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Family planning and resent advanceses

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2013 resent advances …

2013 resent advances

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  • 1. FAMILY PLANNING by DR.VENU
  • 2. 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‖.
  • 3. OBJECTIVES  To avoid unwanted births  To bring about wanted births  To regulate the intervals between pregnancies  To control the time at which births occur in relation to the ages of the parent ; and  To determine the number of children in the family.
  • 4. 1. The United Nations Conference on Human Rights at Teheran in 1968 recognized family planning as a basic human right. 2. The Bucharest Conference on the World Population held in August 1974 endorsed the same view. 'Plan of Action' that "all couples and individuals have the basic human right to decide freely and responsibly the number and spacing of their children and to have the information, education, and means to do so".
  • 5. 3.The World Conference of the International Women's Year in 1975 also declared - ―The right of women to decide freely and responsibly on the number and spacing of their children and to have access to the information and means to enable them to exercise that right‖.
  • 6. SCOPE OF FAMILY PLANNING SERVICES (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 reproductive system, (6)Genetic counseling,
  • 7. (7) Premarital consultation and examination, (8) Carrying out pregnancy tests, (9) Marriage counseling, (10) The preparation of couples for the arrival of their child, (11) Providing services for unmarried mothers, (12) Teaching home economics and nutrition, (13) Providing adoption services
  • 8. HEALTH ASPECTS OF FAMILY PLANNING 1.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. 2. FOETAL HEALTH Foetal mortality (early and late foetal death);abnormal development.
  • 9. 3.INFANT AND CHILD HEALTH - Neonatal, infant and pre- school mortality , - Health of the infant at birth (birth weight), - Vulnerability to diseases.
  • 10. THE WELFARE CONCEPT Family planning is associated with numerous misconceptions - one of them is its strong association in minds of people with sterilization. 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 basically related to quality of life.
  • 11. SMALL - FAMILY NORM 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 1,533million by the year 2050 AD.  SYMBOLISED  In the 1970s, - do ya teen bas.  In the 1980s - 2 - child norm.
  • 12. The current emphasis is on three themes: "Sons or Daughters – two will do"; "Second child after 3 years", and universal immunization”. Small differences in the family size will make big differences in the birth rate. A significant achievement of the Family welfare Programme in India has been the decline in the fertility from 6.4 in 1950s to 2.6 in 2010. The national target to achieve a Net Reproduction Rate of 1 by the gear 2006 which is equivalent to attaining approximately the 2-child norm.
  • 13. ELIGIBLE COUPLES A currently married couple wherein the wife is in the reproductive age, which is generally assumed to lie between the ages of 15 - 45. There will be at least 150 to 180 such couples per 1000 population in India. 20 % of eligible couples - age group 15- 24 yrs  On an average 2.5 million couples are joining the reproductive age group every year. The "Eligible Couple Register" is a basic document for organizing family planning work.
  • 14. TARGET COUPLES Couples who have had 2-3 living children, and family planning was largely directed to such couples. The definition of a target couple has been gradually enlarged to include families with one child or even newly married couples with a view to develop acceptance of the idea of family planning from the earliest possible stage. In effect, the term target couple has lost its original meaning.
  • 15. Target group for spacing method Unsterilized couples =112.2 million (estimated) Unsterilized couples exposed to higher order of birth (3& above) = 50.3 million (estimated) Target group For Sterilization Couple sterilized = 45.4 million TOTAL ECs = 197.4 million As on march 2010
  • 16. COUPLE PROTECTION RATE (CPR) 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‖. Demographers are of the view that the demographic goal of NRR : 1 can be achieved only if the CPR exceeds 60 per cent.
  • 17.  National Population Policy was to attain a CPR of 42 per cent by 1990 , and 60 per cent by the year 2000.  During 2010-2011, the total number of family planning acceptors by different methods .  Sterilization- 5 million  Vasectomy- 0.219 million  Tubectomy- 4.78 million  IUD insertion- 5.6 million  Condom users- 16 million  Oral pill users- 8.3 million
  • 18. However about 60 per cent eligible couples are still unprotected against conception. STATE-WISE BREAK-UP Punjab, Gujarat, Maharashtra, Karnataka, Haryana and Tamil Nadu etc – ahead Bihar, Uttar Pradesh, Assam, Rajasthan, West Bengal, Jammu and Kashmir etc - low
  • 19. NATIONAL POPULATION POLICY 2OOO National population policies intended to decrease the birth rate or growth rate. In April 1976 India formed its first National Population Policy. Legal minimum age of marriage was increased from 15 to 18 for girls and from 18 to 21 for boys
  • 20. IMMEDIATE OBJECTIVE : – To address the unmet needs for contraception, – Health care infrastructure and health personnel and – To provide integrated service delivery for basic reproductive and child health care.  MEDIUM TERM OBJECTIVE: – To bring the TFR to replacement level by 2010 through vigorous implementation of inter sectoral operational strategies.  LONG TERM OBJECTIVE: – Achieve a stable population by 2045 at a level consistent with requirement of sustainable economic growth, social development and environmental protection.
