"Delay the first, postpone the second and

Demography, prerent the third" today, is the scientific study of human population. It
as understood
focuses its attention on three readily observable human phenomena :
(a) changes in population size (growth or decline)
(b) the composition of the population and
(c) the distribution of population in space.
It deals with five ”demographic processes”, namely fertility, mortality, marriage,
migration and social mobility. These five processes are continuously at work within a
population determining size, composition and distribution.
Demographic cycle
The history of world population since 1650 suggests that there is a demographic cycle
of 5 stages through which a nation passes:
(1) FIRIST ISTAGE (High stationary)
This stage is characterized by a high birth rate and a high death rate which cancel
each other and the population remains stationary. India was in this stage till 1920.
(2) SECOND STACE (Early expanding)
The death rate begins to decline, while the birth rate remains unchanged. Many
countries in South Asia, and Africa are in this phase. Birth rates have increased in some
of these countries possibly as a result of improved health conditions, and shortening
periods of breast-feeding (1).
(3) THUD ISTAGE (Late expanding)
The death rate declines still further, and the birth rate tends to fall. The population
continues to grow because births exceed deaths. India has entered this phase. In a
number of developing countries (e.g., China, Singapore) birth rates have declined
rapidly.
(4) FOURTH STAGE (Low stationary)
This stage is characterized by a low birth and low death rate with the result that the
population becomes stationary. Zero population growth has already been recorded in
Austria during 1980—85. Growth rates as little as 0.1 were recorded in UK,
Denmark, Sweden and Belgium during 1980—85. In short, most industrialized
countries have undergone a demographic transition shifting from a high birth and
high death rates to low birth and low death rates.
(5) Fig-TH STAGE : [Declining)
The population begins to decline because birth rate is lower than the death rate.
Some East European countries, notably Germany and Hungary are experiencing this
stage.
 FAMILY PLANNING
Definition
There are several definitions of family planning. An Expert Committee (1971) of the
WHO defined family planning as “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” .
Another EKpert Committee [26} defined and described family planning as follows
"Family planning refers to practices that help individuals or couples to attain certain
objectives :
(a) to avoid unwanted births
(b) to bring about wanted births
(c) to regulate the intervals between pregnancies
(d) to control the time at which births occur in relation to the ages of the parent; and
(e) to determine the number of children in the family.

Scope of family planning services

Family planning is not synonymous with birth control; it is more than mere birth
control. A WHO Expert Committee (1970) has stated that family planning includes in
its purview: -
(1) the proper spacing and limitation of births,
(2) advice on sterility,
(3) education for parenthood,
(4) sex education,
(5) screening for pathological conditions related to the reproductive system (e.g.,
cervical cancer),
(6) genetic counselling,
(7) premarital consultation and examination,
(8) carrying out pregnancy tests,
(9) marriage counselling,
(10) the preparation of couples for the arrival of their first child,
(11) providing services for unmarried mothers,
(12) teaching home economics and nutrition, and
(13) providing adoption service .
These activities vary from country to country according to national objectives and
policies with regard to family planning. This is the modern concept of family planning.
Health aspects of family planning (29, 30, 31)
Family planning and health have a two-way relationship. The principal health
outcomes of family planning were listed and discussed by a WHO Scientific Group on
the Health Aspects of Family Planning (29). These can be summarized under the
following headings.

women’s health: maternal mortality, morbidity of women of child— bearing age,

nutritional status (weight changes, haemoglobin level, etc.) preventable complications of
pregnancy and abortion.
Foetal health: foetal mortality (early and late foetal death) ; abnormal development.
infant and child health: neonatal, infant and pre-school mortality, health of the infant at
birth (birth weight), vulnerability to diseases.
 The welfare concept
Family planning is associate with numerous misconceptions — one of them is its
strong association in the minds of people with sterilization. Others equate it with
birth control. The recognition of its welfare concept came only a decade and half
after its inception, when it was named Family Welfare Programme.
The concept of welfare is very comprehensive and is basically related to quality of
life. The Family Welfare Programme aims at achieving a higher end — that is, to
improve the quality of life of the people.
Small-family norm
Small differences in the family size will make big differences in the birth rate. The
difference of only one child per family over a decade will have a tremendous impact
on the population growth.
The objective of the Family Welfare Programme in India is that people should adopt the
“small family norm” to stabilize the country’s population at the level of some 1,533 million
by the year 2050 AD. Symbolized by the inverted red triangle, the programme initially
adopted the model of the 3—child family. In the 1970s, the slogan was the famous Do Yo
Teen Bas. In view of the seriousness of the situation, the 1980s campaign has advocated the
2—child norm. The current emphasis is on three themes : “Sons or Daughters — two will
do”; “Second child after 3 years", and “Universal Immunization”.
Eligible couples
An “eligible couple” refers to a currently married couple wherein the wife is in the
reproductive age, which is generally assumed to lie between the ages of 15 and 45.
There will be at least 150 to 180 such couples per 1000 population in India. These
couples are in need of family planning services. About 20 per cent of eligible couples
are found in the age group 15—24 years (32). On an average
million couples are joining the reproductive group every year. The “Eligible Couple
Register” is a basic document for organizing family planning work. It is regularly
updated by each functionary of the family planning programme for the area falling
within his jurisdiction.
Couple protection rate (CPR)
Couple protection rate (CPR) is an indicator of the prevalence of contraceptive practice in
the community. It is defined as the per cent of eligible couples effectively protected against
childbirth by one or the other approved methods of family planning, viz. sterilization, IUD,
condom or oral pills. Sterilization accounts for over 60 per cent of effectively protected
couples.
Couple protection rate is based on the observation that 50 to 60 per cent of births in a year
are of birth order 3 or more. Thus attaining a 60 per cent CPR will be equivalent to cutting
off almost all third or higher order births, leaving 2 or less surviving children per couple.
During 2012—2013, the total number of family planning acceptors by different
methods was as follows (34A).

