Family Planning

Dr Priyanka
 Family Planning
• 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 health and welfare of
the family group and thus contribute effectively to the social
development of the country
 Need for Family Planning
• To avoid unwanted births
• To bring out wanted births
• To regulate intervals between pregnancies
• To control the time at which birth occur, in relation to the age
of the parent
• To determine the number of children in the family
In 1952, the Indian Government was one of the
first in the world to formulate a national family
planning programme, which was later expanded
to encompass maternal and child health, family
welfare, and nutrition
 1976: First National Population Policy was passed. Program renamed as Family
welfare

 1992: National child survival and safe motherhood program

 1994: International conference on Population development, Cairo

 1997: The Reproductive and Child Health (RCH) programme was launched

 2000: The National Population Policy advocated a holistic, multi-sectoral

approach towards population stabilization, with no targets for specific
contraceptive methods except for achieving a national average total fertility rate
(TFR) of 2.1 by the year 2010. The target-free approach was recast as the
community needs assessment approach
Need for Contraception- Family planning
 Contraception
• Birth control, also known as contraception and fertility control,
is use of a method or device to prevent unwanted
pregnancy.
• Birth control has been used since ancient times, but effective
and safe methods of birth control only became available in the
20th century
 Contraception
• It is important to help women and their partners to gain
increased control over their reproductive health.

• One of the main ways you can do this is by adopting

appropriate family planning methods either during late
pregnancy, the postpartum period and the post-abortion
period.
• Target couple – Couples with less than three living children
Even new couples can be targeted for advice.
• Eligible couple –Wife in the age group 15 to 44 years.
• 53.5% of the couples in India were protected by contraceptives
in (2015—2016)
• 45.28% still unprotected
• Sterilization –60 % of the contraceptive use.
 Pearl Index

• Pearl index – universally accepted measure of contraceptive

efficiency. It is pregnancy rate per 100 women years of use of a
given contraceptive.
• Used for measuring the failure rate of contraceptives.
• No of failures per 100 women years of EXPOSURE
• Failure Rate per HWY=
Total accidental pregnancies 1200
Total months of exposure
 Promoting contraceptive practices
• Emphasis should be informed choice of contraceptives
• Adopt GATHER approach for counseling
– G: Greet the clients
– A: Ask their need
– T: Tell about different methods- their advantages & disadvantages
– H: Help client to choose suitable method
– E: Explain how to use the method
– R: Return visit & follow up
 Ideal Contraceptive
• Safe
• Effective
• Acceptable socially culturally/ religion
• Inexpensive
• Reversible
• Simple to administer
• Independent of coitus
• Long lasting
• Little medical supervision

• CAFETERIA Approach FOR THE COUPLES

 Unmet need for Family Planning
• Currently married women who are not using any method of
contraception but do not want or want to wait for 2-3 years before
having any more children are defined as having an unmet need for
family planning.

• Unmet needs still continue to be high with an overall unmet need of

13% while in states like UP, Bihar and Jharkhand it continues to be
over 20%.

• NFHS-2 unmet need 16%

Barriers to meeting contraceptive needs
 Types of Contraceptive Methods
Spacing Methods
1. Conventional/ Natural Methods
2. Barrier methods
a) Physical Methods
b) Chemical Methods
c) Combined Methods
3. Intra Uterine Devices
4. Hormonal Methods
5. Post Conceptional Methods – Post coital pill, MTP, Tubectomy and Vasectomy
6. Newer Methods
 Types of Contraceptives --cont
Terminal Methods
• A) Tubectomy
• B) Vasectomy

• Medical Termination of Pregnancy

 A) Conventional/ Natural methods
• In India, many prefer traditional/ conventional/ natural
methods which do not require any external devices.
• The average prevalence for traditional contraceptive use is
6.7 per cent.
• But the traditional contraceptive methods have a high failure
rate—
– Resulting into unplanned pregnancies
– Unsafe abortions
 A) Conventional/ Natural methods
• Abstinence/customary separation
• Breast feeding
• Coitus interruptus (withdrawl method)
• Fertility awareness methods
– Safe period
– Basal body temp (BBT) method
– Cervical mucus method
– Sympto-thermic method
 A) Conventional methods
Breast feeding- Exclusive, periods not yet
• 5-10% conceive only in lactational amenorrhoea