  • 21. NATIONAL SOCIO - DEMOGRAPHIC GOALS FOR 2010 1. Address the unmet needs for basic RCH services, supplies and infrastructure. 2. Make school education up to age 14 years free and compulsory, and reduce drop outs rate from primary and secondary school levels to below 20 percent for both boys and girls. 3. Reduce IMR to 30/1000 live births. 4. Reduce maternal mortality ratio (MMR) to less than 100 per 1000 live births. 5. Achieve universal immunization of children against all Vaccine Preventable Disease (VPD). 6. Promote delayed marriage for girls, at age not less than 18,and preferable after 20 years. 7. Achieve 80% institutional delivery and 100% by trained personnels
  • 22. 8. Achieve universal access to information/ counseling services for fertility regulation and contraceptive with wide basket of choices. 9. Achieve 100% registration of births, deaths, marriage, and pregnancy. 10. Containment of AIDS, and greater integration between the management of AIDS and STD. 11. Prevention and control of communicable diseases. 12. Integration of Indian system of medicine in provision of RCH services, and in reaching out to households. 13. Promote small family norm to achieve replacement level of Total Fertility Rate 2.1. 14. Bring about convergence in implementation of related social sector programmes so that family welfare become people centered programme.
  • 23. CONTRACEPTIVE METHODS Preventive methods to help women avoid unwanted pregnancies.  IDEAL CONTRACEPTIVE  Safe Effective Acceptable Inexpensive Reversible Simple to administer Independent of coitus Long lasting to avoid frequent administration Requiring little or no medical supervision
  • 24.  The present approach in family planning programmes is to provide a "cafeteria choice" that 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.  The term conventional contraceptives is used to denote those methods that require action at the time of sexual intercourse, e.g., condoms, spermicides, etc.
  • 25. Classification of contraceptive methods I. SPACING METHODS Barrier Methods Physical Methods Chemical Methods Combined Methods Intrauterine Devices Hormonal Methods Post Conceptional Methods . Miscellaneous II. TERMINAL METHODS Male sterilization Female sterilization
  • 26. MALE CONDOMS Mostly made of fine latex rubber. Silicon used nowdays to produce semi- dry, pre-lubricated forms. Spermicidal – coated with nonoxynol 9 on inner and outer surfaces.  In India, dry condoms are manufactured and supplied free of cost by the government under brand name ‗Nirodh‘  ADVANTAGE:  Simple spacing method  No side effects  Easily available, safe & inexpensive  Protects against STDs  DISADVANTAGE:  Chances of slip off and tear off Failure rate: 2-3/HWY
  • 27. FEMALE CONDOM Advantages Woman controlled method Prevents STDs including HIV/AIDS Not damaged by oils and other chemicals Disadvantages High motivation Only women who can use diaphragms can use female condom Slippage occurs Expensive Failure rate 21% with typical use and 5% with correct and consistent use
  • 28. VAGINAL DIAPHRAGM Most common and easiest to fit and use Thin, nearly hemispherical dome made of rubber or latex material, with circular, covered metal spring at periphery (flat type and coil type) External diameter of rim is size of diaphragm – 45 mm diameter rising in steps of 5 mm to 105mm (most common 60, 65, 70, 75, 80) Coil spring type (ortho diaphragm mostly
  • 29. CERVICAL CAP OR CHECK PESSARY Small dome shaped rubber appliances designed to cover the cervix Remain in place by suction Cap must be tailored to fit cervix Loosely fit caps may be displaced during intercourse Not suitable if cervix lacerated or irregular in shape 3 or 4 sizes between 22 and 31 mm
  • 30. VAULT CAP Hemispherical, dome shaped rubber or plastic cap that fits into vaginal vault covering the cervix Rim is thick but does not contain metal spring External diameter of rim is size of vault cap, ranging from 50 to 75 mm in 5mm steps Correct size – smallest that fits evenly in vaginal vault VINULE CAP Type of cervical cap made of rubber, fairly rigid String attached for easy removal Useful in cystocele or mild prolapse where diaphragm not retained External diameter of rim is size – 45 to 51 mm in 3mm steps
  • 31. Failure rate:  DIAPHRAGM: 18-28% with typical use and 6% with correct and consistent use  CAPS: parous women – 30-40% with typical use 20-26% with correct and consistent use  nulliparous – 16-20% with typical use 9% with correct and consistent use
  • 32. Advantages No gross medical side effects Control of pregnancy in hands of woman Reasonably safe when properly used Prevent spread of STDs though less effective than condom Disadvantages Use of spermicidal unacceptable and messy for some Suitable for intelligent, highly motivated women of middle or high socioeconomic groups Allergy to rubber Infection may occur if used for long time Erosion Urinary tract infection Occlusive caps do not prevent spread of AIDS Rarely, toxic shock syndrome