Sterilization ... . 4.57 million

Vasectomy 0.12 million
Tubectomy 4.45 million
IUD insertion . 5.41 million
Condom users 13.96 million
Oral pill users 6.2 million
However about 60 per cent eligible couples are still unprotected against conception.
 CONTRACEPTIVE METHODS
(Fertility Regulating Methods)

Contraceptive methods are, by definition, preventive methods to help women avoid

unwanted pregnancies. They include all temporary and permanent measures to
prevent pregnancy resulting from coitus.
It is now generally recognized that there can never be an ideal contraceptive — that is,
contraceptive that is safe, effective, acceptable, inexpensive, reversible, simple to
administer, independent of coitus, long-lasting enough to obviate frequent administration
and requiring little or no medical supervision. The term conventional contraceptives is
used to denote those methods that require action at the time of sexual intercourse, e.g.,
condoms, spermicides, etc. Each contraceptive method has its unique advantages and
disadvantages. The success of any contraceptive method depends not only on its
effectiveness in preventing pregnancy but on the rate of continuation of its proper use.
The contraceptive methods may be broadly grouped into two classes — spacing
methods and terminal methods, as shown below :

Spacing methods
1. Barrier methods
(a) Physical methods
(b) Chemical methods
(c) Combined methods
2. Intra-uterine devices
3. Hormonal methods
4. Post-conceptional methods
5. Miscellaneous.
I I. Terminal methods
1 Male sterilization
2 Female sterilization.

BARRIER METHODS

A variety of barrier or “occlusive” methods, suitable for both men and women are
available. The aim of these methods is to prevent live sperm from meeting the
ovum. Barrier methods have increased in popularity quite recently because of certain
contraceptive and non-contraceptive advantages.
The main contraceptive advantage is the absence of side-effects associated with
the “pill” and IUD.
The non-contraceptive advantages include some protection from sexually
transmitted diseases, a reduction in the incidence of pelvic inflammatory disease and
possibly some protection from the risk of cervical cancer (36).
Barrier methods require a high degree of motivation on the part of the user. In
General they are less effective than either the pill or the loop. They are only effective
if they are used consistently and carefully.
a. PHYSICAL METHODS
1. Condom (37, 38)
Condom is the most widely known and used barrier device by the males around the
world. In India, it is better known by its trade name NIRODH, a sanskrit word,
meaning prevention. Condom is receiving new attention today as an effective, simple
“spacing” method of contraception, without side effects. In addition to preventing
pregnancy, condom protects both men and women from sexually transmitted diseases.
The condom is fitted on the erect penis before intercourse. The air must be
expelled from the teat end to make room for the ejaculate. The condom must be held
carefully when withdrawing it from the vagina to avoid spilling seminal fluid into
the vagina after intercourse. A new condom should be used for each sexual act.
Condom prevents the semen from being deposited in vagina. The effectiveness of
a condom may be increased by using it in conjunction with a spermicidal jelly
inserted into the vagina before intercourse. The spermicide serves as additional
protection in the unlikely event that the condom should slip off or tear.
Condoms can be a highly effective method of contraception, if they are used
correctly at every coitus. Failure rates for the condom vary enormously. Surveys
have reported pregnancy rates varying from 2—3 per 100 women— years to more than
14 in typical users (59) . Most failures are due to incorrect use.
The ADVANTAGES of condom are : (a) they are easily available (b) safe and
inexpensive (c) easy to use; do not require medical supervision (d) no side effects
(e) light, compact and disposable, and (f) provides protection not only against
pregnancy but also against STD.
DISADVANTAGES are : (a) it may slip off or tear during coitus due to incorrect use,
and (b) interferes with sex sensation locally about which some complain while others
get used to it. The main limitation of condoms is that many men do not use them
regularly or carefully, even when the risk of unwanted pregnancy or sexually
transmitted disease is high.
Condoms are manufactured in India by the Hindusthan Latex in Trivandrum, London
Rubber Industries in Chennai and others. Besides commercial outlets, condoms are
supplied under social marketing programme.
Female condom
The female condom is a pouch made of polyurethane, which lines the vagina.
2.Diaphragm
The diaphragm is a vaginal barrier. It was invented by a German physician in 1882.
Also known as “Dutch cap”, the diaphragm is a shallow cup made of synthetic
rubber or plastic material. It ranges in diameter from 5—10 cm (2—4 inches). It has a
flexible rim made of spring or metal. It is important that a woman be fitted with a
diaphragm of the proper size. It is held in position partly by the spring tension and partly
by the vaginal muscle tone. This means, for successful use, the vaginal tone must be
reasonable. Otherwise, in the case of a severe degree of cystocele, the rim may slip
down.
ADVANTAGES - The primary advantage of the diaphragm is the almost total
absence of risks and medical contraindications. DISADVANTAGES : Initially a
physician or other trained person will be needed to demonstrate the technique of
inserting the diaphragm into the vagina and to ensure a proper fit. After delivery, it
can be used only after involution of the uterus is completed.
 3. Vaginal sponge
Another barrier device employed for hundreds of years is the sponge soaked in
vinegar or olive oil, but it is only recently one has been commercially marketed in
USA under the trade name TODAY for the sole purpose of preventing conception. It
is a small polyurethane foam sponge measuring 5 cm x 2.5 cm, saturated with the
spermicide, nonoxynol—9. The sponge is far less effective than the diaphragm,
b. CHEMICAL METHODS
In the 1960s, before the advent of IUDs and oral contraceptives, spermicides
(vaginal chemical contraceptives) were used widely. They
comprise four categories (4J):
a) Foams : foam tablets, foam aerosols
b) Creams, jellies and pastes — squeezed from a tube
c) Suppositories — inserted manually, and
d) Soluble films — C—film inserted manually.

