Demography & Family Planning

Demography
• Scientific study of the human population
• Demographic cycle:
1. First Stage (High Stationary): High BR & DR
2. Second Stage (Early Expanding): Constant BR &
decreasing DR
3. Third Stage (Late Expanding)
4. Fourth Stage (Low Stationary)
5. Fifth Stage (Declining)
• Diverse demography
• The second-most populous country in the world with over 1.18
billion people (estimate for April, 2010, China at 1.33 bn) and
consists of more than one-sixth of the world's population.
• It contributes 17.31% of the world's population and projected that
India will be the largest populated country by 2025
• India has:
• More than two thousand ethnic groups
• Every major religion is represented
• Four major families of languages (Indo-European, Dravidian,
Austro-Asiatic and Tibeto-Burman languages) as well as a
language isolate (the Nihali language spoken in parts of
Maharashtra).
• Further complexity is lent by the great variation that occurs across
this population on social parameters such as income and education.
• Only the continent of Africa exceeds the linguistic, genetic and
cultural diversity of the nation of India.
 Age structure (2007)
• 0-5 years: 10.38% (SOWC 2010)
• 0–14 years: 30.8%
15–64 years: 64.3%
• 65+ years: 4.9%
• Median age: 25.1 years
• Population growth rate 1.548% (2009 est.)
• Birth rate 21.76 births/1,000 population (2009
est.)
• Death rate 6.4 deaths/1,000 population (2009
est.)
• Literacy rate 79.9%
• Percent of the population under the poverty
line 22% (2006 est.)
• Unemployment Rate 7.8%
• Net migration rate − -0.05 migrant(s)/1,000
population (2007 est.)
 World Population at a glance
• Today’s population
• World: 6,824,900,000 (India 1,210,166,000)
• It took all human history to reach 1 billion in 1800
• Next billions in 130, 30, 15, 12 & 12 years respectively
– Reaching 6 billion on 12.10.1999
• Expected to reach 7 billion by 2012 & 8 billion by 2025
• Three-fourths of the population lives in developing
countries which contribute to 95% of the pop growth
 Population growth rate
• Growth rate = CBR – CDR
Rating Annual growth rate (%) Pop doubling time
Negative negative Population halving
time*
Stationary No growth Never
Slow growth < 0.5 > 139 years
Moderate growth 0.5 – 1.0 70 – 139 years
Rapid growth 1.0 – 1.5 47 – 70 years
Very rapid growth 1.5 – 2.0 35 – 47 years
Explosive growth > / equal to 2.0 < 35 years

• India is growing at a rate of 1.54% per year; has reached 1.17 billion &
will overtake China by 2030 (July 2009 estimates)
• *Ukraine – fastest shrinking population; 20 countries including Russia,
Belarus, Bulgaria, Poland, Germany, Japan etc.
 Census
• 1st time in 1872 (Unorganized)
• 1st proper census: 1881
• 2011 census – 15th since 1872
 Population pyramid

