abdominal end of
the resected vas in coagulated; testicular end is
left open prevents congestive epididymitis.
• PER CUTANEOUS VAS-OCCLUSION (popular
in China) - Polyurethane elastomere is injected
into the vas which solidifies and forms a plug
blocking sperm passage.
• NO SCALPEL VASECTOMY – commonly
preferred technique at present.

Selection of candidates
• Ideal-Sexually active and psychologically
adjusted husband having the desired number of
children.
• Any misconception about the fear of castration,
loss of hormones and impotency are to be
removed by sympathetic conversation.
• Eczema & scabies on the scrotal area is a
temporary contraindication.
• If hydrocele or hernia is present, it is corrected
and then vasectomy is done.

Requirements
• Informed consent of the person is a must.
• The surgeon should be convinced about
the family structure of the couple.
• Premedication not necessary.

Procedure
• Identification of vas
deferens.
• Infiltration with
1%
lignocaine.
• Vertical incision.
• Clamp and remove atleast
1cm of the vas.
• Ends are ligated and
sutured into position
(cut ends away from
each other-to reduce

Complications
• Pain
• Bruising and swelling (scrotal haematoma)
• Infection (wound sepsiscellulitis &
abscess)
• Sperm granuloma (5%)
• Post-Vasectomy Pain Syndrome
• Spontaneous Recanalization
• Auto-immune response
• Psychological

Post operative advice
• At least 30 ejaculations may be
necessary for seminal examination to be
negative (sterile)
• Usage of other methods of contraception
until aspermia is established
• T-bandage or scrotal support to be worn
for 15days
• Avoid cycling heavy work or lifting heavy
weights
• Stitches removed on 5th
day of operation

Advantages of Vasectomy
• Simplicity of the surgical procedure
• Lower cost
• Effectiveness (early failure rates-below 1%, late failure
is very rare)
• Done under local anaesthesia as opposed to general
anaesthesia usually needed for female sterilization.
• Minimum training required
• Can be done as an outdoor procedure or a mass
camp in remote villages
• Complications – immediate or late are few

Causes of failure
• Mistaken identifications of the vas
(histological examination is required).
• Spontaneous recanalisation.
• More than one vas on one side.
• Proper post-operative care not taken.

Social factors determining the
acceptance of vasectomy
• Fear of impotency
• Lack of knowledge or
awareness about
vasectomy
• Apprehension
regarding the surgery

Reversal
• By “Vasovasostomy”
• First performed by Earl
Owen in 1971
• Effective only in 50-70%
of the cases
• Very costly procedure
• Depends on the method
used and the time at
which vasectomy was
done (after 2 or more
years occlusion of vas
occurs)
• Sperm counts are not
returned to normal

No scalpel Vasectomy (NSV)
• No-Scalpel Vasectomy is one of the most effective
contraceptive methods available for males.
• First performed by a Chinese surgeon in 1974.
• It is an improvement on the conventional vasectomy
with practically no side effects or complications.
• This new method is now being offered on a voluntary
basis under the Family Welfare programme.

Instruments used to perform
NSV
1. Ring fixation clamp
2. Sharp curved
dissecting clamp
3. Scissors

Procedure• Local anesthesia.
• Vas deferens is fixed in the midline raphe of the
scrotum by a ring forceps.
• A sharp curved dissections clamp is used to
puncture the skin, the puncture hole is enlarged
to about twice the diameter of vas and the vas is
delivered out.
• Part of the vas is dissected and ends ligated and
then pushed back into the scrotum.
• Similar procedure done on the opposite side.
• The puncture holes do not require any closure
(no suturing).

Advantages
• Painless
• Less invasive - no stitches or
sutures required
• Less time-taking
• Less discomfort
• Economical
• The person can leave the hospital
immediately after the procedure
• Simpler than tubectomy (requires
hospitalization of the woman)
• No side effects or complications
• Quick recovery

Evaluation of Contraceptive
methods &
Family planning

Evaluation of contraceptive
methods
• Contraceptive methods are evaluated on
the basis of Use – effectiveness.
• The two methods being used for
measuring contraceptive efficacy are:-
1) Pearl index .
2) life – table analysis .

PEARL INDEX
• It is defined as the number of “ failures per
100 women years of exposure (HWY) .”
• It is normally used for studying the
effectiveness of a contraceptive.
Total accidental
pregnancies
Failure rate per HWY=
X 1200
Total months of exposure

• In the above formula, the numerator must
include every known conception, whether this
had terminated as live –births, still-births or
abortions or had not yet terminated.
• The factor 1200 is the number of months in
100 years.
• The denominator is obtained by deducting
from the period under review of 10 months for
a full-term pregnancy,4 months for an
abortion.