The spermicides contain a base into which a spermicide is incorporated. The

commonly used modern spermicides are “surface-active agents” which attach
themselves to spermatozoa and inhibit oxygen uptake and kill sperms (44).
The main drawbacks of spermicides are : (a) they have a high failure rate (b) they
must be used almost immediately before intercourse and repeated before each sex
act (c) they must be introduced into those regions of the vagina where sperms are
likely to be deposited, and (d) they may cause mild burning or irritation, besides
messiness. The spermicide should be free from potential systemic toxicity.

INTRA-UTERINE DEVICES

Types of IUD
There are two basic types of IUD : non-medicated and medicated. Both are usually
made of polyethylene or other polymers;
in addition, the medicated or bioactive IUDs release either metal ions (copper) or
hormones
(progestogens).
The non-medicated or inert IUDs are often referred to as first generation IUDs.
The copper IUDs comprise the second and the hormone—releasing IUDs the t
hird generation IUDs. The medicated IUDs were developed to reduce the incidence
of side-effects and to increase the contraceptive effectiveness.
shows different types of IUDs currently in use. In India, under the National Family
Welfare Programme, Cu—T—200 B is being used. From the year 2002, Cu—T—380
A has been introduced in the programme .
FIRST GENERATION IUDs
The first generation IUDs comprise the inert or non- medicated devices, usually made of
polyethylene, or other polymers. They appeared in different shapes and sizes — loops,
spirals, coils, rings, and bows. Of all the models, the Lippes Loop is the best known and
commonly used device in the developing countries.
Lippes Loop
Lippes Loop is double—S shaped device made of polyethylene, a plastic material that is
non-toxic, non-tissue reactive and extremely durable. It contains a small amount of barium
sulphate to allow X-ray observation. The Loop has attached threads or “tail” made of fine
nylon, which project into the vagina after insertion. The tail can be easily felt and is a
reassurance to the user that the Loop is in its place. The tail also makes it easy to remove
the Loop when desired.
The Lippes Loop exists in four sizes A,B,C, and D, the latter being the largest. A larger
sized device usually has a greater anti-fertility effect and a lower expulsion rate but a
higher removal rate because of side-effects such as pain and bleeding. The larger Loops (C
and D) are more suitable for multiparous women.
SECOND GENERATION IUDs
It occurred to a number of research workers that the ideal IUD can never be
developed simply as a result of obtaining changes in the usual shape or size (42). A
new approach was tried in the 1970s by adding copper to the IUD. It was found that
metallic copper had a strong anti-fertility effect [47). The addition of copper has made
it possible to develop smaller devices which are easier to fit, even in nulliparous
women. A number of copper bearing devices are now commercially available :
Earlier deuices :
— Copper — 7 . CopperT-200
Never devices :
— Variants of the T device
(i) Cu-T—220 C
(ii) Cu-T—380 A or Ag
— NovaT
— Multiload devices
(i) ML—Cu—250
(ii) ML—Cu—375
The numbers included in the names of the devices refer to the surface area (in sq.
mm) of the copper on the device. Nova T and Cu-T— 380 Ag are distinguished by a
silver core over which the copper wire is wrapped.
The newer copper devices are significantly more effective in preventing
pregnancy than the earlier copper ones or the inert IUDs. The newer copper IUDs —
Multiload devices and variants of the T device — offer the further advantage of
having an effective life of at least 5 years. They can be left in place safely for the
time, unless specific medical or personal reasons call for earlier removal.
Advantages of copper devices
— Low expulsion rate
— Lower incidence of side-effects, e.g., pain and Bleeding
— easier to fit even in nulliparous women
— better tolerated bp nullipara
— increased contraceptive effectiveness
effective as post-coital contraceptives, if inserted within 3—5 days of unprotected
intercourse
THIRD GENERATION IUDs
A third generation of IUDs — based on still another principle, i.e., release of a
hormone — have become available on a limited scale.
The most widely used hormonal device is progestasert, which is a T—shaped
device filled with 38 mg of progesterone, the natural hormone.
The hormone is released slowly in the uterus at the rate of 65 mcg daily. It has
a direct local effect on the uterine lining, on the cervial mucus and possibly on the
sperms. Because the hormone supply is gradually depleted, regular replacement of
the device is necessary.
Another hormonal device LNG—20 (Mirena) is a T—shaped IUD releasing 20
mcg of levonorgeetrel (a potent synthetic steroid);
it has a low pregnancy rate (0.2 per 100 women) and less number of ectopic
pregnancies (40). Long-term clinical experience with levonorgestrel releasing IUD
has shown to be associated with lower menstrual blood loss and fewer days of
bleeding than the copper devices.
The levonorgestrel releasing IUD has an effective life of 10 years (40).
The hormonal devices would be particularly valuable for women in developing
countries in whom excess blood loss caused by inert devices have been shown to
result in significant anaemia. But these devices are more expensive, to be introduced
on a wide scale.