Coitus interruptus- oldest method to avoid pregnancy

• Method-The semen is ejaculated outside the vagina
• Failure may occur due to sperms in the precoital secretions
• Failure rate 25%
• Side effects- anxiety neurosis, pelvic congestion and unplanned
pregnancy
 Natural methods
A) Conventional methods
Fertility awareness methods-
1) Safe method/ Calender method / safe period method
• Depend on time of ovulation.
• Described by Ogino in 1930 .
• Rationale: ovulation occurs on 14 day & ovum viable for 48-72 hrs & sperm remain alive
for 24-48 hrs. so pregnancy occurs if coitus occur in this period.
• The shortest cycle minus 18 days –first day of fertile period
• The longest cycle minus 10 days gives the last day of fertile period
• Safe period – rest of cycle i.e. 5-6 days after menstruation & 5-6 days before next cycle.

• Advantage – most natural

• Disadvantage – most unreliable when cycles are irregular & ovulation time is variable
• Complication—Ectopic pregnancies due to conception late in the menstrual cycle
Safe period (Rhythm Method)
 A) Conventional methods
Fertility awareness methods-
2) Basal body temperature method
• Rise in temperature at ovulation due to progesterone
• 0.3-0.5 deg, restrict it to 3 days after temp rise (post ovulatory
infertile period) till menstruation

3) Cervical mucous method

At ovulation becomes watery, resembling raw egg white

4) Sympto-thermic method
Combines BBT, cervical mucous and safe period method
 B) Barrier Methods - Physical
• Condom- NIRODH
• Method of use- inserted over erect penis. After intercourse it should be
removed carefully so that there is no spill.
• Material- Latex rubber
• Supplied under Social Marketing Programme by GOI & Family Welfare
Programme
Male Condom
 Condom- NIRODH
Advantages
• Easily Available
• Safe & inexpensive
• Easy to use, no medical
supervision
• No side effects
• Protects against pregnancy and
sexually transmitted infections
including HIV
Disadvantages
• May slip off or tear due to
improper use
• May feel loss of sensation
locally
• Failure rate: 2 to 3 –14 per 100
women years of use
• Requires disposal
 Female Condom
• Material: A pouch made of polyurethane. It is prelubricated with
silicon.
• Structure: Two rings: One smaller at the cervix and the bigger ring at
the vagina.
• Method of use: to be inserted before coitus. May be inserted 8
hours before.
• Disadvantage: Expensive
Acceptability
• Failure rate: 5 to 21 per 100 women years of use
Female Condom
 Diaphragm
• Material: Dutch cap- invented by a German physician in 1882.
Made of synthetic rubber or plastic.
• Structure: a cap with a diameter of 5-10 cm. A flexible rim
made of metal or spring.
• Method of use: Before coitus along with a spermicide
• To be retained for more than 6 hours after coitus
• Failure Rate: 6-12 per 100 women years of use
Diaphragm
Diaphragm below cervix
 Diaphragm
Advantages
• No medical contraindications
Disadvantages
• Will need to be explained use by
the physician
• Difficult to store under Indian
conditions
• If left in vagina for more than 6
hours may lead to Toxic Shock
Syndrome
• Caused by staphylococcus bacteria
 Chemical Methods
Vaginal Chemical Contraceptives
Method of action: A “surface active agent” which attach
themselves to sperm inhibit oxygen uptake and kills them
Method of Use: Before each coitus along with barrier method
Products
• Foams- Tablets, Aerosols
• Creams- From a tube/ Pastes, Jellies
• Suppositories/ sponge- inserted manually
• Soluble films- C film inserted manually
 Vaginal sponge (Today)
• Material: Small polyurethane foam sponge of 5cm X 2.5cm,
saturated with the spermicide, nonoxynol-9
• Less effective than the diaphragm
• Previously, sponge soaked in vinegar or olive oil was used
• Now soaked in water before use, once applied used for 24 hrs,
not removed before 6 hours
• Failure rate: 20-40 per 100 women-years in parous women
• 9-20 per 100 women years in nulliparous women
Vaginal Sponge
 Chemical methods

