All in one version 1.5

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Demography, Population Studies and Family
Planning (BPH 203.6 DPSFP)
48 Hours
(Version 1.5)
Upendra Raj Dhakal
urdhakal@gmail.com
Lecturer: Valley College of Technical Science
Version 1.5 (Feedback welcomed)
Unit 1: Introduction to demography and
population studies
(4 hours)

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Concept
Medical
Demography
Introduction to Demography and P.S in PH
• Population health studies is a field of study that address health of all
people in a specific place, such as Kathmandu, Dolpa, or India. It is a
broader aspect of studies, which should address different determinants of
health (social, behavioral, disease, biological mechanisms, etc)
• It is focused on biological determinants of health, epidemiology, aging and
life cycle, social and behavioral shapers of health, etc.
• Demography is derived from Greek words, where Demos = People &
Graphia = field of study
• Demography is a science dealing with static and dynamic aspects of
human population.
➢Static aspects of population include age, sex, marital status, economic characteristics,
social group, religion.
➢Dynamic aspects include fertility, mortality, nuptiality, migration and growth.

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Contd …
• Demography focuses its attention on study of
• Size of population
• Change in population (growth or decline)
• Processes of population change (fertility, mortality and migration)
• Distribution of population
• Structure of population
• Composition of population
• Medical demography is the application of demographic concepts,
models, and techniques to the analysis of the dynamics of morbidity
and mortality at all ages.
• M.D. projects the consequences of health, sickness accidents,
disability and death for the size, composition, and structure of the
population.
Contd …
• Big 3 : Birth, Death and Migration
• On the basis of big 3, population stability or population change is
calculated

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Importance of Demography and population
studies
• Danger of demographic fatigue: ………
• Embracing and hating population: ………..
• Public Health Planning: ………..
• Planning for food supply: ………
• Planning for employment: ……….
• Educational Planning: …………
• Housing Planning: ………..
• Conflict Management and Terrorism: ……………..
• Social Planning: ………………
• Globalization: ………..
Application of D and P.S. in PH, S.D. and P.P.
• Identify population structure by age, sex, etc
• Know distribution of population (geographically)
• Helps in formalizing evidences like
• Population trend and projection
• Fertility
• Mortality
• Migration
• Morbidity, etc
• Evidence based decision making (like in nutrition, MCH, pandemics, etc) and project
development
• Resource identification for different levels of prevention
• Policy and planning to provide public utilities and services (Service utilization, wash,
surveillance and screening, etc)
• Measure the success and failure of program

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Sources of population data …
• There are always two sources of data
• Primary source: It is the first hand source of data, which is original and
collected basically for specific purpose. Eg. Census, projections, registrations,
migration reports and surveys
• Secondary sources: It is the second hand (or further) source of data, which is
converted into different form after certain processing, like descriptive or
inferential analysis and is collected for different purpose. We try adjusting our
need of data using the data collected by others for other purpose. Eg.
Statisticalabstracts, organizational records, Books, Journals, newspapers, etc
Sources in general
Main sources of population data are:
• Population census
• Vital registration
• Sample surveys
• Administrative records
• Service statistics
• Population register
• International publications
• ……

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Importance of Census
• Policymaking, planning, and administrative and research.
• Population censuses data are used for public and private sector policymaking,
planning, and administrative and research purposes.
• Electoral boundary delimitation and allocation of representatives
• The most basic administrative uses of census data is in the demarcation of
constituencies and the allocation of representation on governing bodies.
• Calculating vital indices and health indicators.
• In addition, the census data provides indispensable data for computing health
indices such as infant mortality rate, child mortality rate, maternal mortality rate,
birth rates, population growth rates
• Costly
• ………………
Process of Census
Final results of census
Processing of data using ICR software
Forms are transported into data processing centres
Gather Information (by asking questions and filling up forms)
Visit each and every household

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Types of census
Contd …
• De facto population census involves the counting of only
those who are present physically when the census is
performed. Only people who are living within the borders of
the country or are seen by the census expert are counted.
• De jure population census involves the counting of only
people who have been permanent residents of a specific
area, but they were not necessarily present when the census
was performed. This is population census is also considered
counting by proxy.

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Importance of Civil Registration System and
Vital statistics
• Legal documents are created
• Helps in protecting civil rights of
individuals
• To form the basis of policy
guideline, planning and
projections
• Monitor the demographic trend
• Important tool for studying
population dynamics
• Primary source of information
• ………………
Importance of Sample Survey data
• Reduced cost and time (suitable for limited resources)
• Smaller scale of operation
• High representativeness
• Good statistical significance
• High scope and data accuracy
• Convenience
• Intensive and exhaustive data
• Better rapport
• Precise result
• ……………………

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Importance of Health Institution Data
• Baseline information
• Helps in strategy planning at local level, and to policy level planning
• Identify patient behavior/behavior of service provider
• Disease monitoring
• Cutting down unnecessary costs
• Adopting diagnostic and therapeutic techniques
• Patient well being
• Practitioner performance
• Staffing strategy
• …………….
Importance of Natl. and Intl. Publications
• Resource for data discussion, and drawing conclusion
• Academic career development
• Exchange of population literatures
• Dissemination information
• Kick of or exit plan
• Mass communication
• Discussion in scientific community
• Explore gaps and rise scope
• …………..

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DHS - Intro
• DHS was first conducted simultaneously over more than 90 countries using
similar tools
• DHS is USAID funded project which was first initiated in 1984 as an expansion of
World Fertility Survey (WFS)
• It is conducted in the interval of every 5 years
• It collects information abut fertility and total fertility rate, reproductive health,
maternal health child health immunization and survival, HIV/AIDS, maternal
mortality, malaria and Nutrition
• It is aimed to monitor and evaluate different programs and for policy
development decisions
• DHS includes: Demographic and health Surveys, Aids Indicator Surveys Service
Provision Assessment, Malaria Indicator Survey, Key Indicators Survey Other
Quantitative Data (Geographic Benchmarking), Biomarker Collection, and
Qualitative research
• NDHS was done in 2016 (latest)
DHS - Objectives
• The objective of the survey is to provide up-to-date estimates of:
• Fertility Levels And Preferences,
• Marriage,
• Sexual Activity,
• Family Planning Methods,
• Breastfeeding Practices,
• Nutrition,
• Anemia,
• Childhood And Maternal Mortality,
• Maternal And Child Health,
• HIV/AIDS And Other Sexually Transmitted Infections (STIs),
• Women’s Empowerment, Domestic Violence, And
• Hypertension
That can be used by program managers and policymakers to evaluate
and improve existing programs.

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DHS - Process
• It has 4 stages and can take upto 2.5 years to complete
Unit 2: Demography
(3 hours)

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Concept and importance of Demography. –
Done in Unit 1
Application of D in PH SD PP & R – Done in
unit 1

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Demographic Indicators and their need in PH
• Population statistics :
• Census, population projection, resource distribution, age – sex
distribution, forest coverage, town/village coverage etc
• Vital statistics
• Birth rate, death rate, natural growth rate, projected CBR, projected
CDR, Life expectancy at Birth, IMR, MMR, ASMR, TFR, etc
• Need of these indicators in Public Health: …..
Different measures and calculation of
demography: Population ratio
• Population ratio: Population ratio are used to describe the degree of
balance between two elements of the population. Eg. Male Vs. Female,
Children Vs Women of Reproductive age.
• The ratio is normalized to refer to a standard unit of people, usually 100
persons. It can be normalized in 1000 or 100000 population as per the
convenient.
• Sex ratio: The sex ratio is the ratio of males to females in the population normalized
to (100). We calculate two sex ratio: at birth, and in total population
• The sex ratio at birth is fairly standard, around 105. due to higher mortality among
males, the sex ratio in the total population switches to 95 – 97. For populations with
high levels of sex – selective outmigration (such as male solders leaving a country for
war), particularly in certain age groups (e.g. aged 15 – 29), the sex ratio may be even
smaller

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Contd … (Global)
• Sex ratio at birth: 105 except for Africian populations, where it is 102 103
• Sex ratio for total population: 101.5
• Sex ratio for population 15 – 49, with heavy male outmigration: 99.9
• Eg. Sex ratio at birth = (2456/2102) X 100 = 117
• Dependency ratio: This ratio quantifies the number of persons in a population who are
not economically active for every 100 economically active persons in that population.
• Demographic ratio can be calculated by dividing the population 0-14 years and 65
years and older by the population that is in the 15-64 year age group.
• Eg. (4450/(5000 – 4450)) X 100 = 133
or
• (57%/43%) X 100 = 133
Contd …
• We can calculate separate dependency ratio: Child dependency ratio (pop 0 – 14/ pop 15 –
64) and old age dependency ratio (pop 65+/pop 15 – 64)
• Ranges for child dependency ratios:
• Least Developed: 80.8
• Developing: 53.1
• More Developed: 29.4
• Child – woman ratio: This ratio, the CWR, the ratio of children under 5 per 1000 women
of reproductive age (WORA).
• Child woman ratio is usually calculated by dividing the number of children in the age
group 0-4 (of both sexes) by the number of women of reproductive age (15-49 years), and
then multiplying by 1000.
• Eg. (46/10200) X 1000 = 480