Dependency ratio (Total): 60.25%

 Sex ratios
• Sex ratio: 940
• Child sex ratio (0-6 years): 914
• Highest SR (Kerala 1084), lowest (Daman & Diu
618)
• Highest child SR (Mizoram 971), Lowest child SR
(Haryana 830)
 Population Density (PD)
• Number of persons living per square kilometer
• India: 382 in 2011 Census;
• State with highest PD: NCT Delhi (11297)
• State with lowest PD: Arunachal Pradesh (17)
• District with highest PD: NE Delhi (37,476)
• District with lowest PD: Dibang valley, Arunachal
Pradesh (1)
• India ranks 33 globally in PD; Monaco 1
 Urbanization
• 27.8 % of Indian population lives in urban areas(2009)
• Mega city: More than 10 million population
• 25 megacities globally; 3 in india (Delhi Mumbai,
Kolkata)
• Definition of an urban area: (All three together)
1. A minimum population of 5,000
2. At least 75 per cent of male working population
engaged in non-agricultural pursuits
3. A density of population of at least 400 per sq. km.
 Literacy & Education
• Defined as percentage of people of age 7 years &
above who can read and write with
understanding in any Indian language (1991
census definition)
• Crude literacy rate: Literacy rate with total
population as the denominator.
• 84% World average
• 74.04% (2011); 82% Males & 65% Females
• Kerala – 93.9%; Bihar – 63.8%
 Life Expectancy
• The average number of years which a person
is expected to live according to the mortality
pattern prevalent in that Country
• 2001: 65.4 years total, 63.90 years Males,
66.90 years Females (World ranking 139)
• Highest for Japan (82.6 years)
 Fertility (Natality)
• TFR: Average no of children a woman would bear in her
reproductive life span; approximately equal to
completed family size; (NFHS-III: 2.68, Urban 2.1, Rural
3.0)
• NRR: No of daughters a woman would have with current
fertility & mortality rates; To achieve NRR = 1, CPR > 60%
• GRR: Same as NRR assuming no mortality (1.4 India, 1.5
Rural, 1 Urban)
• Demographic-economic paradox: Inverse correlation b/w
wealth and fertility
• 40.8 % deliveries in India are institutional deliveries
(NFHS-III)
 Fertility – Some more Indices
1. Crude Birth Rate
2. General Fertility rate = No of births in a year /
Mid-year female population aged 15-45 years X
1000
3. Age specific fertility rate = No of live births in a
particular age group / Total females in the same
age group X 1000
 Family Planning
• A basic human right
• Not synonymous with birth control
• 12 components:
1. Spacing & limitation of births
2. Advice on sterility
3. Parenthood education
4. Sex education
5. Screening for reproductive system diseases
6. Genetic counseling
7. Pre-marital counseling & examination
8. Pregnancy diagnosis
9. Preparation of couple for first child
10. Services for unmarried mothers
11. Teaching home economics & nutrition
12. Providing adoption services
 Contraception
• Eligible couple: A currently married couple wherein the
wife is in the reproductive age (15 – 45 years)
• There are 150 -180 eligible couples per thousand
population in India (Total 193 million ECs in India)
• Eligible couple register
• Target couple: Couples with 2-3 living children
• CPR: % of eligible couples effectively protected against
child birth by one of the approved methods of FP viz.
sterilization, IUD, Condom or Oral pills
• CPR 2005: 46.6% {NFHS-III: 56.3% of the currently
married women are using ANY method while 48.5% are
using a modern method}
 Contraceptive use in India
• Condom users: 26.21 million (NFHS-III: 5.2%)
• OCPs: 9.52 million (NFHS-III: 3.1%)
• IUDs: 5.95 million (NFHS-III: 1.7%)
• Tubectomy: 4.40 million (NFHS-III: 37.3%)
• Vasectomy: 0.11 million (NFHS-III: 1.0%)
 Conventional contraceptives
• Conventional contraceptives: Which require
usage at the time of Intercourse
• Condoms, Diaphragms & Spermicides
• Preparations:
• Foams: Tablets or aerosols
• Creams: Jellies & pastes
• Suppositories: Manual insertion
• Soluble films: C-films (Manual insertion)
 IUDs
1st Generation 2nd Generation 3rd Generation
Non medicated / Inert IUDs Medicated or Bio-active IUDs
Lippe’s loop Metallic ions added (Cu / Hormones are added
A / Ag)
Grafenberg’s ring Cu T 7 Progestasert
Cu T 220 B LNG – IUD (Levonorgestrel)
Cu T 380 A