• A failure rate of 10 per HWY would mean that
in the lifetime of the average woman about
one-fourth or 2.5 accidental pregnancies
would result , since the average fertile period
of a woman is about 25 years .
• In designing and interpreting a use –
effectiveness trial, a minimum of 600 months
of exposure is usually considered necessary
before any firm conclusion can be reached.

• The Pearl index is usually based on a specific
exposure and, therefore , fails to accurately
compare methods at various durations of
exposure.
• This limitation is overcome by using the
method of LIFE-TABLE ANALYSIS.

S.N
O
Effectiveness in preventing pregnancy
(pregnancies per 100users per year)
In
Theory
In
Practice
1 Vasactomy 0.15 0.2-0.5
2 Tubectomy 0.05 0.2-1
3 Implant 0.3 0.3
4 Injectable contraceptive 0.25 1
5 IUD 1-3 1-5
6 Oral contraceptive 0.5 1-8
7 Progestin – only pill 1 3-10
8 Condom 1-2 3-15
9 Diaphragm 2 4-25
10 Vaginal(chem.) contraceptives 3-5 10-25
11 Vaginal cont. sponge 11 15-30

S.NO Methods Pregnancy
rate/HWY
1 None Used 80
2 Rhythm 20-30
3 Coitus Interruptus 20-30
4 Condom 14
5 Diaphragm 12
6 IUCD 1.5-3
7 Pill 0.5

LIFE TABLE ANALYSIS
• It caliculates a failure rate for each month of
use.
• A cumulative failure rate can then compare
methods for any specific length of exposure.
• Women who leave a study for any reason
other than unintended pregnancy are
removed from the analysis, contributing their
exposure until the time of the exit.

UNMET NEED FOR FAMILY PLANNING
• It was first explored in 1960s, when data from
surveys of contraceptive knowledge attitude and
practices (KAP) showed a gap between some
women reproductive intention & their contraceptive
behaviour.
• One of the first published use of the term “Unmet
need” appeared in 1977.
• Many women who are sexually active would prefer to
avoid becoming pregnant, but nevertheless are not
using any method of contraception.
• These women are considered to have an “Unmet
need” for family planning.

• The concept is usually applied to married women.
however , it can applied to sexually active fecund women
and perhaps to men, but its measurement has been
limited to married women only.
• It poses a challenge to family planning programme-to
reach and serve millions of women whose reproductive
attitude resembles those of contraceptive user.
• The most common reason for unmet need are-
inconvenient or unsatisfactory services, lack of
information, fears about contraceptive side effects and
opposition from husband or relatives.
• According to the National Family Health Survey -2, about
16% of currently married women in India have an unmet
need for family planning, the unmet need for spacing the
births is the same as the unmet need for limiting the births.

• Unmet need for family planning is highest (27%)
among women below age 20years and is almost
entirely for spacing the births rather than for limiting
the births.
• It is also relatively high for women in age group 20-
24 years(24%) with about 75% of the need being for
spacing the births.
• The unmet need for contraception among women
aged 30 yrs and above are mostly limiting the births.
• Unmet need for family planning is higher in rural
areas than urban areas.
• It is also varies by women education & religion.

• Mary is a 47 year old who has come in for
a routine cervical smear. She asks when
her Multiload IUD should be changed as it
has been in for 6 years now. She is P2G3.

• Advise her it needs changing as soon as
convenient • Discuss that it can remain
until after menopause • Take out her IUD
now and advise her she needs to use
condoms until another can be inserted

Case 2
• Jotsna comes to talk to you about an IUD.
She is a 20 year old P0G0 in a long term
relationship. She likes the idea of having
a contraceptive method that doesn’t
contain hormones but her periods are
already quite heavy and painful.

• that copper IUDs have no hormones but
may worsen heavy, painful periods
especially initially
• • Hormone releasing IUSs don’t usually
cause hormonal side effects and will help
her heavy, painful periods
• • • All of the above

Case 3
• Angha comes in to get emergency
contraception. The condom broke last
night. Her LMP started 12 days ago and
she has a regular monthly cycle. She
doesn’t take any medications. Her BMI is
32

• Give her I pill now but advise her she
needs a postcoital IUD and arrange this
for her

Case 4
• Preet wants to “go on the pill” and would
like to try Mala D as her friend likes it. You
check her personal and family history and
her BP and BMI. All straightforward.

• You recommend she start with a second
generation pill

Family planning community medicine lecture

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