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Contd …
• Ranges for the CWR:
• Least Developed: 710
• Developing: 400
• More Developed: 255
• Maternal Mortality Ratio: The maternal mortality ratio (MMR) is the number of maternal
deaths per 100,000 live births.
• The numerator only includes deaths to women during their pregnancy or in the first 6
weeks after delivery.
• This ratio is often used in lieu of the maternal mortality rate (the number of maternal
deaths per 100,000 women aged 15-49 (WORA) per year) because of the difficulty in
obtaining accurate data to calculate the rate of this relatively infrequent event in a
population which is subject to great underestimation, since all pregnancies, births and
deaths tend to be underreported .
Contd …
• Ranges for the MMR:
• Least Developed: 1000
• Developing: 440
• More Developed: 12

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Difference MM Rate and MM Ratio
MM Rate =
𝑵𝒖𝒎𝒃𝒆𝒓 𝒐𝒇 𝒎𝒂𝒕𝒆𝒓𝒏𝒂𝒍 𝒅𝒆𝒂𝒕𝒉𝒔 𝑜𝑐𝑐𝑢𝑟𝑖𝑛𝑔 𝑖𝑛
𝑟𝑒𝑓𝑒𝑟𝑒𝑛𝑐𝑒 𝑝𝑒𝑟𝑖𝑜𝑑 (𝑢𝑠𝑢𝑎𝑙𝑙𝑦 1 𝑦𝑒𝑎𝑟)
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑾𝑶𝑹𝑨 𝑖𝑛 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛
𝑖𝑛 𝑟𝑒𝑓𝑒𝑟𝑒𝑛𝑐𝑒 𝑝𝑒𝑟𝑖𝑜𝑑
𝑥 𝟏, 𝟎𝟎,𝟎𝟎𝟎
MM Ratio =
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝒍𝒊𝒗𝒆 𝒃𝒊𝒓𝒕𝒉𝒔 𝑜𝑐𝑐𝑢𝑟𝑖𝑛𝑔
𝑤𝑖𝑡ℎ𝑖𝑛 𝑡ℎ𝑒 𝑟𝑒𝑓𝑒𝑟𝑒𝑛𝑐𝑒 𝑝𝑒𝑟𝑖𝑜𝑑
𝑥 𝟏, 𝟎𝟎, 𝟎𝟎𝟎
Population Ratio with different levels of HWs
Assignment
• PHO: Population = 492
• PHEd: Population = 1
• Environmental Health Officer: Population = --
• Public Health Nutritionist: Population = --
• Medical
• Dr: Population = 28477 (MBBS/BDS)
• Specialist:population = 8301
• Nurse:population = 61421 (PCL)
• HA:Population = 1975
• ANM:Population = 34432
• CMA: Population = 4254
• Paramedics: population = ---

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PHO Population
• There is no specific ratio defined for PHO:Populatin yet. NHSP suggests – Environmental and
Public Health Workers = 0.01 per 1000 population
• For being a PHO one should be licensed from NHPC, but superior complexity of doctors and
intervention from allied health sectors has limited real PH
• Pandemic has raised a question upon the role of PHO population ratio
• There should be appropriate number of core public health worker in each community
• According NHSSP 2013 report, PHO composition is 5%, where 32809 are public health sector
workers, mostly occupied by non public health professionals
• 30% PHO were found below 30 years
• Higher concentration in Central Region
• HP had largest number of PHO (39%) followed by central level hospitals (23%).
• 76% doctors were in central hospitals and 9% in district hospitals
• 82% were permanent and 13% were contracted
• Majority of PH workers is governed by Health Service Act, 1997/98; but a significant number of
staff, mainly administrative and management staff are governed by Civil Service Act, 1993
PHE:Population
• Though Public Health Educationalists are registered in very few
numbers, there is no specific provision of PHE in Nepal
• Government has different Health Education Officer post in different
levels of Ministry, but are not Public Health Educators

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Environmental Health Officer: Population
• There is no specific data of Environmental Health Officer, rather it is
merged with Public Health Workers in NHSSP, 2013 and is termed as
“Environmentaland Public Health Workforce”
Public Health Nutritionist: Population
• Nutritionist and dietitian are still outside the main stream of
governmentrecognition
• There is no council for them yet, rather have only associations

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General Physician: Population
• 0.09 per 1000 population
Specialist: Population
• 0.07 per 1000 population

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Nurses:Population
• 0.50 per 1000 population(As a whole including Midwifery)
HA
• Not available

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ANM
• Not available separately
CMA

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Paramedics
HRs distribution in short
• WHO estimates that at least 2.5 medical staff (physicians, nurses and
midwives) per 1000 people are needed to provide adequate coverage
with primary care interventions (WHO – World Health Response,
2006)

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Year
Per 1000 population
Physicians Nursing/Midwifery Physiotherapists
2018 34280
2017 33505
2016 32630
2015 31635
2014 0.6 0.36 30650
2013 0.55 36315
2012 0.51 35680
2011 34905
2010 33535
2009 0.63 32635
2008 0.52
2007 0.52
2006 0.46
2005 0.61
2004 0.21
Nurses population
Staff Nurse 61421
NNC registered –
Annual Report
2076/77
ANM 34432
Foreign Nurses 844
Midwives Bachelor 11

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Ayurveda Group
MD/MS/PG 115
Nepal Ayurveda Medical Council
Annual Report 2076/77
BAMS/equivalent 760
Ayurveda B Pharmacy 5
AHA/Equivalent 1560
AAHW/TSLC 2563
Trad Healers 19
Foreign practitioners 4
Doctors
Male Female Total Nepal
Ayurveda
Medical
Council
Annual
Report
2076/77
MBBS/BDS 17995 10482 28477
MD/MS 5906 2395 8301
Foreign Doctors 185

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Nepal Health Professional Council
Specialization First Second Third Total
PH 126 366 - - 492
Health Education - 1 - - 1
Medicine - - 1975 2279 4254
Medical Microbiology 7 7 14
Health Lab 3 113 856 1768 2740
Radiography 7 40 262 309
Biochemistry 5 5
Homeopathy 3 3
Acupuncture 1 6 7
Physiotherapy 17 171 20 208
Dental Science 107 5 112
Naturopathy 8 8
Ophthalmology 2 148 228 378
Operation Theater and Allied Health Science 15 15
Clinical Psychology 2 2
Speech and hearing 2 2
Sub Total 171 855 3472 4052
Total 8550
Be careful
These data Provided in Annual Report 2076/77 are not accurate

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Demographic Record and its importance
• Demographic statistics are measures of the characteristics of,
or changes to, a population. Records of births, deaths,
marriages, immigration and emigration and a regular census
of population provide information that is key to making sound
decisions about national policy.
• It is important to know the situation and trend, forecast, plan
and policy formation, resource allocation and distribution,
etc…..
Importance
• Nearly everything is connected with demography
• Population planning
• Development works
• Terrorism and regional conflict
• Embracing and Hating Immigration
• Globalization
• Degradation of the environment
• Danger of demographic fatigue

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Unit 3: Population Structure,, Characteristics and
Components
(6 hours)
Concept
• Population structure refers many agendas
• Population structure (genetics) is also known as population stratification
• Population Pyramid
• Age class structure
• F – statistics
• Poplation density
• Population dynamics
• Population genetics
• Populatin growth
• Population size
• Etc …

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Healthy and Unhealthy population structure
• Population structure is defined by the organization of genetic
variation and is driven by the combined effects of evolutionary
processes that include recombination, mutation, genetic drift,
demographic history, and natural selection.
• The rates of natural increase, births, death, infant mortality and life
expectancy all affect population structure of a country
• Population structure of a country can be shown by a population or
age – sex pyramid
• Healthy and unhealthy population is a ratio between specific (or
collection) disease or condition to healthy population
Types of population pyramid

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TYPES OF POPULATION PYRAMID
• While all countries' population pyramids differ, three types have been identified by the fertility and mortality rates of a
country
• Expansive pyramid - A population pyramid showing a broad base, indicating a high proportion of children, a rapid rate of
population growth, and a low proportion of older people. This type of pyramid indicates a population in which there is a
high birth rate, a high death rate and a short life expectancy. E.g. Kenya, India
• Stationary pyramid - A population pyramid typical of countries with low fertility and low mortality. E.g. Argentina
• Contractive pyramid - A population pyramid showing lower numbers or percentages of younger people. The country will
have a greying population which means that people are generally older. E.g. Sweden
• They can also be related to the DTM
Uses of population pyramid
• Compare male and female population.
• Shows dependent and independent population
• Shows specific age group separately.
• Helps in planning (long term)
• Resource allocation
• ….