Mechanism of action of IUDs

At present, the most widely accepted view is that the IUD causes a foreign—body
reaction in the uterus causing cellular and biochemical changes in the endometrium and
uterine fluids, and it is believed that these changes impair the viability of the gamete and
thus reduce its chances of fertilization, rather than its implantation.
Medicated IUDs produce other local effects that may contribute to their
contraceptive action. Copper seems to enhance the cellular response in the
endometrium (48). It also affects the enzymes in the uterus. By altering the
biochemical composition of cervial mucus, copper ions may affect sperm motility,
capacitation and survival
Advantages
The IUD has many advantages : (a) simplicity, i.e., no complex procedures are
involved in insertion; no hospitalization is required (b) insertion takes only a few
minutes (c) once inserted IUD stays in place as long as required (d) inexpensive (e)
contraceptive effect is reversible by removal of IUD (f) virtually free of systemic
metabolic side-effects associated with hormonal pills (g) highest continuation rate, and
(h) there is no need for the continual motivation required to take a pill daily or to use a
barrier method consistently;
only a single act of motivation is required. However, as with most contraceptive
methods, the IUD can produce side-effects such as heavy menstruation and/or pain.
Contraindications
ABSOLUTE . (a) suspected pregnancy (b) pelvic inflammatory disease (c) vaginal
bleeding of undiagnosed aetiology (d) cancer of the cervix, uterus or adnexia and other
pelvic tumours (e) previous ectopic pregnancy (50).
RELATIVE : (a) anaemia (b) menorrhagia (c) history of PID since last pregnancy
(d) purulent cervical discharge
(e) distortions of the uterine cavity due to congenital malformations, fibroids (f)
unmotivated person (45).
The ideal IUD candidate
The Planned Parenthood Federation of America (PPFA) has described the ideal
IUD candidate as a woman :
— who has borne at least one child
 — has no history of pelvic disease has normal menstrual
periods
— is willing to check the IUD tail
— has access to follow-up and treatment of potential problems, and
— is in a monogamous relationship.

Timing of insertion
 Although the loop can be inserted at almost anytime during a woman’s reproductive
years (except during pregnancy), the most propitious time for loop insertion is during
menstruation or within 10 days of the beginning of a menstrual period (42). During
this period, insertion is technically easy because the diameter of the cervical canal is
greater at this time than during the secretory phase.
 The IUD insertion can also be taken up during the first week after delivery before the
woman leaves the hospital (“immediate postpartum insertion”).
 . IUD insertion can also be taken up immediately after a legally induced first trimester
abortion. But IUD insertion immediately after a second trimester abortion is not
recommended . Since there is a risk of infection, most physicians still do not approve
of an IUD insertion after an illegal abortion.
Follow-up
An important aspect of IUD insertion is follow-up which is sadly neglected. The
objectives of the follow-up examination are : (a) to provide motivation and emotional
support for the woman (b) to confirm the presence of the IUD, and (c) diagnose and treat
any side-effect or complication.
The IUD wearer should be given the following instructions : (a) she should regularly
check the threads or “tail” to be sure that the IUD is in the uterus; if she fails to locate the
threads, she must consult the doctor (b) she should visit the clinic whenever she
experiences any side- effects such as fever, pelvic pain and bleeding, and (c) if she misses a
period, she must consult the doctor.
SIDE—EFFECTS AND COMPLICATIONS