  • 33. VAGINAL SPONGE Introduced in 1980s ‗Today‘ most popular Soft, disposable foam sponge made of polyurethane. Round shaped with depression at centre of upper surface to fit over cervix Saturated with spermicide nonoxynol 9 Attached nylon loop for removal Moistened with water, squeezed gently to remove excess water and inserted high up in vagina to cover cervix Acts for 24 hrs Failure rate – 9 – 27 per 100 women years Must be removed and thrown away after 8-24 hrs
  • 34. Drawbacks: May get broken – difficult removal High pregnancy rate Toxic shock syndrome Allergic reactions Vaginal dryness, soreness May damage vaginal epithelium – increase risk of HIV transmission
  • 35. SPERMICIDES  Non ionic surfactants which alter sperm surface membrane permeability, resulting in killing of sperms  Developed in late 19th century  Use decreasing due to high failure rate  Types and distribution: spermicidal agents contain nonoxynol 9. few products contain octoxynol 9 and menfegol  Chemical suppositories:  Cheapest but least effective  Melt at body temperature  Manual insertion high in vagina 10-15 min before sexual act
  • 36. 2. Contraceptive creams and jellies liquefy at lower temperature than most creams so more suitable for women with dry vagina 3. Foam tablets effervesce on contact with vaginal moisture placed deep in vagina close to cervix more effective than pessaries Tablets have to be used about 10 min before act and action lasts for 1 hour Failure rate – 0.3-5 per 100 women years ‗Today‘ tablets 4. Aerosols or foams foaming chemical contraceptive creams with butane propellant stored under pressure that may be released by pressing valve slightly more effective but more messy 5. C-film 5cm squares of water soluble , semitransparent plastic impregnated with nonoxynol9 either placed over glans penis before coitus or high in vagina 3-5 min before coitus active for 2 hrs
  • 37. Advantages No instructions by doctors or nurses Easily available and easy to use No gross medical side effects Disadvantages Messy to use Failure rate high when used alone Can increase spread of HIV infection by irritating vaginal and cervical mucosa Failure rate – 21% with typical use and 6% with correct and consistent use.
  • 38. classification IUD Medicated Third Generation Eg. Hormonal IUD Second Generation Eg. Copper IUD Non medicated First Generation Eg. Lippe’s loop 8/6/2013 38
  • 39. First generation iud They are inert or Nonmedicated devices made up of polyethylene Different shapes and sizes LIPPE‘S LOOP:  Double ‗S‘ shaped device  Made up polyethylene material  Non toxic, non tissue reactive & extremely durable  Small amount of Barium Sulphate is also added for radiological examination  Available in 4 sizes A,B,C &D Failure rate: 3-5 / HWY 39
  • 40. Second generation Iud Made up of metal – copper. EARLIER DEVICES Copper - 7 Copper - T 200 NEWER DEVICES Variants of T device  T copper 220C  T copper 380A Nova T Multi load devices Failure rate: 0.8/HWY  ML-Cu250  ML-Cu375 40
  • 41. Third generation iud Hormone releasing IUD Progestastert Most commonly used T shaped device filled with 38mg of progesterone Releasing rate 65µg/day. Effective for 1 yr Failure rate: 0.2 / HWY LNG-20 (Minera) Releases 20µg of levonorgesterol. Effective for 5 yrs Effective rate 99% 8/6/2013 41
  • 42. ADVANTAGES OF IUDs: Safe, Effective, Reversible Inexpensive High continuation rate DISADVANTAGES OF IUDs: Heavy bleeding and pain Pelvic Inflammatory diseases Ectopic pregnancy May come out accidently if not properly inserted 8/6/2013 42
  • 43. TIMING OF INSERTION: Inserted with a plunger Any time during women‘s reproductive period Except in pregnancy Most ideal time is during or within 10 days of the beginning of menstruation the diameter of cervical cavity is greatest at this time. 8/6/2013 43
  • 44. IDEAL IUD CANDIDATE: Who has borne at least 1 child Has no history of PID Has normal menstrual periods Is willing to check IUD tail Has an access to follow up and treatment of potential problems Is in monogamous relationship 8/6/2013 44
  • 45. Classification of hormonal contraceptives Hormonal contraceptives Oral Pills Combined pills Progesterone only pills (POP) Once – a – month (long acting) pills Male pill Post coital pill Depot Preparations Injectables Subdermal Implants Vaginal Rings8/6/2013 45
  • 46. Combined pills Composition: In early 1960s – Oestrogen - 100-200µg and Progesterone - 10mg Greater side effects Nowadays Oestrogen - 30-35µg and Progesterone - 0.05-0.15mg. Taken from 5th to 25th day of menstrual cycle, followed by a break of 7 days (withdrawal bleeding). FAILURE RATE: 0.1/HWY
  • 47. Main type A) MALA-D: (Levonorgestrol 0.15mg + EE 0.03mg) Packet of 28 tabs. 21 are white and 7 are brown coloured containing Ferrous Fumarate.(Rs – 3/-) B) MALA-N : (Levonorgestrol 0.15mg + EE0.03mg) Packet of 28 tabs. Govt Supply. Mechanism of action: A) Prevents ovulation B) Prevents implantation C) Makes cervical secretions thick Effectiveness 100% effective if taken correctly.