• Numbers represent the surface area of Cu in

square mm
• B refers to the size (A,B, C & D)
• MC side effect is Bleeding;
• MC cause of removal of IUD is Pain
 Duration of protection: IUDs
• Change of IUDs:
• Lippe’s loop: Indefinitely
• Progestasert: 1 year
• CuT 200: 4 years
• Nova-T: 5 years
• LNG IUD: 7-10 years
• CuT 380 A: 10 years (Replaces all other models
w.e.f. 2003)
 Contraindications
• Absolute:
– Pregnancy,
– Sepsis / PID,
– Unexplained vaginal bleeding,
– Malignancies &
– Previous ectopics
• Relative:
– Anemia,
– Menorrhagia,
– Fibroids,
– Unmotivated
 The Ideal IUD candidate
• Planned parenthood federation of America:
1. Who has borne at least one child
2. Who has no history of pelvic disease
3. Has normal menstrual periods
4. Is willing to check the tail of IUD
5. Has access to follow-up & treatment of
potential complications and
6. Is in a monogamous relationship
 Miscellaneous important points
• Timing (for insertion) – Any time but within 10
days of onset of periods is best
• Within a week of delivery: Immediate post-
partum insertion
• 6-8 weeks after delivery: Post-puerperal
insertion (Best)
• Technique of insertion: Withdrawl technique
• Follow-up: After 1st periods, 3rd Periods &
thereafter 6-12 month intervals
 Misc points (contd.)
• Lowest pregnancy rate (Failure rate): LNG IUD
(0.2%)
• Highest pregnancy rate: Lippe’s loop & CuT 200
(Both 3%)
• Expulsion rate: Highest – Lippe’s loop (12-20%) &
lowest – Progestasert (2.7%)
• Removal rate: Highest – LNG IUD (17%) & lowest
– Progestasert (9.3%)
 Natural contraceptive methods
1. Abstinence: Only method which is 100% effective
(Theoretically)
2. Coitus-Interreptus (Withdrawl technique)
3. Calendar technique, fertile period: (First described by Ogino
in 1930) Shortest cycle - 18 days gives first & the longest
cycle - 10 days, gives last day of fertile period. Calendar
technique is associated with two complications – Ectopics &
embryonic abnormalities
4. BBT method: 0.3 to 0.5 degree increase after ovulation
5. Cervical mucus method (Billing’s method or Ovulation
method)
6. Symptothermic method: Combines temperature, cervical
mucus and calendar technique
 Hormonal contraceptives - I
• Oral Pills:
1. Combined pill: Mala-D & Mala-N (free of cost); Norgestrol
0.15 mg & Ethinyl estradiol 0.03 mg
2. Progesteron only pill (POP): Minipill – Increases cervical
mucus thickness (In addition a progesterone Desogestrel
also inhibits ovulation)
3. Post coital pill: Emergency contraception
4. Centchroman (Non-steroidal, Weekly pill): This pill (30 mg)
is to be taken twice a week on fixed days for first three
months , followed by one pill a week thereafter ; Saheli is
the brand name; Socially marketed.
5. Once a month (long-acting) pill: Quinestrol – Not successful
6. Male pill: Gossypol
 Centchroman (Ormiloxifene)
• Ormeloxifene is a SERM
• In some parts of the body, its action is estrogenic (e.g, bones), in
other parts of the body, its action is anti-estrogenic (e.g., uterus,
breasts)
• It causes an asynchrony in the menstrual cycle between
ovulation and the development of the uterine lining, although
its exact mode of action is not well defined.
• In clinical trials, it caused ovulation to occur later than it normally
would in some women, but did not affect ovulation in the
majority of women, while causing the lining of the uterus to build
more slowly.
• It speeds the transport of any fertilized egg through the fallopian
tubes more quickly than is normal.
• Presumably, this combination of effects creates an environment
such that if fertilization occurs, implantation will not be possible.
 Hormonal contraceptives - II
• Depot (slow release) formulations
1. Injectables: Progestone only (DMPA & NET-
EN); Combined injectables (Cyclofem / Cyclo-
provera)
2. Subcutaneous implants: Norplant
(The original Norplant consisted of a set of six small (2.4 mm × 34 mm)
silicone capsules, each filled with 36 mg of levonorgestrel)

3. Vaginal rings
 Injectable contraceptives
• A. Progestin only:
1. Depo-Provera, Megestron, Contracep, Depo-
Prodasone – All contain DMPA 150 mg to be
injected i/m, once X 3 months
2. 104 mg DMPA; S/c, once X 2 months – Depo-
subQ provera (DMPA-SC)
3. Noristerat, Norigest, Doryxas – Norethisterone
enanthate (NET-EN) 200 mg one i/m, X 2months
 Injectable contraceptives
B. Combined injectables
• Cyclofem: MPA 25mg + Estradiol cypionate
5mg – Monthly i/m
• Mesigyna, Norigynon: NET-EN 50mg +
Estradiol valerate 5mg – Monthly i/m
• All combined injectables are monthly I/m
Adverse effects of Hormonal contraceptives

• Cardiovascular effects: MI, Cerebral

thrombosis, Venous thrombosis, Pulmonary
thrombo-embolism. Age & Smoking are
independent risk factors
• Carcinogenesis: Breast cancer – No role;
Cervical cancer & Liver Malignancies: +
• Metabolic effects – alteration in lipid (decline in
HDL) & carbohydrate metabolism (increased
glucose & insulin levels)
 Other adverse effects
• Liver disorders: Adenomas, cholestatic jaundice
• Cessation of lactation
• Slight delay in subsequent fertility
• Ectopics: POPs
• Fetal development: If taken during early
pregnancy: +/-
• Common unwanted effects: Breast tenderness /
Weight gain / Headaches / Bleeding disturbances
 Non contraceptive benefits
1. Benign breast diseases
2. Ovarian cysts
3. Iron deficiency anemia
4. PID
5. Ectopic pregnancy
6. Ovarian cancer
 Contraindications
• Absolute: Ca breast & Genital tract, Liver
disease, h/o thrombo-embolism, CVD,
hyperlipidemia, undiagnosed abnormal
uterine bleeding
• Relative: Age > 40, Smoker > 35 years, special
situations (on ATT, ART etc), Nursing mothers,
Mild hypertension
 Sterilization
• NSV
• Barrier method X 3 months or
• 30 ejaculations
• 48 hours rest & not to wet the area
• Criteria (Eligibility):
– Husband: 25-50 years
– Wife: 20 – 45 years
– 2 living children @ the time sterilization
– Consent of the spouse
Acceptors of vasectomy (Government
Setting)
Acceptors of vasectomy (Private Setting)
 Emergency contraception (Before implantation)