1. Bleeding,Pain, Pelvic inflammatory disease (PID), Uterine perforation,

Pregnancy,Ectopic pregnancy,Expulsion, Fertility after removal, Cancer and
teratogenesis, Mortality
HORMONAL CONTRACEPTIVES
Hormonal contraceptives when properly used are the most effective spacing methods of
contraception. Oral contraceptives of the combined type are almost 100 per cent effective in
preventing pregnancy. They provide the best means of ensuring spacing between one
childbirth and another. More than 65 million in the world are estimated to be taking the
“pill” of which about 9.52 million are estimated to be in India.
Gonadal steroids
To physicians in general medicine, the term “steroid” refers to adrenocortical hormones,
while to those in gynaecology, it implies gonadal steroids, i.e., oestrogens and
progestogens.
a. Synthetic oestrogens : Two synthetic oestrogens are used in oral contraceptives. These
are ethinyf-oestrodiol and mestranol. Both are effective. In fact, mestranol is inactive until
converted into ethinyl oestradiol in the liver (59).
 b. Synthetic progestogens : These are classified into three groups — pregnanes, oestranes
and gonanes. (i) Pregnanes These include megestrol, chlormadinone and medroxy—
progesterone acetate. The pregnane progestogens are now not recommended in oral
contraceptives because of doubts raised by the occurrence of breast tumours in beagle dogs.
(ii) Oestrones : These are also known as 19—nortestosterones, e.g., norethisterone,
norethisterone acetate, lynestrenol, ethynodiol diacetate and norethynodrel. These are all
metabolized to norethisterone before becoming active. For some women, oestranes are
more acceptable than gonanes. (iii) Gonanes : The most favoured gonane is levonorgestrel
(59) .
Classification
Hormonal contraceptives currently in use and/or under study may be classified as
follows :
A. Oral pills
1. Combined pill
2. Progestogen only pill (POP)
3. Post-coital pill
4. Once—a—month (long—acting) pill
5. Male pill
B. Depot (slow release) formulations
1. Injectables
2. Subcutaneous implants
3. Vaginal rings
A. ORAL PILLS
1. Combined pill
The combined pill is one of the major spacing methods of contraception. The "original
pill” which entered into the market in the early 1960s contained 100—200 mcg of a
synthetic oestrogen and 10 mg of a progestogen. Since then, a number of
improvements have been made to reduce the undesirable side-effects of the pill by
reducing the dose of both the oestrogen and progestogen. At the present time, most
formulations of the combined pill contain no more than 30—35 mcg of a synthetic
oestrogen, and 0.5 to 1.0 mg of a progestogen. The debate continues about the
minimum effective dose of the progestogen in the pill which will produce the least
metabolic disturbances.
Types of pills
The Department of Family Welfare, in the Ministry of Health and Family Welfare,
Government of India has made available 2 types of low-dose oral pills under the
brand names of MALA-N and MALA—D. It contains Levonorgestrel
mg and Ethinyl estradiol 0.03 mg. Mala—D in a package of 28 pills (21 of oral contraceptive
pills and 7 brown film coated 60 mg ferrous fumarate tablets) is made available to the
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 centres, etc.

2.Progestogen-only pill (POP)

This pill is commonly referred to as “minipill” or “micropill”. It contains only
progestogen, which is given in small doses throughout the cycle. The commonly used
progestogens are norethisterone and levonorgestrel.
The progestogen-only pills never gained widespread use because of poor cycle control
and an increased pregnancy rate (60}. However, they have a definite place in modern—
 day contraception. They could be prescribed to older women for whom the combined pill
is contraindicated because of cardiovascular risks. They may also be considered in young
women with risk factors for neoplasia .
3.Post-coital contraception
Post-coital (or “morning after”) contraception is recommended within 72 hours of an
unprotected intercourse. Two methods are available :
(a) IUD : The simplest technique is to insert an IUD, if acceptable, especially a
copper device within 5 days.
(b) Hormonof : More often a hormonal method may be preferable. In India
Levonorgestrel 0.75 mg tablet is approved for emergency contraception. It is used as one
tablet of 0.75 mg within 72 hours of unprotected sex and the 2nd tablet after 12 hours of
1st dose.

Two oral contraceptive pills containing 50 mcg of ethinyl estradiol within 72 hours
after intercourse, and the same dose after 12 hours.
OT
Four oral contraceptive pills containing 30 or 35 mcg of ethinyl estradiol within 72
hours and 4 tablets after 12 hours.
Mifepristone 10 mg once within 72 hours.
4.Once—a—month (long-acting) pill
Experiments with once—a—month oral pill in which quinestrol, a long-acting
oestrogen is given in combination with a short-acting progestogen, have been
disappointing (63). The pregnancy rate is too high to be acceptable. In addition, bleeding
tends to be irregular.
5.Male pill
The search for a male contraceptive began in 1950 (64) .Research is following 4
mainlines of approach .
(a) preventing spermatogenesis (b) interfering with sperm storage and maturation (c)
preventing sperm transport in the vas, and (d) affecting constituents of the seminal
fluid. Most of the research is concentrated on interference with spermatogenesis.

A male pill made of gossypol — a derivative of cotton-seed oil, has been very much
in the news. It is effective in producing azoospermia or severe oligospermia, but as
many as 10 per cent of men may be permanently azoospermic after taking it for 6
months. Further gossypol could be toxic.
MODE OF ACTION OF ORAL PILLS
The mechanism of action of the combined oral pill is to prevent the release of the
ovum from the ovary. This is achieved by blocking the pituitary secretion of
gonadotropin that is necessary for ovulation to occur. Progestogen—only preparations
render the cervical mucus thick and scanty and thereby inhibit sperm penetration.
Progestogens also inhibit tubal motility and delay the transport of the sperm and of the
ovum to the uterine cavity .

EFFECTIVENESS
Taken according to the prescribed regimen, oral contraceptives of the combined
type are almost 100 per cent effective in preventing pregnancy. Under clinical trial
 conditions, the effectiveness of progestogen—only pills is almost as good as that of the
combination products. However, in large family planning programmes, the
effectiveness. The effectiveness may also be affected by certain drugs such as
rifampicin, phenobarbital and ampicillin .
RISKS AND BENEFITS