  • 48. Eg. MALA-D MALA-N
  • 49. Contraindications to OCP Use Absolute Contraindications Cancer of breast and Genitals H/O venous thrombo- embolism Vascular disease- CAD or CVD Liver disease ( i.e. Viral hepatitis, cirrhosis) Pregnancy Congenital hyper lipidaemia Age above 40 yrs. Smoking and age above 35 yrs HTN with SBP>160, DBP>99 Chronic renal diseases Epilepsy , Migraine Hyper lipidaemia LDL>160 DM with secondary complications Infrequent bleeding, Amenorrhea. 49
  • 50. Progesterone only pills  Minipill or Micropill. Composition: Low dosage of progesterone, mainly Norethisterone (or) Levonorgestrel. Dosage: One tab daily throughout the menstrual cycle It is mainly given in older women in whom combined pills are C/I as in CVDs Efficacy 96-98% Failure rate:0.5/HWY
  • 51. Mechanism of action:  Makes cervical mucosa thick – action starts in 2-4 hrs last for 24hrs.  Decreases the motility of Fallopian tubes.  Prevent pregnancy without preventing ovulation, as ovulation occurs in 20-30% women. Suitable for Lactating women Smokers above 35 yrs old Estrogen sensitive women Disadvantages:  Higher risk of neoplasia in women taking POP than in women on Combined Pills  Poor control of cycle.
  • 52. POST-COITAL COTRACEPTIVE (a) IUD : WITH IN 5 DAYS (b) HORMONAL : More often a hormonal method may be preferable. In India Levonorgestrel 0.75 mg tablet is approved .( 1Tab-with in 72 hrs) (or) 2 tab-50mcg of EE with in 72 hrs after intercourse & same dose after 12 hrs. (or) 4 tab-30-35 mcg of EE with in 72 hrs& 4 tab- after 12 hrs (or) mifepristone 10 mg in 72 hrs
  • 53. Mechanism of action: Hypermotility of fallopian tube Hypermotility of uterus hence no implantation and fertilization Disadvantages: Nausea and vomiting. Next period may start earlier or later Do not protect against STI & HIV  1 % failure rate
  • 54. Male pills The hormones which reduce sperm count tend to reduce testosterone levels hence they affect potency and libido Gossypol: Cotton seed derivative Causes azoospermia and severe oligospermia Toxic Use for 6 months leads to complete sterility 8/6/2013 54
  • 55. Once a month (long acting) pill  In this method a long acting oestrogen (Quinestrol) + short acting progesterone is given.  But the results are highly disappointing. 8/6/2013 55
  • 56. Injectable contraceptives Injectable contraceptives. Progesterone only injectables DMPA (depot- medroxy progesterone acetate) NET-EN ( Norethisrerone Enanthate) DMPA-SCCombined injectables CLASSIFICATION 8/6/2013 56
  • 57. Progesterone only injectables DMPA: Dose: 150mg IM every 3 months. MOA: suppresses ovulation Advantage: doesn‘t affect lactation, useful in postpartum period. Can be used in the multiparae of age >35yr NET-EN: Dose: 200mg IM every 2 months Both DMPA & NET-EN are given in 1st 5 days of menstrual cycle. They are given deep IM in gluteus muscle. 57
  • 58. New formulation of DMPA (Uniject) Prefilled, single use syringe could be particularly They contain a special formulation of DMPA, called DMPA-SC (104 mg). Short needle meant for subcutaneous injection Useful to provide DMPA in the community. Injections by appropriately trained community health workers is safe, effective, and acceptable. 58
  • 59. Side effects: Disruption of normal menses Amenorrhoea Contraindications: Breast cancer Genital cancer Undiagnosed uterine bleeding Suspected malignancy Lactating women FAILURE RATE: 0.3/HWY 8/6/2013 59
  • 60. Combined injectables  Containing long-acting progesterone with short action estrogen 25 mg DMPA + 15 mg estradiol cypionate (Cyclofem) and  50 mg NET-EN + 5 mg estrdiol valerate (Mesigyna)  Given once a month and produce a menstruation like pattern. The trials are currently taking place in India.  MOA:  Suppression of ovulation  Alteration of cervical and endometrial secretions.  C/I:  Pregnancy Thrombo embolytic disorders  Cerebrovascular disease Coronary artery disease  Migraine Breast cancer  DM 60