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Trend of population
growth in developed
and developing
countries
Trends between developed and developing countries
• Each day 200,000 more people are added to the world food demand.
• The world’s human population has increased near fourfold in the past 100 years (UN
population Division, 2007); it is projected to increase from 6.7 billion (2006) to 9.2 billion
by 2050(UN Population Division, 2007).
• It took only 12 years for the last billion to be added, a net increase of nearly 230,000 new
people each day, who will need housing, food and other natural resources.
• The largest population increase is projected to occur in Asia, particularly in China, India
and Southeast Asia, accounting for about 60% and more of the world’s population by 2050
(UN Population Division, 2007).
• The rate of population growth, however, is still relatively high in Central America, and
highest in Central and part of Western Africa.
• In relative numbers, Africa will experience the most rapid growth, over 70% faster than in
Asia (annual growth of 2.4% versus 1.4% in Asia, compared to the global average of 1.3%
and only 0.3% in many industrialized countries) (UN Population Division, 2007).
• In sub-Saharan Africa, the population is projected to increase from about 770 million to
nearly 1.7 billion by 2050.

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Importance of Age – Sex structure in PH
• Couple planning
• Population planning
• Skewed population
• Resource allocation
• Vaccination
• Hospital services
• Education
• Food services
• Job security
• ………….
Literacy rate, sex ratio and dependency ratio
• The literacy rate is defined by the percentage of the population of a given age group
that can read and write. The adult literacy rate corresponds to ages 15 and above, the
youth literacy rate to ages 15 to 24, and the elderly to ages 65 and above.
• Basic/Simple literacy rate =
Number of Literates (Specific age +)
Population of same age group 𝑥 100
• Sex ratio: The sex ratio is the ratio of males to females in a population. In most
sexually reproducing species, the ratio tends to be 1:1. As of 2014, the global sex
ratio at birth is estimated at 107 boys to 100 girls (1,000 boys per 934 girls).

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Contd …
• Sex Ratio at Birth =
Number of male birth
Number of female birth
𝑥 100
• Dependency ratio: It is the relationship between the
number of children (0-14. years old) and older persons (65
years or over) to the working-age population (15-64 years
old).
• Dependency Ratio =
Number of Dependants
Working Population
𝑥 100
Young and old age population and aging
• Youth population:People less than 15.
• Young population: A population with relatively high proportion of
children, adolescents, and young adults, a low median age, and thus a
high growth potential.
• Old age population is defined as people aged 65 and over. Some
countries consider 60 as an old age beginning.
• Population aging refers to changes in the age composition of a
population such that there is an increase in the proportion of older
persons. Ageing is the result of continuous decline in fertility rates
and increased life expectancy.

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Decaying population
• Decaying means decreasing.
• If something is decaying, it means that a value is decreasing
(example–population of Japan is decaying over time). ... A
growth or decay factor describes the rate at which a quantity is
changing over a certain period of time via a multiplication
sequence (factor implies multiplication).
• Exponential decay occurs when the amount of decrease is
directly proportional to how much exists. Divide the final count
by the initial count. For example, if you had 100 people to start
(eg. eginning of the year) and later had 80 people (eg. end of
the year), you would divide 80 by 100 to get 0.8.
Unit 4: Population theories, policy and programs
(6 hours)

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Early thinking on population issues
• Greek Thinking
• Greek scheme of political life, the individual was only part of the state
• Marriage was an institution created by the legal and political system
• Main objective of marriage was procreation
• Continual wars had decreased the population and demanded constant supply
of men
• All Spartans were compelled to get married
• Celebacy was a punishable offence by Law and denounced in public
• Roman Thinking
• Conquest, Power and Empires needed a rapidly expanding population
• Encouraged procreation by granting special privileges
Malthusian doctrine and Neo – Malthusians,
Cornucopial concepts
• Pre Malthusian Theories
• The Marcantilist School
• Beginning of the 16th Century to the end of 18th century
• Almost all trading nations adopted the “Marcantilism” economic thought.
• Agriculture alone couldnot sustain the economy of nation, so they need to export
goods
• In such situations demand for workers increased.
• Malthusian (Malthusian doctrine)
• Malthus was the first to notice the impending issue of there being more people than
could be supported by the food supply.
• In 1798 Thomas Malthus published his view on the effect of population on food
supply. His theory has 2 basic principles
• Population growsat geometric rate i.e. 1 2 4 16 32 …
• Food production increasesat an arithmetic rate i.e. 1 2 3 4 …

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Contd …
• The consequencie of these two principles is that
eventually, the population will exceed the
capacity of agriculture to support the new
population numbers. Population would rise until a
limit to growth was reached. Further growth
would be limited when:
• Preventive checks – postponement of marriage
lowering of fertility rate), increased cost of food, etc
• Positive checks – famine, war, disease will incrase the
death rate
• Malthusian ideas are often supported by Western
governmnets because it highlights the problem of
too many mouths to feed, rather than uneven
distribution of resources.
• Popular example of Ester Island
Post Malthusian Theory
• Anti Nationalist Policies: Reducing the birth rate
• Theory: Neo Malthusians
• Belief: Population si growing faster than the world is running of finite sources. Unless
government limit the growth of their population, the world will face a crisis of
resources – shortage leading to conflict and war
• Evidence: Oil wars (Iraq invading Kuwait in 1990). USA invading Iraq 1991 and 2001).
Water conflict between Israel and Palestine, Easter Island – 1800s
• Policy: Reduce Birth Rates by introducing free contraception, improving education of
poor women, encouraging people to have fewer children
• Example: Mauritius, China
• Mauritious: Isolated island in Indian Ocean, Population was growing rapidly in 1950s
leading to over cultivation. The island is rapidly approaching the over population.
Government and religious faiths come together to decline population and increase
food, and promoted for importing foods.

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Contd …
• Pro Nationalist Policies: Increasing the birth rate
• Theory: Boserp, Mao – Ze - Dung
• Belief: Population is a countries greatest asset. People can work, are productive, and
can be inventie. The more people you have, the more workers, the greater the
number of consumers for industrial goods, the more taxes can be paid, the more
trade can take place.
• Evidence: When countries face starvation – its usually due to civil war or climate
change – not too many people to feed. As the worlds population has grown – there
have been fewer famines – not more. The most successful economies of the 21st
century are the ones with larger population (USA CHINA Brasil, India, UK, Germany
…)
• Policy: Increase Birth Rates by introducing incentives for women to have more
children (paid maternity leave, free child – care, increased child – allowances for 3rd
child) or increase immigration by encouraging new settlers
• Examples: Under populated countries with large land areas sparse population –
Canada, Australia, Brazil, New Zealand.
Cornucopian concepts
• A cornucopian is a futurist who believes that continued progress and
provision of material items for mankind can be met by similarly continued
advances in technology.
• Fundamentally they believe that there are enough matter and energy on
the Earth to provide for the population of the world.
• Looking further into the future they posit that the abundance of matter and
energy in space would appear to give humanity almost unlimited room for
growth.
• The term comes from the cornucopia, the "horn of plenty" of Greek
mythology, which magically supplied its owners with endless food and
drink.
• The cornucopians are sometimes known as "Boomsters", and their
philosophic opponents—Malthus and his school—are called "Doomsters"
or "Doomers."

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Demographic transition theory
• Demographic transition is a phenomenon and theory which refers to the historical
shift from high birth rates and high infant death rates in societies with minimal
technology, education (especially of women) and economic development, to low birth
rates and low death rates in societies with advanced technology, education and
economic development, as well as the stages between these two scenarios
• Although this shift has occurred in many industrialized countries, the theory and model
are frequently imprecise when applied to individual countries due to specific social,
political and economic factors affecting particular populations.
• However, the existence of some kind of demographic transition is widely accepted in
the social sciences because of the well-established historical correlation linking
dropping fertility to social and economic development.
• Scholars debate whether industrialization and higher incomes lead to lower
population, or whether lower populations lead to industrialization and higher incomes.
Scholars also debate to what extent various proposed and sometimes inter-related
factors such as higher per capita income, lower mortality, old-age security, and rise of
demand for human capital are involved.