a. Adverse effects

1. Cardiovascular eJecfs

2. Carcinogenesis

3. Metabolic effects
4. Other adverse effects
Liner disorders
5. Common unwanted effects
Breast tenderness : Weight gain, Heodoche ond migraine, Bleeding disturbances
b. Beneficial effects
c. the Oxford Family Planning Association’s long-term prospective studies of pill
use in Britain have shown that using the pill may give protection against at least
6 diseases: benign breast disorders including fibrocystic disease and
fibroadenoma, ovarian cysts, iron— deficiency anaemia, pelvic inflammatory
disease, ectopic pregnancy and ovarian cancer.
Contraindications
(a) Absolute : Cancer of the breast and genitals; liver disease; previous or present
history of thromboembolism; cardiac abnormalities; congenital hyperlipidaemia;
undiagnosed abnormal uterine bleeding.
Special problems requiring medical surueiffonce : Age over 40 years; smoking and
age over 35 years; mild hypertension; chronic renal disease; epilepsy; migraine;
nursing mothers in the first 6 months; diabetes mellitus; gall bladder disease;
history of infrequent bleeding, amenorrhoea, etc.
Duration of use
The pill should be used primarily for spacing pregnancies in younger women. Those
over 35 years should go in for other forms of contraception. Beyond 40 years of
age, the pill is not to be prescribed or continued because of the sharp increase in the
risk of cardiovascular complications .
. DEPOT FORMULATIONS
The need for depot formulations which are highly effective, reversible, long—
acting and oestrogen—free for spacing pregnancies in which a single administration
suffices for several months or years cannot be stressed. The injectable
contraceptives, subdermal implants and vaginal rings come in this category.
1. Injectable contraceptives
There are two types of injectable contraceptives. Progestogen—only injectables and
the newer once—a—month combined injectables. The formulation and injection
schedules of injectable contraceptives are as shown in Table 23.
A. PROGESTOGEN—ONLY INJECTABLES
 Thus far, only two injectable hormonal contraceptives — both based on progestogen
— have been found suitable. They offer more reliable protection against unwanted
pregnancies than the older barrier techniques. These are :
a. DMPA (Depot—medroxyprogesterone acetate)
b. NET—EN (Norethisterone enantate)
c. DMPA—SC

a. DMPA (82)
Depot—medroxyprogesterone acetate (DMPA or Depo— provera) has been in use
since 1960s. The standard dose is an intramuscular injection of 150 mg every 3
months. It gives protection from pregnancy in 99 per cent of women for at least 3
months.
b. NET—EN
Norethisterone enantate (NET—EN) has been in use as a contraceptive since 1966.
However, it has been less extensively used than DMPA. It is given intramuscularly in
a dose of 200 mg every 60 days. Contraceptive action appears to include inhibition of
ovulation, and progestogenic effects on cervical mucus. A slightly higher (0.4)
pregnancy rate (failure rate) has been reported as compared to DMPA.
Adm inistration
The initial injection of both DMPA and NET—EN should be given during the first
5 days of the menstrual period. This timing is very important to rule out the
possibility of pregnancy. Both are given by deep intramuscular injection into the
gluteus maximus. The injection site should never be massaged following injections.
c. DMPA—SC 104 mg (82)
A new lower-dose formulation of DMPA, depo-subQ prooera 104 (also called
DMPA—SC), is injected under the skin rather than in the muscle. It contains 104 mg of
DMPA rather than the 150 mg in the intramuscular formulation. Like the
intramuscular formulation, DMPA—SC is given at 3-month intervals.
Side-effects
Both DMPA and NET—EN have similar side effects, the most common being
disruption of the normal menstrual cycle, manifested by episodes of
unpredictable bleeding, at times prolonged and at other times excessive.
Contraindications
These include cancer of the breast; all genital cancers; undiagnosed abnormal
uterine bleeding; and a suspected malignancy. Women usually should not start
using a progestin-only injectable if they have high blood pressure (systolic k 160
mm Hg or diastolic ñ 100), certain conditions of the heart, blood vessels, or liver
including history of stroke or heart attack and current deep vein thrombosis. Also,
a woman breast-feeding a baby less than 6 weeks old should not use progestin-only
injectables
B. COMBINED INJECTABLE CONTRACEPTIVES
These injectables contain a progestogen and an oestrogen. They are given at
monthly intervals, plus or minus three days. Combined injectable
contraceptives act mainly by suppression of ovulation. The cervical mucus is
affected, mainly by progestogen, and becomes an obstacle to sperm
penetration. Changes are also produced in endometrium which makes it
unfavourable for implantation if fertilization occurs, which is extremely
unlikely.
2. Sub dermal implants
The Population Council, New York has developed a subdermal implant known as
Norplant for long-term contraception. It consists of 6 silastic (silicone rubber) capsules
containing 35 mg (each) of levonorgestrel (85) . More recent devices comprise
fabrication of levonorgestrel into 2 small rods, Norplant (R)—2, which are
comparatively easier to insert and remove. The silastic capsules or rods are implanted
beneath the skin of the forearm or upper arm. Effective contraception is provided for
over 5 years. The contraceptive effect of Norplant is reversible on removal of capsules. A
large multicentre trial conducted by International Committee for Contraception Research
(ICCR) reported a 3—year pregnancy rate of 0.7. The main disadvantages, however,
appear to be irregularities of menstrual bleeding and surgical procedures necessary to
insert and remove implants.
POST-CONCEPTIONAL METHODS
(Termination of pregnancy)