• Yuzpe & Lancee Method: Use of combined oral

pills
• POP (Minipill): Levonergestrel, in a dose of
1.5 mg, either as two 750 μg doses 12 hours
apart, or more recently as a single dose within 24
hours best – 89% effective.
• IUD insertion: Within 5 days
• Antiprogestin (Mifepristone RU 486): 600 mg stat
within 72 hours
 Emergency contraceptive pills
Names of OCPs No. of tablets to be
used in 1st & 2nd
dose
Low dose pill (30-35 Mala-D, Mala-N, 4+4 Start within 72
mcg Estrogen) Pearl, Nordette, hours
Novelon, Ovral-L,
Ecroz
Standard dose pill Ovral, Ovral-G, 2+2 Start within 72
(50 mcg Estrogen) Duolutin hours
Progestin only pill E pills, ECee2, Nor 1+1 Supplied under the
(0.75 mg LNG) Levo, Pill 72 National Program
(Start within 72
hours)

Mifepristone 1 pill Within 72 hours

 Pearl Index
• The index was introduced by Raymond Pearl in
1933. It has remained popular for over seventy
years, in large part because of the simplicity of the
calculation
• Contraceptive failure rate: Per hundred women
years of use = Total accidental pregnancies / Total
months of exposure X 1200
 Pearl Indices
Method Pearl Index
No method used 80
Rhythm method (Calendar) 24
Coitus interreptus 18
Male condoms 2 – 14
Female condoms 5- 21
Diaphragm 12
IUD 0.5 – 2.0
Oral pill 0.1 – 0.5
Centchroman (Saheli) 2-3
 Female Condom Vs Male Condom
Characteristic Male Female
Material Latex Polyurethane (less
commonly Nitrile polumer
& Latex)
Pearl Index 2 - 14 5- 21
No of rings 1 2
Reusable No Yes
Prevention of STIs Yes Yes
 Male contraception
• Pharmaceutical methods
• One goal of research is to develop a male oral
contraceptive, a male contraceptive that can be taken in
pill form by mouth, as The Pill was for women.
• Calcium channel blockers such as nifedipine may cause
reversible infertility by altering the lipid metabolism of
sperm so that they are not able to fertilize an egg.
• Adjudin, a non-toxic analog of lonidamine which, in tests
on rats, has been shown to cause reversible infertility.[19]
The drug disrupts the junctions between nurse cells (Sertoli
cells) in the testes and forming spermatids. The sperm are
released prematurely and never become functional
gametes. A new targeted delivery mechanism has made
Adjudin much more effective.[20]
• Multiple male hormonal contraceptive protocols have been
developed. One is a combination protocol, involving injections of
Depo-Provera to prevent spermatogenesis, combined with the
topical application of testosterone gel to provide hormonal
support.
• Another is a monthly injection of testosterone undecanoate,
which recently performed very well in a Phase III trial in China.
• Research has been performed on interference with the
maturation of sperm in the epididymis.
• Phenoxybenzamine has been found to block ejaculation, which
not only gives it the potential to be an effective contraceptive, but
could also lead to much cleaner sex. Studies have found that the
quality of the semen is unaffected and the results are reversible
by simply discontinuing the treatment.
• Silodosin, an α1-adrenoceptor antagonist with high uroselectivity,
has been shown to completely block ejaculation in human males
while permitting the sensation of orgasm.
 Other techniques

• Reversible inhibition of sperm under guidance (

RISUG) consists of injecting styrene maleic
anhydride in dimethyl sulfoxide into the
vas deferens and leads to long lasting sterility. A
second injection washes out the substance and
restores fertility. (As of 2007, RISUG is in Phase III of
human testing)
• Vas-occlusive contraception consists of partially or
completely blocking the vas deferens, the tubes
connecting the epididymis to the urethra. While a
vasectomy removes a piece of each vas deferens,
the intra vas device (IVD) and other injectable plugs
 Regular Menstrual Cycle
• A woman who experiences variations of less
than eight days between her longest cycles
and shortest cycles is considered to have
regular menstrual cycles.
• Length variation between eight and 20 days is
considered as moderately irregular cycles.
• Variation of 21 days or more between a
woman's shortest and longest cycle lengths is
considered very irregular
• Eumenorrhea denotes normal, regular
menstruation that lasts for a few days (usually 3
to 5 days, but anywhere from 2 to 7 days is
considered normal).
• The average blood loss during menstruation is
35 milliliters with 10–80 ml considered normal.
• Because of this blood loss, women are more
susceptible to iron deficiency than men are.
• “Plasmin” inhibits clotting in the menstrual fluid.