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Contd …
• Stage 1: It applied to most of the world before the industrial
revolution both birth rates and death rates were high. As a result,
population size remained fairly constant but can have major swings
with events such as wars or pandemics
• Stage 2: The introduction of modern medicine lowers death rates,
especially among children, while birth rates remain high; the
result is rapid population growth. Many of the least developed
countries today are in Stage 2.
• Stage 3: Birth rates gradually decrease, usually as a result of
improved economic conditions, an increase in women’s status,
and access to contraception. Population growth continues, but
at a lower rate. Most developing countries are in Stage 3.
• Stage 4: Birth and death rates are both low, stabilizing the
population. These countries tend to have stronger economies,
higher levels of education, better healthcare, a higher
proportion of working women, and a fertility rate hovering
around two children per woman. Most developed countries are
in Stage 4.
• Stage 5: A possible Stage 5 would include countries in which
fertility rates have fallen significantly below replacement level
(2 children) and the elderly population is greater than the
youthful population.
It is many times defined in 4 stages:
1. Pre industrial stage
2. Transational stage
3. Industrial stage
4. Post industrial stage
Contd…
• Stage 1: Death rates and birth rates both are high
• Stage 2: Fall in death rate, population increases
• Stage 3: Decline in birth rate stabilizes the population
• Stage 4: Birth and death rates both low, population stable
• Stage 5 (new): Higher death rates than birth rates, population
contraction

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Population Policy
• Population policy is the construction of institution or process, or their
modification through the elected political representatives that can
directly or indirectly influence the population change
• Population Policy is constructed as a long term plan
• Forecasting the population determines the change and/or update of
population policy
Essential requisite of population policy
• Trend analysis of population growth and government perception.
• Integration of demographic policy with development policy.
• Reduction (Silence or promote) in the rate and incidence of
unwanted fertility
• Reduction (Silence or promotion) in demand for larger sized families
• Greater investment (Static or reduction) in adolescents to tackle the
population problem that it must deal with by a comprehensive and
effective population program

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Three types of population policy
• Pro natalist (aka natalist)
• A pro-natalist policy is a population policy which aims to encourage more births
through the use of any form of incentives. Eg Sweden, Iran, France, Russia, Hungery,
etc
• Anti natalist
• that negatively values coming into existence and procreation. Antinatalists argue that
humans should abstain from procreation because it is morally wrong (some also
recognize the procreation of other sentient beings as problematic). Eg. China India,
Singapore, etc
• Eugenics
• Eugenics is the practice or advocacy of improving the human species by selectively
mating people with specific desirable hereditary traits. It aims to reduce human
suffering by “breeding out” disease, disabilities and so-called undesirable
characteristics from the human population.
Overview of current population policy - 2071 (2014
– 2034) and program in Nepal (Assignment - 2)
• It was initiated from first 5 year plan in 1956 – 1961
• Population Perspective plan (PPP) has formulated based on
multidisciplinary approach since 10th plan for 20 years (2010 – 2031)
• Focused on integration population into all concerns areas of the
development
• Scientific census start from 2008

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Contd …
• Objectives:
• Establish coordination and cooperation between stakeholders
• Develop reproductive health services
• Build up appropriate lifestyle and environment friendly livelihood
• Effective management of immigration and emigration, and
urbanization
• Including GESI in all dimensions of development
• Appropriate survey and research of demographic data and their
analysis and management
• Promoting independent population group for GDP
Contd … Population policy 2071 (Targets 2014
– 2034)

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Contd ….15th Dev plan (2076/77 – 2080/81)
• The National Planning Commission has prepared a
preliminary draft of 15th five-year development plan for
fiscal year 2019- 20 to 2023-24. The15th five-year
development plan has managed on the basis of 25 year vision
paper. The 25 year plan has focused on the country’s
development vision and targets with the slogan of
“Generating Prosperity and Happiness”. The 25 year plan
focuses the following quantitative targets.
Contd …. 25 years master plan (2075 – 2100)

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Contd …Institution development of the
population
Unit 5: Components of population change from
public health perspective
(9 hours)

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Ancient perception – Siddhartha Gautam
Concern – Birth (suffering)
• In buddhism, birth is known as JATI
• Birth is considered as Dukkha (suffering)
• There are four form of birth in traditional buddhism
• Birth from egg: birds, fish, reptiles
• Birth from womb mamals
• Birth from moisture: microscopic organisms, maggots, rotting flesh
• Birth by transformation: modification/correction
• Only beings who achieve enlightenment (bodhi) in this lifetime
escape rebirth in this cycle of birth – and - death
Concern - Aging
• In buddhism old age is known as pali (12th link)
• Everything that borns, passess through the aging cycle and dies
• Meditation to aging is the application of ahimsa spirit
• Increasingly fragile and infirm bodies and minds are scared, and worthy of
the greatest kindness and care
• To respect our aging at every stage is the greatest kindness we can offer to
ourselves and those we love
• We gain wisedom as the years go by
• Aging is an ideal time for the cultivation of the inner life, but it’s also itself a
doorway to spiritual practice, regardless of religious (spiritual) faith
• The Dharmapada has one chapter known as “Jaravagga” that consisted of
eleven verses about old age

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Concern – Morbidity (Byadhi)
• From a Buddhist view, causes of diseases are not only these detectable
etiologies, but also kammas and other undetectable beings.
• Non-human beings such as a demon (yakkha) and ghosts are also
the causes of illness
• If we are born, we are always subjected to illness
• Buddhism has destigmatized mental illness (eg. Patacara: literarly naked
women (“Patachari” was elcomed and healed)
• Morbidity is the consequence of an unhealthy life – style
• Morbidity can be the effect of bad karma of the past lives
• Greed (lobha), hatred (dosa) and andger (moha) are the cause of illness
• Four kinds of illness: recoverable, dangerous but recoverable, dangerous and
recoverable but with limitations, dangerous leading to death
Concern - Mortality
• Death is fundamental and final stage of growth (Nothing lasts)
• Death simple leads to rebirth/reincarnation if there is no enlightenment
• Death can strike at any time
• Death is considered as the greatest of all teachers
• Buddhists prepare for death in many ways, depending upon how well they have learnt to
master their own mind, through meditation
• They famalirize themselves with the long succession of experiences and hallucinations
which follow death
• During death: Bio dynamics degrades, food is not digested, heat diminishes from
extremities to inwards
• As earth elements dissolves into water elements, one can no longer stand, the head lolls,
the face takes on a gray complexion and one loses saliva.
• 5 senses disappear

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Concern - Migration
• Buddhists have a pattern of religiously motivated migration (temple building,, migration of missionary
monks, transference of Buddhist knowledge)
• Small community of monks and nuns, known as bhikkus, sprung up along the roads that Buddha travelled.
• Before the birth of King Ashoka, Buddhism was dominated by Hinduism for 200 years
• Ashoka promoted Buddha expansion by sending monks to surrounding territories to share the teachings of
the Buddha
• Different buddhism (Tharveda and Mahayana) claims that migration has created multicultural societies in
buddhism
• Buddhism and monastic education helped to establish internal migration patterns in Tibet that continue
today in both internal and out-migration flows
• Buddhism population is low and due to low fertility rate in Buddhists, it is assumed to disappear soon
• Monastries were set up in remote rural localities where monks devotion and learning propagated and
sustained the faith among surrounding population while also providing a focus for economic exchange and
political activity
Contd … 12 Nidanas
Ignorance Formations Consciousness
Name and
Form
Six sense
Bases
Contact Feelings Craving
Clinging Becoming Birth
Old Age &
Death

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Fertility and birth (concept)
• Birth and fertility are closely related in population biology
• Dispite of their close relationthere are differences
• Fertility is an ability to give reproduction.
• When it comes into TFR, it is an individual specific parameter of a female, which measures the average
number of children/offspring a female could give birth to over her entire lifetime
• The fertility rate has been defined for a female if she would be to experience the usual age-
specific fertility rates throughout her lifetime and survives throughout her reproductively viable
period.
• Birth is the beginning of life
• Birth rate is a parameter of the entire population, while fertility rate is a parameter of a group
of individuals in the population
• Fertility rate determines birth rate, not the other way around
• Fertility rate applies for females in the reproductive age, but there is no such restriction for
birth rate
• Birth rate is expressed in relation to a time interval, while fertility rate is expressed in relation
to the number of females in the reproductive age
Calculations

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Population as a system
Birth Bin - migranth
Natural Change Migrational Change
Total
Population
Population Gain
Population Loss
Deaths Out Migrants
+
_
+
_
Inputs
Process
&
Stores
Outputs
Basic terminology
• Fertility = Production of a live birth (natality)
• Prenatal= Conception to beforebirth
• Natal = Related to birth
• Antenatal= pregnancyto beforebirth
• Perinatal= Pregnancyto one weak after birth
• Postnatal= After birth
• Infertility = Inabilityto producea live birth
• Parity = Number of women born alive to woman
• Gravidity= Numberof pregnancies a woman has had whetheror not they producea live birth
• Fecundity = Physiologicalcapacity to conceive (reproductivepotential)
• Infecundity(sterility) Inability of a woman to conceive a pregnancy
• Primarysterility = Never able to conceive a pregnancy
• Secondarysterility = Inabilityto conceive after one or morechildren havebeen born
• Fecundability= Probabilitythat a woman will conceive duringa menstrualcycle

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Measuring tool
• Child – Woman Ratio (CWR)
• Age Specific Fertility Rate (ASFR)
• General Fertility Rate (GFR)
• General Marital Fertility Rate (GMFR)
• Crude Birth Rate (CBR)
• Total Fertility Rate (TFR)
• Net Reproduction Rate (NRR)
Rate, Ratio and Proportion
Ratio
Rate Proportion Prevalence Percentile
Rate
Percentage
Proportion