  • 61. NORPLANT Sub dermal implants A flexible plastic single flexible rod 4cm long x 2mm diameter Contains 35mg LEVONOGESTREL 3 years pregnancy rate 0.7 8/6/2013 61
  • 62. Benefits  Reliable long term contraception  Improvement in menorrhagia and dysmenorrhoea  Beneficial effect on acne in 59%  No adverse effects on bone mass  No significant effect on lipids, haemostasis or liver function Adverse side effects  Bleeding pattern altered: Amenorrhoea 20%  Weight gain of >10% in 21%  Hormonal ‗nuisance‘ effect eg breast pain, headache, libido decrease, dizziness, nausea  Other (<2.5%) alopecia, depression, change in libido 8/6/2013 62
  • 63. The Patch (OrthoEvra) Is a thin & plastic patch  That sticks to the skin. The sticky part of the patch contains the hormones: norelgestromin (progestin) and ethinyl estradiol (estrogen). Weekly for 3wks then patch free 1 week. These hormones are absorbed continuously through the skin and into the bloodstream. 8/6/2013 63
  • 64. 64 Vaginal ring (Nuvaring)  Etonorgestrel 120mcg +Ethinylestradiol 15mcg daily Use for three weeks with a withdrawal week Inhibits ovulation Cycle control good Non-latex  Implanted intra vaginally  The progesterone is absorbed slowly through the vaginal mucosa.  Store 2-8 degrees; if room temperature, up to 4-12 Effectiveness: Overall perfect use failure rate 0.3%, typical use failure rate 8% 64 8/6/2013
  • 65. Post conceptional methods Classification Post conceptional methods Menstrual Regulation Menstrual Induction Oral Abortifacient Abortion 8/6/2013 65
  • 66. Menstrual regulation No legal restriction Aspiration of uterine content  Within 6-14 days of missed period Cervical dilatation needed in nullipara Early complications : Bleeding, Uterine perforation and trauma. Late complications : Tendency to abortion or premature births, infertility, menstrual disorders, ectopic pregnancy & Rh isoimmunization 66
  • 67. Menstrual induction Based on disturbing the normal progesteron- prostaglandin balance by IU application of 1.5mg solution or 2.5-5mg pellet of prostaglandin F 2. Causes sustained uterine contraction for 7 min. followed by cyclical contraction for 3- 4 hrs. Bleeding starts and continues for 7-8 days. 8/6/2013 67
  • 68. Oral Abortifacient Mifepristone + Misoprostol – 95% successful in terminating pregnancies upto 9 weeks. Commonly used regimen Mifepristone 200mg oral on day 1 followed by  Misoprostol 800mcg vaginally immediately or 6 -8 hrs later. Other regimen is Mifepristone 600mg oral on day 1 followed by Misoprostol 400mcg orally on day 3 Follow up visit is must within 14 days for clinical and/or USG examination 8/6/2013 68
  • 69. abortion Definition: Termination of pregnancy before the foetus becomes viable . LEGALISATION Medical termination of pregnancy act 1971 1) Conditions under which abortion is done  Medical Eugenic Humanitarian Socio-economic  In failure of contraceptive device 8/6/2013 69
  • 70. 2) Who can perform abortion? If < 12 weeks 1 RMP having experience in OB-GYN If > 12 weeks -20 weeks then 2 RMP opinion 3) Where can abortion be done? Place approved by Chief medical officer of district i.e DM& HO. 8/6/2013 70
  • 71. Miscellaneous methods 1. Abstinence 2. Coitus Interruptus: failure rate 25/HWY 3. Safe period/rhythm period/ calendar method Basis: ovulation from 12th - 16th day before onset of menses Calculation: 1st day of fertile period = shortest cycle-18days Last day of fertile period = longest cycle-10days 8/6/2013 71