Menstrual regulation
A relatively simple method of birth control is “menstrual regulation”. It consists of
aspiration of the uterine contents 6 to 14 days of a missed period, The immediate
complications are uterine perforation and trauma. Late complications (after 6
weeks) include a tendency to abortion or premature labour, infertility, menstrual
disorders, increase in ectopic pregnancies and Rh—immunization.
Menstrual regulation differs from abortion in 3 respects (88) :
(a) the lack of certainty if a pregnancy is being terminated. Microscopic examination
of the aspirated material can confirm pregnanc.y post facto, but it is not obligatory
(b) the lack of legal restrictions, and
(c) the increased safety of the early procedure.
Menstrual induction
This is based on disturbing the normal progesterone— prostaglandin balance by
intrauterine application of 1—5 mg solution (or 2.5—5 mg pellet) of prostaglandin
F2. Within a few minutes of the prostaglandin impact, performed under sedation,
the uterus responds with a sustained contraction lasting about 7 minutes, followed
by cyclic contractions continuing for 3—4 hours. The bleeding starts and continues
for 7—8 days.
ABORTION
Abortion is theoretically defined as termination of pregnancy before the foetus
becomes viable (capable of living independently). This has been fixed
administratively at 28 weeks‘, when the foetus weighs approximately 1000 g.
Abortion is sought by women for a variety of reasons including birth control. In fact,
in some countries (e.g., Hungary) the legal abortions exceed live births.
Abortions are usually categorized as spontaneous and induced. Spontaneous
abortions occur once in every 15 pregnancies (89). They may be considered
“Nature’s method of birth control”. Induced abortions, on the other hand, are
deliberately induced — they may be legal or illegal. Illegal abortions are hazardous;
they are usually the last resort of women determined to end their pregnancies at the
risk of their own lives.
 THE MEDICAL TERMINATION OF PREGNANCY ACT 1971
The Medical Termination of Pregnancy Act, 1971 lays down :
1. The conditions under which a pregnancy can be terminated.
2. The person or persons who can perform such terminations, and
3. The place where such terminations can be performed.
1. The conditions under n›hich a pregnancy can be
terminated under the RFP Act. 1971 :
There are 5 conditions that have been identified in the
Act :
a. Medical — where continuation of the pregnancy might endanger the mother’s life or
cause grave injury to her physical or mental health.
b. Eugenic - where there is substantial risk of the child being born with serious
handicaps due to physical or mental abnormalities.
c. Humonitorion — where pregnancy is the result of rape.
d. Socio-economic — where actual or reasonably foreseeable environments (whether
social or economic) could lead to risk of injury to the health of the mother, and
Failure oJ confr‹icepfiue devices — The anguish caused by an unwanted
pregnancy resulting from a failure of any contraceptive device or method can
be presumed to constitute a grave mental injury to the health of the mother.
This condition is a unique feature of the Indian law and virtually allows
abortion on request, in view of the difficulty of proving that a pregnancy was
not caused by failure of contraception.
The written consent of the guardian is necessary before performing abortion in
women under 18 years of age, and in lunatics even if they are older than 18 years.
MTP RULES (1975)
Rules and Regulations framed initially were altered in October 1975 to eliminate
time—consuming procedures involved in MTP and to make services more readily
available. These changes have occurred in 3 administrative areas (93, 94).
1. Approval by Board
Under the new rules, the Chief Medical Officer of the district is empowered to
certify that a doctor has the necessary training in gynaecology and obstetrics to do
abortions. The procedure of doctors applying to Certification Boards was removed.
2. Qualification required to do abortion
The new rules allow for registered medical practitioners to qualify through on the
spot training :
“If he has assisted a RMP in the performance of 25 cases of medical
termination of pregnancy in an approved institution”.
The doctor may also qualify to do MTPs under the new rules if he has one or more
of the following qualifications which are similar to the old rules :
(a) 6 months housemanship in obstetrics and gynaecology.
(b) a postgraduate qualification in OBG.
(c) 3 years of practice in OBG for those doctors registered
before the 1971 MTP Act was passed.
(d) 1 year of practice in OBG for those doctors registered on or after the date of
commencement of the Act.
3. The place there oborfion is performed
Under the new rules, non—governmental institutions may also take up abortions
provided they obtain a licence from the Chief Medical Officer of the district, thus
 eliminating the requirement of private clinics obtaining a Board licence.
MISCELLANEOUS

1. Abstinence
2. Coitus interruptus
3. Safe period (rhythm method)
This is also known as the “colendor method” first described by Ogino in 1930. The
method is based on the fact that ovulation occurs from 12 to 16 days before the onset
of menstruation (see Fig. 8). The days on which conception is likely to occur are
calculated as follows :

The shortest cycle minus 18 days gives the first day of the fertile period. The

longest cycle minus 10 days gives the last day of the fertile period. For example, if a
woman’s menstrual cycle varies from 26 to 31 days, the fertile period during which
she should not have intercourse would be from the 8th day to the 21st day of the
menstrual cycle, counting day one as the first day of the menstrual period. Fig. 8
shows the fertile period and the safe period in a 28-day cycle.
The drawbacks of the calendar method are :
(a) a woman’s menstrual cycles are not always regular. If the cycles are irregular,
it is difficult to predict the safe period
(b) it is only possible for this method to be used by educated and responsible couples
with a high degree of motivation and cooperation
(c) compulsory abstinence of sexual intercourse for nearly one half of every month
— what may be called “programmed sex”
(d) this method is not applicable during the postnatal period, and
(e) a high failure rate of 9 per 100 woman—years (39) . The failures are due to
wrong calculations, inability to follow calculations, irregular use and “taking
chances”.