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Crude Birth Rate (CBR)
(Mid year populationis calculated by adding the population of Jan 1 and
December 31 of the given year and dividing the sum by 2)
• Suppose that, in census 2011, the census day was June 22
(Asadh) with population of 2,31,51,423. Considering the day as
mid-year. The total number of live births in the year was 7,66,312,
find out the crude birth rate (CBR).
• Solution next slide
CBR=
𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ 𝑖𝑛 𝑎 𝑝𝑙𝑎𝑐𝑒 𝑜𝑟 𝑐𝑜𝑢𝑛𝑡𝑟𝑦 𝑖𝑛 𝑎 𝑓𝑖𝑥𝑒𝑑 𝑦𝑒𝑎𝑟
𝑇𝑜𝑡𝑎𝑙 𝑚𝑖𝑑 −𝑦𝑒𝑎𝑟 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑜𝑓 𝑡ℎ𝑒 𝑝𝑙𝑎𝑐𝑒 𝑖𝑛 𝑎 𝑦𝑒𝑎𝑟
𝑥 1000
Here,
• Total number of live birth in Nepal in 2001 (B) = 766312
• Total midyear population of the year (P) = 23151423
• Crude Birth Rate (CBR) =?
Now,
• CBR = (Formula)
= (766312/23151423) x 1000
= 33.10
So, CBR = 33.10 birth per thousand
Therefore, there were 33.1 live births per 1000 population in Nepal in
2001. Crude birth rate of Nepal is 33.1 per thousand.

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Age Specific Fertility Rate (ASFR)
(It can be calculated by making specific age group of 5 years 10 years or as per our
convenience)
• Suppose, the total population of females of age group 20-24 was 35000 in
2007 in Birgunj. The women of the same age group gave birth to 2500
babies in the same year. Calculate age specific fertility rate (ASFR)
• Solution in next slide
ASFR =
𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ 𝑡𝑜 𝑎 𝑓𝑒𝑚𝑎𝑙𝑒 𝑜𝑓 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑎𝑔𝑒
𝑇𝑜𝑡𝑎𝑙 𝑚𝑖𝑑 −𝑦𝑒𝑎𝑟 𝑓𝑒𝑚𝑎𝑙𝑒 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑜𝑓 𝑡ℎ𝑒 𝑠𝑎𝑚𝑒 𝑎𝑔𝑒 𝑔𝑟𝑜𝑢𝑝
𝑥 1000
Solution.
• The total number of live births given by the women of age group 20-24 = 2500
• The total midyear population of women of the same age group (20-24) =
35000
• Age specific fertility rate for the age group 20-24 (ASFR20-24) = ?
Here,
• ASFR20-24 = (Formula)
= 2500/35000 * 1000
= 71.42
= 71.42 infants per 1000 women
Therefore, in Birgunj, per thousand women of age group 20-24 gave
birth to about 71 babies in the year 2007

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Total Fertility Rate (TFR)
• It is aka FR Period Total Fertility Rate (PTFR) or Total Period
Fertility Rate (TPFR)
• Calculate TFR from the following ASFR according to the data of
1991 A.D. in Nepal.
Age ASFR (per 1000 women) Age ASFR (per 1000 women)
15 – 19 95 35 – 39 151
20 – 24 286 40 – 44 77
25 – 29 272 45 – 49 28
30 – 34 212 Total 1121
TFR=
𝐶𝑙𝑎𝑠𝑠 𝑠𝑖𝑧𝑒 𝑥 ∑ 𝐴𝑆𝐹𝑅
1000
Here,
• ∑ASFR = 1121
• TFR = (5 x 1121)/1000
= 5.61
= 5.61 children per women
Therefore, a woman gave birth to about 6 children in average, in
her reproductive life according to the census 1991.
• The total fertility in 2001 AD in Nepal was 4.1 per woman. But it
decreased to 3.1 per women according to Nepal Demographic
and Health Survey, 2006, 2.44 in 2011 and 2.03 in 2016.
• There is a decreasing trend of total fertility rate in Nepal which
is good but it is still higher than the world’s average total fertility
rate. The world’s average total fertility rate is 2.8 children per
woman

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Child Woman Ratio and its use
(In some formulas, 14 – 45 years women are considered)
• Ranges for CWR
• Least Developed : 710
• Developing : 400
• More Developed : 225
• Mugu has 4896 children under age 5 and (WORA – Women of
Reproductive Age) 10200 women aged 15 – 49. Calculate CWR
CWR=
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑐ℎ𝑖𝑙𝑑𝑟𝑒𝑛 𝑢𝑛𝑑𝑒𝑟 𝑎𝑔𝑒 5
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑤𝑜𝑚𝑒𝑛 𝑎𝑔𝑒 15 −49
𝑥 1000
Solution
• The total number of under 5 years children = 4896
• The total women of age 15 – 49 = 10200
• CWR= ?
Here,
• CWR = (Formula)
= 4896/10200 * 1000
= 480
= 480 child per 1000 women
Therefore, in Mugu, per thousand women of age group 15-49 bear
480 child

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Standard birth rate and its purpose
• Standarized rates are a statistical measure of any rates in a population.
• There are adjusted rates that take into account the vital differences
between populations that may affect their birthrates or death rates
• Standardization is necessary for following reasons
• Defective data
• Fluctuation in age specific rates
• Difference in the age composition of the populations
• Standardization removes the confounding effect (effect due to heterogenecity) of
age structurevariations
• Standardization (Adjustment) can be done directly (age specific) or
indirectly (taking average)
Purpose of standardization
• Procedure of adjustment of crude rates to eliminate from them the effect of
differences in population composition with respect to age and/or other variables
• It is necessary because:
• Rates are affected by the demographic composition of the population for which they are
calculated
• Age composition is a key factor affecting crude rates
• For purpose of comparision of rates over time or from area to area, is important
to determine the difference between the rates after taking into account the
differences in the composition of the populations
• Adjusted rates have no direct meaning in themselves; they must be compared
with the original crude rates or with other adjusted rates using the same standard
• Population whose crude ratio is used in formula gives the standardized ratio
• Standarization can be done by two ways: Directly and Indirectly

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Direct standardization
• Simple and most straight forward technique
• Provides the best basis for determining the differences between two
crude rates
• The rates from two or more study populationsare applied to a
common population distribution (standard population)
• Often directly standardized rates are calculated for a series of
populations using the same standard
• The series could be the same population at different time points
Indirect Standardization
• The rates from a standard populationare applied to the distribution
of one or more study populations
• Choice of standard rates is upto the demographer
• Indirect standardization can be deceptive
• It is used if:
• If there is no rates available for study population.i.e only counts are available
• Rates for study population are not reliable because of small numbers of
events or population

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Standardization Formula (DSMR, DSBR only)
Age group (Study)
Rates (Pokhara) per 1000
(Standard)
Population (Kathmandu)
Expected number of
birth (Pokhara)
Expected number of
birth (Kathmandu)
15 – 19 18 725719 13063 15063
20 – 24 58 574357 33313 36313
25 – 29 57 536226 30565 35565
30 – 34 36 443702 15973 19973
35 – 39 19 379184 1955 2955
Total 2985012 102073 109869
Total number of birth, Kathmandu 375117
Total number of birth, Pokhara 18247
CBR Kathmandu 48.7
CBR Pokhara 18.5
DSBRstudy=
𝐸𝑥𝑝𝑒𝑐𝑡𝑒𝑑 𝑏𝑖𝑟𝑡ℎ (𝑠𝑡𝑢𝑑𝑦 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛)
𝐴𝑐𝑡𝑢𝑎𝑙 𝑏𝑖𝑟𝑡ℎ (𝑠𝑡𝑎𝑛𝑑𝑎𝑟𝑑 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛)
𝑥 𝐶𝐵𝑅 𝑆𝑡𝑎𝑛𝑑𝑎𝑟𝑑 𝑃𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛
Calculate DSBR of Pokhara
Solution
• DSBR = Formula
• Given:
• …….
• …….
• ……...
• Thus, DSBRPokhara = (102073/375117) X 48.7 = 13.3
• Hence, …………….

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Indirect Standardization Formula (ISMR, ISBR only)
Age group (Study)
Rates (Pokhara) per 1000
(Standard)
Population (Kathmandu)
Expected number
of birth (Pokhara)
Expected number
of birth
(Kathmandu)
15 – 19 79 105764 8355 15063
20 – 24 159 109914 17476 36313
25 – 29 171 94576 16172 35565
30 – 34 140 81144 11360 19973
35 – 39 107 60063 6427 2955
40 – 44 50 45825 2291 3032
Total 497286 62082 112901
Total number of birth, Kathmandu 375117
Total number of birth, Pokhara 18247
CBR Kathmandu 48.7
CBR Pokhara 18.5
IDSBRstudy =
𝐴𝑐𝑡𝑢𝑎𝑙 𝑏𝑖𝑟𝑡ℎ (𝑠𝑡𝑢𝑑𝑦 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛)
𝐸𝑥𝑝𝑒𝑐𝑡𝑒𝑑 𝑏𝑖𝑟𝑡ℎ (𝑠𝑡𝑢𝑑𝑦 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛)
𝑥 𝐶𝐵𝑅 𝑆𝑡𝑎𝑛𝑑𝑎𝑟𝑑 𝑃𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛
Solution
• IDSBR = Formula
• Given:
• …….
• …….
• ……...
• Thus, ISBRPokhara = (18247/62082) X 48.7 = 14.3
• Hence, …………….