  • 72. Drawbacks: Irregular cycle so difficult to predict Only for educated and responsible couples  Programmed Sex High Failure rate 9/ HWY Complication: Embryonic Abnormalities, Ectopic Pregnancy 8/6/2013 72
  • 73. 4) Natural family planning method: Basis: same as calendar method but here the women employs self recognition of certain signs and symptoms associated with ovulation. a) Basal Body temperature method b) Cervical mucous method c) Symptothermic : It is based on the observation of changes in different body signs: cervical secretions, basal body temperature and the position of the opening of the cervix. 5) Lactation 8/6/2013 73
  • 74. Terminal methods Terminal methods Male sterilization Vasectomy No scalpel vas occlusion Female sterilization Tubectomy Laparoscopic occlusion Tubal inserts (no incision)8/6/2013
  • 75. vasectomy 8/6/2013 75
  • 76. Failure Rate: 0.15/HWY (due to mistaken identification of vas) COMPLICATIONS: Operative Sperm granules Spontaneous recanalisation Autoimmune response Psychological response 8/6/2013 76
  • 77. No scalpel vas occlusion METHODS Elastomer plugs: Gets hardened and plugs the vas SHUG: preformed silicon rubber plug is inserted. RISUG: Reversible Inhibition of Sperm Under Guidance8/6/2013 77
  • 78. Tubectomy Failure rate: 0.5/HWY 78
  • 79. Approaches to the fallopian tubes, surgical procedures, timing of procedure,and related occlusion techniques 8/6/2013 79
  • 80. Evaluation of contraceptive methods Contraceptive efficiency: It is the measurement of unplanned pregnancies even after the use of contraceptive measures. 1) Pearl Index: no. Of failures/100 woman-yr of exposure Failure rate/HWY= Total accidental pregnancies × 1200 total months of exposure 2)Life-table analysis - calculates a failure rate of each month of use. 8/6/2013 80
  • 81. RECENT ADVANCES
  • 82. 1.New Male Pill The pill contains desogestrel as well as testosterone.  Blocks the production of sperm while maintaining male characteristics and sex drive. It must be taken daily. 100% effective and completely reversible in preliminary clinical trials . In clinical trials, all of the participants‘ sperm counts dropped to zero, which means that the male pill would be more effective than the condom and even the female pill. 82
  • 83. 2. CatSper Blocker Sperm rely on calcium ions in sperm- tail for mobility and fertilization.  Humans -ion-channel gene -CatSper.  Blocking CatSper action - effective form of birth control.  Men or women could take this potential CatSper ―blocker‖ because it could be made to act ‖wherever sperm are present.‖
  • 84. 3. Spray On -Contraceptive Australian biotech company Acrux has come up with a world‘s first — a contraceptive spray for women. Metered Dose Transdermal System (MDTS) to administer a pre-set dose of the Nestorone to the skin (forearm) every 14 days. The fast-drying spray gradually absorbed into the bloodstream. Suitable for Breastfeeding mothers Who cannot tolerate contraceptive pills with oestrogens. Leaves no visible residue & less irritation than patches. Because it does not have to be taken at the same time every day, it will suit women who often forget to take the Pill.
  • 85. 4. Adjudin “the male patch” Adjudin (2,4-dichlorobenzyl- 1H-indazole-3-carbohydrazide) is non-hormonal male contraceptive drug, which acts by blocking the maturation of sperm in the testes, but without affecting testosterone production. Normal spermatogenesis returned in 95% within 210 days after the drug had been discontinued. The oral dose effective for contraception is so high that there have been side effects in the muscles and liver, therefore the drug is being manufactured as implant or patch for males.