Disadvantages
High failure, not effective alone, irritation, repeated each sex act
 Characteristics of barrier methods
• Prevent live sperm from meeting ovum
• No side effects of pill/ IUD
• Prevent STD/ HIV, reduce PID
• Protect from cervical cancer
• Require high degree of user motivation
• Less effective overall than pill/ IUD
 Intra Uterine Contraceptive Devices
(IUCDs)
• Material- A small flexible, plastic device, usually with copper, is
inserted into the womb by a qualified medical practitioner, after
menstruation, abortion, or 4-6 weeks after delivery. The most
common is Copper-T 380 A.
• Mode of Action- It prevents the fertilized egg from settling in the
womb. Copper ions have spermicidal activity. It is 95–98%
effective and can be removed when pregnancy is desired.
• It may cause heavy bleeding in some women.
• Failure Rate: 0.8%
 Types of Intra-uterine devices
• Non-medicated e.g. loops, spirals, coils,
First generation rings

• Earlier devices: Cu-7, Cu T-200

Second generation • Newer devices: Cu T-220 C, Cu T-380 A,
Nova T, Multiload devices

• Hormone releasing: Progesterone IUD,

Third generation Levonorgestrel IUD
 Mechanism of action of IUDs
Causes foreign body reaction

Causes cellular and biochemical changes in the endometrium & uterine

fluids

Impairs the viability of the gamete & thus reduce its chances of
fertilization, rather than its implantation
Parts of Copper T
 Intra Uterine Contraceptive devices (IUCDs)
Non Medicated- Lippes loop (The first IUCD )
Made of polyethylene, plastic, S shaped with a tail of thread
which Puts out into the vagina and can be felt by the women.
Also contains some Barium Sulphate for X Ray visualisation
Method of use – Inserted inside the uterus.
Sizes-ABCD.
Size-- C & D are for multiparous women.
The larger the size more antifertility effect.
 Medicated IUCDs (2nd generation)

• Copper T 380-A (380 mm surface sq of copper )

• Material—plastic with a core of silver over which the copper wire are
wrapped.
• Mode of action– A foreign body reaction causing cellular & biochemical
changes in the endometrium and uterine fluids. There is change in the
composition of the cervical mucous and this effects the sperm motility,
and survival.
• Period of use—10 years
• Effectiveness– Pregnancy rate. 0.5 to 0.8%
• Expulsion rate -5%. Removal Rate –14%
IUCD: CU-T 380 A
 An ideal IUCD Candidate
(Planned Parenthood Federation of America)

• Has at least one child

• No H/O Pelvic disease
• Normal menses
• Willing to check tail
• Has access to follow up & treatment for problems
• Monogamous relationship
 IUCD- 380A
Advantages
•Effective contraceptive and reversible
•Can be retained up to 10 years.
•Simple to insert. ANM does it.
•Can be inserted any time except during pregnancy.
•Free of metabolic side effects

•Best Time is within 10 days from beginning of menses

•Post partum insertion best 6 to 8 weeks after delivery
•Immediate insertion after first trimester post abortion .
•One time insertion
 IUCD- 380A
Disadvantages
•Bleeding 10—20% of all removals
•Pain- backache, cramps in lower abdomen. 15 to 40 % of all removals
•Pelvic inflamatory disease (PID): Users 2 to 8 times more likely to
develop disease. Gardnerella,Anerobic streptococci,Coliform bacilli,
Actinomyces
•Immediate post partum insertion may have injury to uterus as
perforation (Rate 1:150 to 1:9000)
•Physician perforartion rate 0.3%
•Expulsion in some 5%
Steps in Insertion
 Contraindications for IUCD
Absolute: Relative:
• Suspected pregnancy, • Anaemia
• PID—Pelvic Inflamatory Disease • Haemorrhagia
• Vaginal bleeding • H/O PID
• Purulent cervical discharge
• Carcinoma cervix or adenexa
• Distortions in uterine cavity
• Previous ectopic pregnancy • Fibroids
 Pregnancy with IUD
• Failure rate in first year is 3%
• 50% usually end in spontaneous abortion
• If continued probability of premature birth increases by 4 times.
Action to be taken –
• Remove the IUD,
• Legal abortion
• Fertility after removal- 70% conceive within one year of removal
 Third generation IUDs
• Release of hormone