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Standard Notations used
Notations Meaning
ri Rate of ith group in study population
ni Number of persons in ith group in the study population
n Total number of person in study population = Σni
pi Proportion of persons in ith group in study population = ni/n = weight
e Number of events in study population= Σri X ni
Contd …
Notations Meaning
Ri Rate of ith group in standard population
Ni Number of persons in ith group in the standard population
N Total number of person in standard population = ΣNi
Pi Proportion of persons in ith group in standard population=
Ni/N = weight
C Crude rate in standard population

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Exercise
• Calculate directly and indirectly standardized crude birth rates for
population 1 and population2 by using the standard population
Age group (i) Population 1 Population 2 Standard Population
Rate (ri) Prop. In
group (ni/n)
Rate (ri) Prop. In
group (ni/n)
Rate (Ri) Prop. in
group (Ni/N)
1 30 0.8 32 0.3 20 0.6
2 15 0.2 16 0.7 35 0.4
CBR 30 X 0.8 + 15 X 0.2 = 27 32 x 0.3 + 16 X 0.7 = 20.8 20 x 0.6 + 35 x 0.4 = 26
DSBR = Σri [(Ni/ΣRi X Ni)] X C IDSBR = Σri [(ni/ΣRi X Ni)] X C
Solution
Thus, standardized CBR for population 1 using direct formula is 24 and indirect formula is 30.5, and
standardized CBR for population 2 using direct formula is 25.6 and indirect formula is 17.7
Population 1 Population 2
Direct Method
DSBR = Σri [(Ni/ΣRi X Ni)] X C
DSBR= 30 X 0.6 + 15 X 0.4 = 24.0 DSBR= 32 X 0.6 + 16 X 0.4 = 25.6
Indirect Method
IDSBR = Σri [(ni/ΣRi X Ni)] X C
IDSBR= (27/(20 X 0.8 + 35 X 0.2)) X 26
= 30.5
IDSBR= (20.8/20 X 0.3 + 35 X 0.7) X 26
= 17.7
Σri [(Ni/ΣRi X Ni)] =
𝐸𝑥𝑝 𝑏𝑖𝑟𝑡ℎ (𝑠𝑡𝑢𝑑𝑦 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛)
𝐴𝑐𝑡 𝑏𝑖𝑟𝑡ℎ (𝑠𝑡𝑎𝑛𝑑𝑎𝑟𝑑 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛)
Σri [(ni/ΣRi X Ni)] =
𝐴𝑐𝑡. 𝑏𝑖𝑟𝑡ℎ (𝑠𝑡𝑢𝑑𝑦 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛)
𝐸𝑥𝑝 𝑏𝑖𝑟𝑡ℎ (𝑠𝑡𝑢𝑑𝑦 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛)

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Difference between two methods
• In direct standardization, the weights are constant across study
population
• In indirect standardization, the weights (ni) are influenced by the
distribution of the study population
Replacement level of fertility
• The average number of children per woman necessary to sustain a
population size
• Ideally would be 2 children per woman, one to replace mother and
another to replace father
• Ranges from 2.1 in developed countries (low IMR and good medical
care) to 2.5 in developing countries (high IMR and medical care is not
enough)
• A TFR of 2.1 is considered as replacement level of fertility (UN
Population Division)
• It is often considered as Zero Population Growth (ZPG)

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Population momentum (Population Lag Effect)
• Population momentum is a consequences of the demographic transition.
• Population momentum explains why a population will continue to grow
even if the fertility rate declines
• Population momentum is defined as the ratio of the size of the population
at the new equilibrium level to the size of the initial population
• It is typically caused by a shift in the countries demographic transation.
When mortality rates drop, the young surviver childhood and the aging
population live longer. Fertility rate remain high, causing the overall
population size to grow
• According to population momentum, even if high fertility rates were
immediately replaced with replacement level of fertility rates, the
population would continue to grow due to the pre – childbearing
population entering childbearing years.
Population Momentum in population pyramid
High percentage of population at
or before child bearing age
There is a lag, when children and youth who
have already been born have not yet meet
their child bearing years

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Population Momentum
• Population Momentum Factor (PMF) = CBR X Average Life Expectancy at Birth
• > 1 = There is positive momentum in the population which will lead to further
growth
• 1 = Natural increase is not contributing to population growth
• < 1 – There is negative momentum, with a high probability that the population
will decline in size
Average Life Expectancy at birth represents the average life span of a ficitious
generation subject to the age specific mortality conditions of the year. The average
number of years a newborn could expect to live when he was born, considering other
mortality factors constant
Factors affecting fertility
• Service factors
• FP services
• Low capacity of service providers
• Care and support
• ………
• Economic Factors
• Supportduring and after pregnancy
• Dependency
• ……..
• Social Factors
• Gender inequality and violence (rape)
• Religious issues
• Value of child
• Demographic indicators
• …………..
• Policy and regulations/Political
• Government guidance and justice
• Urbanization
• Average age of marriage
• Social security
• ……….
• Individual Factors
• Perception and esteem
• Status of women
• Disease condition and Sterility
• Knowledge of FP/Celibacy
• Health related factors
• Drugs
• Sexual dysfunction/decreaselibido
• Mental health status
• …….

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Infertility management
Contd …
• Two episodes of Semen Analysis (4 days gap), testicular size
• Further investigations need to be done in female like salphangen blockades (Generaly – Tubal
patency or Laproscopy, Mid Luteal serum progesterone evaluation)
• Spermicidal effect
• Both partners should be seen together
• Privacy and sufficient clinical time
• H/O taking
• Counselling
• Routine examination
• Age factors
• Sexual intercourse in every 2 – 3 days
• Not recommended to have sex during ovulation (due to ovulation stress)
• Quiting smoking and alcohol habit, it cause erectile dysfunction

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Contd …
• BMI should be less than 29
• Folic Acid supplement prior to the conception
• Rubella immunity, if vaccinated wait 1 mth for conception
• Bromocriptine along with tocoferol
• Surgery
• IUI: Intrauterine Insemination (Injecting sperm into mature egg inside the body
using a syringe)
• IVF: Invitro fertilization (fertilization is done outside the body using multiple
sperms and implanted)
• ICSI: Intracytoplasmic Sperm Injection (special IVF – Single sperm is injected
directly to a mature ova outside the body and implanted)
• Surrogacy
Birth Rate/Natality – CBR Already done
• Birth Rate is the number of individuals born in a population in a given amount of time
• Age Specific Birth Rate: AGE-SPECIFIC BIRTH RATE is the number of resident live births to
women in a specific age group for a specified geographic area (country, state, county, etc.), divided
by the total population of women in the same age group for the same geographic area (for a
specified time period, usually a calendar year). This figure is multiplied by 1000 to give a rate per
1000 population.
• Age specific birth rate (ASBR) = No. of resident Live Birth to Women of Specific Age Group/No
of Women in same age group) X 1000
• Eg: 356000 live births in 2008 among the state resident women who are 20 – 24 years old and
310,000 state resident women who are 20 – 24 years old in 2008
= 36000/310000 X 1000 = 11.6 live birth per 1000 state resident women who are 20 – 24
years old in 2008

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Continue …. General Fertility Rate (GFR)
• GFR avoids some of deficiencies of CBR by changing denominator from total
population to number of women in the reproductive age usually 15 – 49 years
• GFR is a ratio of total years registered live birth to the WORA in per 1000
• It restricts the denominator to potential mothers by excluding all men and large
group of women not “exposed to the risk” of child bearing by reason of age
• A step in the direction of measuring fertility against the proper proportion of the
population
• Can be calculated easily as CBR and requires only the age and sex distribution of
the population
• Can be computed in the situation in which the registration of the births and
enumeration of the population are satisfactory but when direct evidence of births
by age of parents is lacking
Contd …
• Eg: 36000 live births in 2020 in Province 2 and 310,000 women are 15
– 49 years old.
GFR = 36000/310000 X 1000 = 11.6 live birth per 1000 women who
are 15 – 49 years old in 2020
GFR =
𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ
𝑇𝑜𝑡𝑎𝑙 𝑊𝑂𝑅𝐴 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 (15 − 49 𝑦𝑒𝑎𝑟𝑠)
𝑋 1000