  • 86. 5. contraction inhibitor pill “dry orgasm” 2 different types of smooth muscle in vasa deferentia  Longitudinal muscle fibers and circular muscle fibers. When segments of vasa deferentia were exposed to phenoxybenzamine or thioridazine , the longitudinal smooth muscle fibers did not contract. The circular smooth muscles did, causes, clamping the vas shut.  Thioridizine‘s side effects were so extreme(hives, difficult breathing;,swelling of face) that the manufacturer discontinued it in 2005, the common side effects of phenoxybenzamine are dizziness , fast heartbeat & stuffy nose. 8/6/2013 86
  • 87. 6. Anti-Fertility Vaccines Contraceptive vaccine either target Gamete production ( FSH and LH) Gamete function Gamete outcome (hCG). CVs targeting gamete function are better choices but induce oophoritis affecting sex steroids.  Antisperm antibody-mediated immunoinfertility provides a naturally occurring model to indicate how an antisperm vaccine will work in humans. The hCG vaccine is the first vaccine to undergo clinical trials in humans. Both the efficacy and the lack of immunotoxicity have been reasonably well
  • 88. 7. R.I.S.U.G Reversible Inhibition of Sperm Under Guidance (RISUG), developed at IIT Kharagpur in India by Dr. Sujoy K Guha. It is currently undergoing clinical trials in India. RISUG is a non-hormonal injectable contraceptive composed of SMA (styrene maleic anhydride) mixed with DMSO (solvent dimethylsulfoxide). Partially blocks the vasa deferentia and destructs the sperm The differential charge from the gel ruptures the sperm‘s cell membrane, stopping the sperm before they can even start their journey to the egg. Reversals by multiple injection of dimethyl sulfoxide or sodium bicarbonate – and several months to reverse.
  • 89. 8. Hydrothermal Male Control  Methods used include Hot water applied to the scrotum Heat generated by ultrasound Artificial cryptorchidism (holding the testicles inside the abdomen) using specialized briefs.  Raising the body temperature above 42 degrees Celsius initiates certain processes, resulting in cells disability. It is called Heat Shock Factor (HSF).It disable sperm cells.  Hot water bath (about 46.7 degrees Celsius)for 45 minutes daily for 3 weeks - simple wet heating - ensure up to 6 months of male infertility.  ultrasound method - the testicles are heated with the help of ultrasound - only two procedures 48 hours - temporary infertility for up to 10 months.
  • 90. 10. SILCS Diaphragm The SILCS diaphragm is a silicone barrier contraceptive device . Its dome is filled with BufferGel that acts both as a spermicide and microbicide that not only immobilizes the sperms but also kills them and fights infections. It avoids the need for many sizes and a pelvic exam for a correct fit; it is designed as a ―one size fits most‖ device. The new device is being evaluated for comfort and ease-of-use in studies, underway in the Dominican Republic, South Africa, Thailand, and the United States.
  • 91. 11. Injectable silicone plugs Often used by men in China as a potential alternative to vasectomy. There are two tested types of injected plugs: Medical-grade polyurethane (MPU) Medical-grade silicone rubber (MSR). The polymer (special ingredient) is injected directly into the vasa differentia, Once injected, the polymer solidifies in place, forming a flexible plug. The procedure takes less than 30 minutes under local anesthesia. It is easier to reverse. It takes 2 to 4 years after the reversal procedure.
  • 92. 12.Essure The Essure procedure involves placing a small & flexible device called a Micro- insert into each fallopian tubes. The Micro- inserts are made from materials that have been well studied and used successfully in the heart and other parts of the human body for many years. Once the Micro-inserts are in place, body tissue grows into the Micro- inserts, blocking the fallopian tubes.
  • 93. SOCIOLOGY OF FAMILY PLANNING Basic social cell. Sociologists and economists believed that living standards of the people can not be improved while population growth unchecked. Attitude surveys have shown that awareness of family planning is very widespread and over 60 per cent people have favorable to restricting or spacing births.
  • 94. Studies have shown that the population problem complicated by deep-rooted religious and other believes. Attitudes and practices favoring larger families. Preference for male children. Most of these beliefs stem from ignorance and lack of communication. The experience of all countries which a successful population control show that the best motivation is economic, a desire to improve standard of living. The solution to the problem is one of mass education and communication.
  • 95. UNMET NEED Women have an unmet need if they are sexually active do not want to have a child soon or at all are not using any contraceptive method are able to conceive  In 1960s – “KAP – gap” In 1977 - Unmet Need
  • 96. Who has unmet need? Fifteen percent of married women in developing countries: 24% in Sub-Saharan Africa 11% in South and Southeast Asia 10% in North Africa and West Asia 12% in Latin America and the Caribbean
  • 97. More than 100 million married women have an unmet need for contraception South & Southeast Asia Central Asia Latin America & Caribbean North Africa & West Asia Sub-Saharan Africa Number (in millions) and % distribution of married women with unmet need 60 (56%) 29 (27%) 7 (7%) 9 (8%) 3 (3%)
  • 98. Reasons for nonuse can be grouped into a few broad categories Opposition to family planning Lack of knowledge Access and cost Health concerns and side effects of methods Misconceptions about pregnancy risk
  • 99. CONTRACEPTION AND ADOLESCENCE 10 and 20 per cent of all pregnancies- developing countries - USA. "At Risk―-Many are undesired, and occur in unmarried adolescents who then resort to legal or illegal abortion, performed under unsatisfactory medical conditions. PREVENTION-Through educational programmes dealing with responsible sexual behavior.  Adolescents are ambivalent about family planning to request contraception is to reveal one's sexuality.