• Progestasert:
 Device with 38 mg of natural hormone, progesterone
 Direct local effect on the uterine lining, cervical mucus and on sperms

• Mirena:
 Contains a potent synthetic steroid, levonorgestrel
 Less side-effects
 More expensive, so can not be introduced on a wide scale
IUD with hormone
(3rd generation)
 Hormonal Contraceptives
• Combined pill 100% success
• 65 million worldwide, 10 million Indian users
Oral Pills
• Combined pill
• Progesterone Only Pill
• Post- coital pill
• Once a month pill
• Male Pill
Depot (slow release formulations)
• Injectables
• Subcutaneous implants/ vaginal rings
 Oral Pills
1) Combined Pill:
• It is one of the major spacing method of contraception. At present time
most formulations contain no more than 30-35 mcg of a synthetic
oestrogen & 0.5 to 1.0 mg of a progestogen.
• Pill is given for 21 consecutive days beginning on 5th day of menstrual cycle,
followed by a break of 7 days during which menstruation occurs.
• When bleeding occurs, it is considered as first day of next cycle.
• Bleeding which occurs is not normal bleeding, but an episode of
incompletely formed endometrium caused by withdrawal of exogenous
hormones. Therefore it is called as withdrawal bleeding rather than
menstruation.
If bleeding does not occur, woman is instructed to start the second cycle one
week after the preceding. one Pill should be taken every day at fixed time.
 Combined Pills:
• Department of Family Welfare, GOI has made two types of formulations
under the brand names- MALA-N & MALA-D. It contains Levonorgestrel
0.15 mg & Ethinyl estrdiol 0.03 mg.
• MALA-D in a package of 28 pills (21 of oral contraceptive & 7 brown
tablets of 60 mg ferrous fumerate is made available to consumer under
social marketing at a price of Rs.3 per packet.
• MALA-N is supplied free of cost through all PHCs, urban family welfare
centers.
 Oral Pills
2) Progestogen-only Pill (POP):
• This is commonly referred to as “minipill” or “micropill”.
• It contains only progestogen, which is given in small dosage throughout the
cycle.
• Commonly used Progestogen pills are norethisterone & levonorgestrel.
• These pills never became popular because of poor cycle control & high
pregnancy rate.
• However they could be prescribed to elderly woman for whom combined
pill is contraindicated due to cardiovascular risk
 Oral Pills
3) Post-coital Contraception:
It is method of contraception that is used to prevent pregnancy, after
unprotected coitus. Also known as the “morning after pill” or “emergency
contraception.”
Post-coital contraception is recommended within 72 hours of unprotected
intercourse.
IUD:
Simplest technique is to insert IUD, if acceptable, especially a copper T
device within 5 days.
Hormonal:
In India Levonorgestrel 0.75 mg tablet is approved for emergency
contraception. It is used as one tablet within 72 hours of unprotected sex &
second tablet after 12 hours of first dose.
Failure rate is less than 1%.
 Oral Pill
4) Once-a-month (long-acting) Pill:
• In this quinestrol-a long acting oestrogen is given in combination with
short acting progestogen.
• But the pregnancy rate is too high to be acceptable & bleeding tends to
be irregular.
5) Male Pill:
• An ideal male contraceptive would decrease sperm count while leaving
testosterone at normal levels.
• A male pill made of gossypol- a derivative of cotton seed oil, has been
very much in news. It is effective in producing azoospermia, but as
many as 10% of men will be permanently azoospermic after taking it for
6 months. It may be toxic also.
 Mode of Action of Oral Pills
• Mechanism of action of combined oral pills is to prevent the release of
the ovum from the ovary.
• This is achieved by blocking the pituitary secretion of gonadotrophin that
is necessary for ovulation to occur.
• Progestogen-only tablet renders the cervical mucosa thick & scanty &
thereby inhibit the sperm penetration.
• Progestogen also inhibit the tubal motility & delay the transport of the
sperm & of the ovum to uterine cavity.
 Effectiveness
• Taken according to prescribed regimen, oral contraceptive of
combined type are almost 100% effective in preventing the
pregnancy.
• Some women do not take the pill regularly, so the actual rate is
lower.
• Effectiveness may also be affected by certain drug like Rifampicin,
Phenobarbitone & Ampicillin
 Oral Pills- Adverse Effects
CVS EFFECTS
-MI, cerebral thrombosis
-Risk increases with age/ smoking increased content of oestrogen