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Baby boom
• It is a period marked by a significant increase in birth rate
• Latest boom effect was seen after WW2, when winners were
confident of having bigger family size, and survivers feeling safe
• Shoulders were paid extra if they had family and children
• People born during this period are often called baby boomers
• The cause of baby boom involves various fertility factors
• The most well known baby boom occured in mid twentieth century,
just after 2nd world war (1930 – 1960)
• It is aka shockwave or the pig in the python
Baby bust
• Baby bust effect is seen when there is marked decline in birth rate
• It is followed by boom effect (1965 – 1980), but Nepal was booming at that time
• They are also known as Generation X or slackers
• Reason for bust effect: fall in polygyny, increase in divorce rate, technological
advancement, economic uncertinity
• Baby busters are people who desire flexible work schedule so that they can maintain a
balance between work and personal life, prefer flat rather than hierrarchial structure,
change job to widen their experience and to increase the scope of their careers
• Covid 19 is creating baby bust effect. Its not booming, because of mental
unpreparedness for being able to conceive.
• Women delayed pregnancy or wished to have fewer children because of pandemics
• Its because of: Physical health, Mental condition, Financial uncertianity, lack of social
support,

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Measures of reproduction: Concept and
importance of Gross and net reproduction rate
• Reproduction can be understood by using the terminology Fertility
Dynamics
• It quantifies the birth performance of a population over a period of time
• Used to compare the fertility levels of a number of population, during a
particular time interval
• Exhibit a time trend in fertility in a population in the study of differential
fertility by various socio – economic, racial and ethnic groups
• It can be measured through:
• Gross Reproduction Rate
• Net Reproduction Rate
Gross Reproduction Rate (GRR)
• The number of female births an average women would have if she lived
through the end of her reproductive span
• Indicates the number of daughters of a hypothetical cohort of women by
the end of the reproductive life if she bears the birth according to a given
schedule of age – specific fertility rates (taking only female births) without
experiencing any mortality till the end of reproductive life
• It is special case of TFR, the difference is in GRR only female births are
considered instead of total birth
• It is the sum of age specific fertility rates calculated from the female
births for each year of reproductive period
• China “One Child” policy leads to a distortion of sex ratio at birth in favor of
boys, leading to a lower GRR
• GRR = 1 means able to reproduce, and GRR = 2 means population doubling

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Contd …
• Suppose GRR is 3. If a female child is born at that time, and survives
through her child – bearing period, than she will give birth to 3 female
children in her turn, on the average
GRR = Σ
𝐴𝑆𝐹𝑅 (𝑐𝑜𝑛𝑠𝑖𝑑𝑒𝑟𝑖𝑛𝑔 𝑜𝑛𝑙𝑦 𝑓𝑒𝑚𝑎𝑙𝑒 𝑏𝑖𝑟𝑡ℎ)
1000
𝑋 𝐶𝑙𝑎𝑠𝑠 𝑠𝑖𝑧𝑒
• It can also be calculated using TFR
GRR =
𝑁𝑜 𝑜𝑓 𝑓𝑒𝑚𝑎𝑙𝑒 𝑏𝑖𝑟𝑡ℎ𝑠
𝑇𝑜𝑡𝑎𝑙 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝐵𝑖𝑟𝑡ℎ
𝑋 TFR
GRR is same as TFR, only
the difference is female
birth are only considered
while calculating ASFR,
and other sex are
ignored
Calculations
• Calculate GRR from the following ASFR according to the data
of 1991 A.D. in Nepal.
Age
ASFR
Total birth per
1000 women
ASFR
(Female birth)
(per 1000
women)
Age
ASFR
Total birth per
1000 women
ASFR
(Female birth)
(per 1000
women)
15 – 19 95 45 35 – 39 310 151
20 – 24 390 186 40 – 44 77 27
25 – 29 355 172 45 – 49 78 28
30 – 34 240 112 Total 1545 721
GRR=
𝐶𝑙𝑎𝑠𝑠 𝑠𝑖𝑧𝑒 𝑥 ∑ 𝐴𝑆𝐹𝑅 (𝐹𝑒𝑚𝑎𝑙𝑒 𝑏𝑖𝑟𝑡ℎ)
1000
GRR =
𝑁𝑜 𝑜𝑓 𝑓𝑒𝑚𝑎𝑙𝑒 𝑏𝑖𝑟𝑡ℎ𝑠
𝑇𝑜𝑡𝑎𝑙 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝐵𝑖𝑟𝑡ℎ
𝑋 TFR

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Without TFR
Here,
• ∑ASFR(Females) = 721
• GRR = (5 x 721)/1000
= 3.605
Therefore, a woman gave birth to
about 4 female children in
average, in her reproductive life
according to the census 1991.
Solution
ASFR =
𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑓𝑒𝑚𝑎𝑙𝑒 𝑏𝑖𝑟𝑡ℎ 𝑡𝑜 𝑎 𝑓𝑒𝑚𝑎𝑙𝑒 𝑜𝑓 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑎𝑔𝑒
𝑇𝑜𝑡𝑎𝑙 𝑚𝑖𝑑 −𝑦𝑒𝑎𝑟 𝑓𝑒𝑚𝑎𝑙𝑒 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑜𝑓 𝑡ℎ𝑒 𝑠𝑎𝑚𝑒 𝑎𝑔𝑒 𝑔𝑟𝑜𝑢𝑝
𝑥 1000
Using TFR
Here,
• TFR = 5 X 1545/1000 = 7.725
• GRR = (721/1545) X 7.725
= 3.605
Therefore, a woman gave birth to about
4 female children in average, in her
reproductive life according to the
census 1991.
TFR=
𝐶𝑙𝑎𝑠𝑠 𝑠𝑖𝑧𝑒 𝑥 ∑ 𝐴𝑆𝐹𝑅 𝑓𝑒𝑚𝑎𝑙𝑒
1000
Net Reproduction Rate
• The average number of daughters that female members of a birth
cohort would bear during their reproductive life span if they were
subject to the observed age – specific maternity rates and mortality
rates through their lifetimes
• NRR = 1 equals exact replacement fertility
• NRR is GRR adjusted for mortality schedule of cohort of women
• Number of daughter that would be born to a cohort of women during
their lifetime if they experience a fixed scheduled of ASFR and ASMR

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Contd…
• This rate consists of hypothetical cohort of women, their death and their
female births during their child – bearing period. i.e 15 – 49 years
• NRR is a measure of number of daughters that a cohort of new born girl
babies will bear during their life time assuming a fixed schedule of fertility
rates and a fixed set of mortality rates
• NRR is a measure of the extent to which a cohort of newly born girls will
replace themselves under given schedule of age specific female of fertility
and mortality
• NRR is always lower than GRR because it takes into account that some
women die before completing their child bearing years.
• NRR = 1 (Exact Replacement), >1 (population is more than it is replicating
itself), < 1 (population is not replicating itself)
Contd …
• If 1000 females give birth to 1 girl each and 1000 girls are born and if these
girls live till fertility, the net reproduction rate becomes 1000/1000 = 1.
• Now, if the number of girls comes to 1200, this rate will be 1200/1000 = 1.2
• Against this, if this number becomes 800, then the net reproduction rate will
become 800/1000 = 0.8 which means that the fertility rate is decreasing in
the country.
NRR =
𝑁𝑜 𝑜𝑓 𝒇𝒆𝒎𝒂𝒍𝒆𝒔 𝑒𝑥𝑝𝑒𝑐𝑡𝑒𝑑 𝑡𝑜 𝑏𝑒 𝑏𝑜𝑟𝑛 𝑡𝑜 1000 𝑛𝑒𝑤𝑙𝑦 𝑏𝑜𝑟𝑛 𝒈𝒊𝒓𝒍𝒔
1000

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Morbidity
• Incidence: The number of new events or new cases of a disease in a defined
population, within a specified period of time
• Prevalence: The total number of all individuals who have an attribute or disease
at a particular time divided by population at risk of having attribute or disease at
this point of time. Reflects the chronicity of disease
• Notification rates
• Attendance rates at OPD
• Admission, readmission and discharge
• Duration of stay in hospital
• Absent in school or work
• Hospital data
• …
Incidence
• It is also known as Measure of Morbidity for new cases.
• It is the rate of the development of new cases of a disease that occur
during a specified period of time in previously disease free or
condition free individuals
• It is not influenced by the duration of the disease
• Many times, the denominator in formula uses mid – interval/year
population at risk, instead of Estimated number of people in
population (risk population)