  • 100. For this reason, adolescent girls sometimes choose the risk of an undesired pregnancy and of an abortion. BARRIER METHODS HORMONAL CONTRACEPTION; Hormonal methods are perfectly suitable for adolescents, who generally do not suffer from such problems as cardiovascular contraindications. The demographic future of the world will depend on them, on how well informed they are, and on their sense of responsibilities.
  • 101. AT CETRE FWP Central minister of Health & family welfare SECRETARY SPECIAL SECRETARY JIONT SECRETARY ADDITIONAL SECRETARY SERVICE DELIVERY SYSTEM OF FAMILY PLANNING
  • 102. The National Institute of Health and Family Welfare acts as an apex technical institute for promoting health and family welfare in the country through education, training services, research and evaluation. “Central Family welfare Council” consisting of all the State Health Ministers to review the implementation of the programme.  ―A Population advisory Council‖ headed by the Union Health Minister, members of Parliament, and persons from the fields related to population control was set up in 1982. This body acts like a ―think tank‖ .
  • 103. State welfare bureau part of state director of health & family welfare (25) Dist. Family welfare bureau Dist. Family welfare officer Dist. Mass Education and Media officer CHCs(4,535) PHCs(147,069) At village level Urban family welfare centers(1,083)10 city family welfare bureaus Statistical officer 1979 family welfare and national malaria eradication pro. Regional offices Family welfare cell AT STETE LEVEL
  • 104.  Community Needs Assessment Approach  Involvement of private sector  Incentives and Dis-incentives  Family Welfare linked health insurance scheme  Postpartum Programme  Population education
  • 105. VOLUNTARY ORGANIZATIONS The Family Planning Association of India,  The Family Planning Foundation and the Population Council of India. The Indian Red Cross, The Indian Medical Association, Rotary Clubs,  Lions Clubs, Citizens Forum,  Christian Missionaries and Private Hospitals.
  • 106. INTERNATIONAL LEVEL ―International Planned Parenthood Federation‖ is the world's largest private voluntary organization supporting family planning services in developing countries. The United Nations Fund for Population Activities (UNFPA). the US Agency for International Development (USAID) Population Council,  Ford Foundation, The Pathfinder fund and World Bank besides WHO and UNICEF.
  • 107. NATIONAL FAMILY WELFARE PROGRAMME India launched a nation-wide family planning programme in 1952,first country in the world. Beginnings the programme were modest with the establishment of a few clinics and distribution of educational material, training and research. Third Five Year Plan (1961-66)- "the very centre of planned development‖.- the purely ―clinic approach" to the more vigorous "extension education approach" for motivating the people for acceptance of the 'small family norm".
  • 108. The introduction of the Lipples Loop in 1965 necessitated the creation of a separate Department Family Planning in 1966 in the Ministry of Health. Fourth Five Year Plan (1969-74)- "top priority" to the programme. The Programme was made an integral part of MCH activities of PHCs and their sub-centres. In 1970- All India Hospital Postpartum Programme  1972 - Medical Termination of Pregnancy (MTP) act were introduced. Fifth Five Year Plan (1975-80)- 1976- National Population Policy
  • 109. 1977- Ministry of Family Planning was renamed ― Family Welfare‖ The 42nd Amendment of the Constitution has made "Population control and Family Planning" . The acceptance of the programme is now purely on voluntary basis. The Rural Health Scheme in 1977 and the involvement of the local people. 1978- the Alma Ata Declaration - The acceptance of the primary health care approach to the achievement of HFA/2000 AD led the formulation of a National Health Policy in 1982.
  • 110. The Sixth and Seventh Five Year Plans were accordingly set to achieve these goals. 1985 – 86- Universal Immunization Programme The oral rehydration therapy 1992 these programmes were integrated under Child Survival and Safe Motherhood (CSSM) Programme. 1994- the International Conference on Population and Development in Cairo- implementation of Unified Reproductive and
  • 111. Ninth Five Year Plan the RCH Programme integrates all the related programmes of the Eighth Five Year Plan.  The concept of RCH is to provide  need based, client oriented, demand driven, high quality integrated services. The investment on family welfare programme 0.65 crores during the first plan, the Eleventh Plan period-136,147 crores
  • 112. Evaluation of Family Planning 1. Evaluation of need 2. Evaluation of plans 3. Evaluation of performance a. Services b. Response c. Cost analysis d. Other activities 4. Evaluation of effects 5. Evaluation of impact
  • 113. Thank u

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