METABOLIC EFFECTS
-Progesterone- Hypertension (decreased HDL), blood clotting, elevations
of blood sugar & plasma insulin

OTHERS
-Hepatocellular adenoma & gall bladder disease
-Ectopic pregnancy (POP)
-Breast tenderness, weight gain, migraine, bleeding
 Oral Pills- Contraindications
Absolute:
CA breast, Liver disease, H/o thromboembolism, cardiac abnormalities,
congenital hyperlipidemia, abnormal uterine bleeding

Under surveillance
Above 35 years, smoking, hypertension, chronic renal disease, epilepsy,
migraine, lactating (first 6 mnths), diabetes mellitus, gall bladder disease,
amenorrhoea

Annual medical examination

 Oral Pills- Beneficial Effects

-Benign breast disorders

-Ovarian cysts
-Iron deficiency anaemia
-PID
-Ectopic pregnancy
-Ovarian cancer
 Chhaya
Chhaya is a non-hormonal, non-steroidal, once a week contraceptive pill.
How does it work?
• Chhaya prevents implantation of fertilized egg in the uterus
How is it used?
• Take one pill twice a week for the first 3 months
• From 4th month take pill once a week on the first pill day
• The first pill can be taken on the first day of the menstrual cycle or any other day provided
pregnancy has been ruled out
• After finishing one pack, take the first pill from next pack on scheduled day
Why Chhaya is the right choice?
• Chhaya is an effective reversible method of contraception
• It is safe for women of all age groups.
• It is safe for breastfeeding women, even immediately after childbirth
• Return to fertility on stopping the pills is prompt
 Depot formulations
Progestin only injectables
Depot medroxyprogesterone acetate
IM 150 mg 3 monthly, suppresses ovulation, no motivation, no effect on
lactation, ideal in post partum period, multipara above 35 yrs; but weight
increase, irregular bleeding, prolonged infertility after use
 Antara DMPA
Injectable contraceptive (MPA) is a hormonal contraceptive method for women that prevents
pregnancy for three months.
How does it work?
• It prevents monthly ovulation, thickens cervical mucus thus blocking sperms from meeting eggs.
• Makes implantation of fertilized egg difficult
How is it used?
• Get an injection every 3 months
• It can easily be administered in the arms, thighs or buttocks
• The date of subsequent dose may be remembered from MPA card provided.
Why injectable is the right choice?
• It is a long-term effective, reversible method of contraception
• Suitable for breastfeeding women (after 6 weeks of childbirth)
• Does not require daily attention
• Ensures user privacy
 Net-EN (Norethisterone enantate)
• It is given intramuscularly in a dose of 200 mg every 60 days.
• Contraception includes inhibition of ovulation & progestogenic effect on
cervical mucus.
• Initial injection of both DMPA & NET-EN should be given during first 5
days of menstrual period.
• Injection site should never be massaged after the injection
• Both DMPA & NET-EN have similar side effects like disruption of normal
menstruation, woman may become amenorrhoeic
• Contraindications include cancer of breast, all genital cancers,
undiagnosed abnormal uterine bleeding.
Combined injectible contraceptive
An alternative injectable containing long-acting progesterone
preparation with short action estrogen 25 mg DMPA + 15 mg
estradiol cypionate (Cyclofem) and 50 mg NET-EN + 5 mg estrdiol
valerate (Mesigyna) are currently available, which are given once
a month.
• CI: pregnancy, CVS disorders, CA, diabetes
• Not suitable for breast feeding women till 6 months
• Injectables inhibit ovulation by:
– preventing the LH surge and lowering FSH and LH.
– by thickening the cervical mucous and rendering the
endometrium less suitable for implantation
– by hindering the rate of ovum transport.