Natural family planning methods

Breast-feeding
Birth control vaccine

TERMINAL METHODS
(Sterilization)
Voluntary sterilization is a well—established contraceptive procedure for couples
desiring no more children. Currently female sterilizations account for about 85 per
cent and male sterilizations for 10—15 per cent of all sterilizations in India (10f),
inspite of the fact that male sterilization is simpler, safer and cheaper than female
sterilization.
Sterilization offers many advantages over other contraceptive methods — it is a one-time
method; it does not require sustained motivation of the user for its effectiveness; provides the
most effective protection against pregnancy; the risk of complications is small if the
procedure is performed according to accepted medical standards; and it is most cost-effective.

G uidelines Jor sferilization

Sterilization services are provided free of charge in Government institutions.
Guidelines have been issued from time to time by the Government covering various
aspects of sterilization. These are (105, 106):
a. The age of the husband should not ordinarily be less than 25 years nor should it
be over 50 years.
b. The age of the wife should not be less than 20 years or more than 45 years.
c. The motivated couple must have 2 living children at the time of operation.
d. If the couple has 3 or more living children, the lower limit of age of the
husband or wife may be relaxed at the discretion of the operating surgeon, and
e. It is sufficient if the acceptor declares having obtained the consent of his/her spouse
to undergo sterilization operation without outside pressure, inducement or coercion,
and that he/she knows that for all practical purposes, the operation is irreversible,
and also that the spouse has not been sterilized earlier.
Male sterilization (107, 108)
Male sterilization or vasectomy being a comparatively simple operation can be
performed even in primary health centres by trained doctors under local anaesthesia.
When carried out under strict aseptic technique, it should have no risk of mortality. In
vasectomy, it is customary to remove a piece of vas at least 1 cm after clamping. The
ends are ligated and then folded back on themselves and sutured into position, so that the
cut ends face away from each other. This will reduce the risk of recanalization at a later
date. It is important to stress that the acceptor is not immediately sterile after the
operation, usually until approximately
30 ejaculations have taken place [44). During this intermediate period, another method of
contraception must be used. If properly performed, vasectomies are almost 100 per cent
effective.
Following vasectomy, sperm production and hormone output are not affected. The
sperm produced are destroyed intraluminally by phagocytosis. This is a normal process in
the male genital tract, but the rate of destruction is greatly increased after vasectomy.
Vasectomy is a simpler, faster and less expensive operation than tubectomy in terms of
instruments, hospitalization and doctor's training. Cost-wise, the ratio is about 5 vasectomies
to one tubal ligation.
COMPLICATIONS
The very few complications that may arise are :
(a) Operotiue :
(b) Sperm granules
(c) Spontaneous reconofizotion
(d) Autoimmune response :
(e) Psychologicol

Post-operafiue aduice
To ensure normal healing of the wound and to ensure the success of the operation,
the patient should be given the following advice :
 1. The patient should be told that he is not sterile immediately after the
operation; at least 30 ejaculations may be necessary before the seminal
examination is negative [44).
2. To use contraceptives until aspermia has been established.
3. To avoid taking bath for at least 24 hours after the operation.
4. To wear a T—bandage or scrotal support (ldngot) for 15 days : and to keep the
site clean and dry.
5. To avoid cycling or lifting heavy weights for 15 days; there is, however, no
need for complete bed rest.
6. To have the stitches removed on the 5th day after the operation.
No scalpel vasectomy
No scalpel vasectomy is a new technique that is safe, convenient and acceptable to
males. This new method is now being canvassed for men as a special project, on a
voluntary basis under the family welfare programme. Under the project, medical
personnel all over the country are to be trained. Availability of this new technique at
the peripheral level will increase the acceptance of male sterilization in the country.
The project is being funded by the UNFPA.
Female sterilization
Female sterilization can be done as an interval procedure, postpartum or at the time of
abortion. Two procedures have become most common, namely laparoscopy and
minilaparotomp.
(a) Laparoscopy
This is a technique of female sterilization through abdominal approach with a
specialized instrument called “laparoscope”. The abdomen is inflated with gas (carbon
dioxide, nitrous oxide or air) and the instrument is introduced into the abdominal cavity to
visualize the tubes. Once the tubes are accessible, the Falope rings (or clips) are applied to
occlude the tubes. This operation should be undertaken only in those centres where
specialist obstetrician—gynaecologists are available. The short operating time, shorter
stay in hospital and a small scar are some of the attractive features of this operation.
Patient selection : Laparoscopy is not advisable for postpartum patients for 6 weeks
following delivery; however, it can be done as a concurrent procedure to MTP.
Haemoglobin per cent should not be less than 8. There should be no associated medical
disorders such as heart disease, respiratory disease, diabetes and hypertension.
It is recommended that the patient be kept in hospital for a minimum of 48 hours after
the operation.
Complications : Although complications are uncommon, when they do occur they may
be of a serious nature requiring experienced surgical intervention. Puncture of large blood
vessels and other potential complications have been reported as major hazards of
laparoscopy.
(b) Minilap operation
Minilaparotomy is a modification of abdominal tubectomy. It is a much simpler
procedure requiring a smaller abdominal incision of only 2.5 to 3 cm conducted under
local anaesthesia. The minilap/Pomerop technique is considered a revolutionary procedure
for female sterilization. It is also found to be a suitable procedure at the primary health
centre level and in mass campaigns. It has the advantage over other methods with regard
to safety, efficiency and ease in dealing with complications. Minilap operation is suitable
for postpartum tubal sterilization.