• Effectiveness:
– The reported first year failure rate of DMPA is 0.3%.
– 1.4 for NET-EN.
– Pregnancy rate with Mesigyna is 0.18 per 100 women years and
nil for cyclofem.
Advantages:
– Long-term pregnancy protection, but reversible.
– No daily pill taking.
– Clients can return as much as up to 2 weeks late for next injection.
– Can be used by lactating mothers as soon as 6 weeks after childbirth.
– No estrogen side-effects.
– Helps prevent ectopic pregnancies.
– Helps prevent uterine fibroids.
– May help prevent ovarian cancer.
Disadvantages:
• Common side effects:
– Changes in menstrual bleeding are likely
– May cause weight gain.
• Delayed return of fertility (until level of DMPA in the body drops).
About a 4-8 month longer wait before pregnancy.
• May cause headaches, breast tenderness, moodiness, nausea,
hair loss, less sex drive, and/or acne in some women.
• Does not protect against sexually transmitted diseases including
HIV/AIDS.
 Depot Formulations
Sub Dermal Implants
-Norplant- 35 mg levonorgestrel, 5 yearly
-Problems: menstrual bleeding, surgery

Vaginal rings
-Levonorgestrel
Etonogestrel/ethinyl estradiol.
NuvaRing is a contraceptive vaginal ring, about 2 inches in
diameter that releases a combination of estrogen and
progestin over 3 weeks, followed by 1-week ring-free period.
 Exercises
• Advice a newly married women • A 35 year old healthy women
after having unprotected coitus with two children aged 3 & 5
the day before. years presenting four days after
coitus.
 Exercise on OCs
• A 35 year old women with 3,5 & 7 year old children has
• Deep vein thrombosis
• Hypertension
• Hyperlipidemia
• Ischemic heart disease
 Tubectomy
• This is a permanent surgical method in which the fallopian
tubes are cut and ends tied to prevent the sperms from
meeting the eggs.
• Reliable method requiring only 1 day of hospitalization and
can be performed anytime, preferably after last child’s birth.
Rarely, the tubes may join and fertility may return. A few
women tend to have heavier periods after this method.
• Typical use failure rate: 0.5%.
 Vasectomy
• A permanent surgical method in which, the vasa differentia
which carry the sperms from the testes to the penis, are
blocked.
• This prevents the sperms from being released into the
semen at the time of ejaculation.
• It is a simple and reliable method not requiring
hospitalization.
• Typical use failure rate: 0.15%.
 Metered dose transdermal system
• Spray on contraceptive
• Progestin only-NESTORONE
• Phase III trials
 Trans-cervical sterilization
Essure
• 4 cm long , 2 mm diameter
microcoil
• Spring like device
• Inserted in each fallopian tube
through hysteroscope.
• Tube is blocked permanently
when scar tissue grow inside.
 RISUG
“Reversible Inhibition of Sperm Under Guidance”

Developed by IIT & AIIMS.

- clear polymer gel made of Styrene maleic anhydrate ( SMA )
mixed with Dimethyl Sulphoxide ( DMSO ) injected in to Vas
deferens  partially blocks Vas, preventing sperm from
coming in to ejaculate.
- Phase I & Phase II trials cleared.
- VASALGEL is similar to it.
 Intra Vas Device ( IVD )
- 2 devices inserted in to each Vas .
- Needs special surgical skill.
- wider trials needed.