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Contd …
• Statistically,
• There are two fundamental approaches to measure incidence rate:
• Cumulative Incidence Rate, and
• Incidence Density Rate
𝐼𝑛𝑐𝑖𝑑𝑒𝑛𝑐𝑒 𝑅𝑎𝑡𝑒 =
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑛𝑒𝑤 𝑐𝑎𝑠𝑒𝑠
𝑖𝑛 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑝𝑒𝑟𝑖𝑜𝑑 𝑜𝑓 𝑡𝑖𝑚𝑒
𝐸𝑠𝑡𝑖𝑚𝑎𝑡𝑒𝑑 𝑝𝑒𝑜𝑝𝑙𝑒 𝑖𝑛 𝑡ℎ𝑒 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛
𝑎𝑡 𝑡ℎ𝑒 𝑠𝑎𝑚𝑒 𝑝𝑒𝑟𝑖𝑜𝑑 𝑜𝑓 𝑡𝑖𝑚𝑒
𝑥 100
Cumulative incidence rate (Incidence Proportion)
• Number of new cases of disease occurring over a specified period of
time in a population at risk at the beginning of the interval.
• CIR is generally expressed in decimal per thousand for specific time.
• If it is measured for entire life, it is known as Lifetime risk.
CIR=
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑛𝑒𝑤 𝑐𝑎𝑠𝑒𝑠 𝑑𝑢𝑟𝑖𝑛𝑔 𝑡ℎ𝑒 𝒔𝒑𝒆𝒄𝒊𝒇𝒊𝒄 𝒑𝒆𝒓𝒊𝒐𝒅 𝑜𝑓 𝑡𝑖𝑚𝑒
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑎𝑡 𝑡ℎ𝑒 𝑏𝑒𝑔𝑖𝑛𝑛𝑖𝑛𝑔 𝑜𝑓 𝑡𝑖𝑚𝑒
𝑥 1,000

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Example
• If there had been 500 new cases of illness X in a population of 30000 in a
year, Incidence rate will be: 500/30000X 1000 = 16.7/1000 per year
Thus, Incidence ratio for disease X per 1000 population is 17.7
• If 200 people free from chronic disease X observed over 3 years, 10 cases
develop the disease x. Than 3 Year CI = 10 cases/200 people = 10/200 =
0.05
Thus, the 3 year risk for one of 200 people to develop disease X,
conditional on not dying from another cause is estimated as 0.05
or 5%
Incidence density rate (Person Time Incidence)
• Number of new cases of disease occurring over a specified period of
time in a population at risk throughout the interval.
• We need to add up period of time each individual was present in the
population, and was at risk of becoming a new case of disease.
• Denominatoruses person – time at risk.
• It is calculated in an open population (with migration), and every
person contributesdifferent duration of “at risk” interval
𝐼𝐷 =
𝑵𝒖𝒎𝒃𝒆𝒓 𝒐𝒇 𝒏𝒆𝒘 𝒄𝒂𝒔𝒆𝒔 𝑑𝑢𝑟𝑖𝑛𝑔 𝑡ℎ𝑒
𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑝𝑒𝑟𝑖𝑜𝑑 𝑜𝑓 𝑡𝑖𝑚𝑒
𝑇𝑜𝑡𝑎𝑙 𝑝𝑒𝑟𝑠𝑜𝑛 − 𝑡𝑖𝑚𝑒 𝑎𝑡 𝑟𝑖𝑠𝑘 𝑑𝑢𝑟𝑖𝑛𝑔 𝑡ℎ𝑒 𝑖𝑛𝑡𝑒𝑟𝑣𝑎𝑙
𝑥 1,000

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Example
• Approximately, 100000 women in the Nurses Health Study ages 30 –
64, were followed for 1140172 person years from 1076 to 1990,
during which time 2214 new cases of breast cancer occurred.
• Incidence density or Incidence rate = 2214/140172 = 0.00194 events
per person - year
(It can also be normalized as 194 events per 100000 (105) person –
years)
Relation between CI and ID
• The numerator does not differ between the two types of incidence.
• However, the denominator can differ in incidence density from
cumulative incidence because it takes account of:
• Cases who left during the defined year
• Cases who died
• Cases who had disease once and will not have it again in the same season
• Cases who entered in between in the defined year.

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Prevalence
• Prevalence is a measurement of all individuals affected by the disease at a
particular time. It is also known as Measure of Morbidity for new and old
cases.
• All current cases (New + old) existing in a given point in time or over a
period of time in a given population.
• It is of three types:
• Point prevalence
• Period prevalence, and
• Lifetime prevalence
Point - Prevalence
• Point prevalence is a measure of the proportion of people in a population
who have disease or condition at a particular time (generally a month or
less or even a day)
• It is like a snapshot of the disease in time and is expressed in percentage.
• It is used to study chronic diseases
• It can be used to calculate specifically for age, gender, etc.
• When type of prevalence is not specified, we should consider it is point
prevalence
𝑃𝑡. 𝑃 =
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑒𝑥𝑖𝑠𝑡𝑖𝑛𝑔 𝑐𝑎𝑠𝑒𝑠 𝑵𝒆𝒘 + 𝑶𝒍𝒅 𝑜𝑓 𝑎
𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑒𝑑 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 𝑜𝑛 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑑𝑎𝑡𝑒
𝑬𝒔𝒕𝒊𝒎𝒂𝒕𝒆𝒅 𝒑𝒆𝒐𝒑𝒍𝒆 𝑖𝑛 𝑡ℎ𝑒 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛
𝑎𝑡 𝑡ℎ𝑒 𝑠𝑎𝑚𝑒 𝑝𝑜𝑖𝑛𝑡 𝑜𝑓 𝑡𝑖𝑚𝑒
𝑥 100

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Example
• On June 30, 2020 A community has
• Population of 1600
• 29 current cases of hepatitis B
• P = 29/1600 = 0.018 = 1.8 per 100 (1.8%)
Period Prevalence
• It is the proportion of the population with a given disease or
condition over a specific period of time.
• Simply, it answers like: How many people in a population suffered
from common cold in 2018.
• It is expressed in percentage.
𝑃𝑑. 𝑃 =
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑒𝑥𝑖𝑠𝑡𝑖𝑛𝑔 𝑐𝑎𝑠𝑒𝑠 𝑵𝒆𝒘 + 𝑶𝒍𝒅 𝑜𝑓 𝑎
𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑒𝑑 𝑑𝑖𝑠𝑒𝑎𝑠𝑒 𝑜𝑛 𝑎 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑡𝑖𝑚𝑒 𝑖𝑛𝑡𝑒𝑟𝑣𝑎𝑙
𝑬𝒔𝒕𝒊𝒎𝒂𝒕𝒆𝒅 𝒑𝒆𝒐𝒑𝒍𝒆 𝑖𝑛 𝑡ℎ𝑒 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛
𝑎𝑡 𝑡ℎ𝑒 𝑠𝑎𝑚𝑒 𝑝𝑒𝑟𝑖𝑜𝑑 𝑜𝑓 𝑡𝑖𝑚𝑒
𝑥 100

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Example
• Between June 30 and August 30, 2020, A community had
• Average population of 1600
• 29 esisting cases of Hepatitis B on June 30
• 6 Incident (new) cases of hepatitis B between July 1 and August 30
• PP = (29+6)/1600 = 0.022 = 2.2 per 100 (2.2%)
Lifetime Prevalence
• It is the proportion of individuals in population that at some point in
their life during the time of assessment, has experienced a case.
• The cases might have experienced a diseased condition, accident,
crime, harassment, …
• It is also known as cumulative prevalence

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Example
Not Important
Relationship between Prevalence and Incidence
• Prevalence = Incidence x Mean (average) duration of illness
P = I X D
Calculations: Try yourself

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Healthy and morbid population
• Health is a state of complete physical, mental and social well being
and not merely the absence of disease or infirmity. (WHO)
• Health cannot be a state of completeness, rather is a relative term
and it has escaped spiritual health.
• Morbidity is any departure, subjective or objective, from a state of
physical or psychological well being
• Health and Morbidity cant be defined without healthy population and
morbid population
• Healthy population are relatively with less health problems than
another population
Meaning of morbidity and it importance in
population studies
• Morbidity is any departure, subjective or objective, from a state of physical
or psychological well being
• Importance
• Measures the extent of a nations health and provision of health facilities
• The cause of death and illness
• High risk age group for certain condition
• Advances in prevention and treatment
• Specialized care
• Immunization
• Visualizes different types of disease: endemic, epidemic, pandemic, sporadic, …
• ……….

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Overview of morbidity indicators
Refer HMIS indicator book in pdf
Population mobility due to morbidity
particularly during epidemics
• Population floating to different places due to certain medical
conditions
• These population majorly include migrant workers and asylum
seekers
• It is influenced by
• Searching for a safe place
• Available, Accessible, Affordable of health care service
• Better health care service
• Modern technology
• Political, social and economic status/consequencies

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The light shaded countries, including Australia, denote countries that are non-endemic,
while the dark shaded countries are countries where dengue is already established.

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Mortality (Concept and Importance)
• Mortality simply means death
• Mortality rate is a measure of the number of death (in general or due
to specific cause) in a particular population, scaled to the size of that
population, per unit of time
• Eg. Crude Death Rate, Perinatal mortality, Maternal mortality, Infant
mortality, Child mortality, Standarized mortality ratio, ASMR, cause
specific death rate, cumulative death rate, case fatality rate, infection
fatility rate, ………..
Importance
• Trend analysis
• Prioritizing health actions
• Designing interventions
• Clues for epidemiological studies
• Assessment and monitoring of public health problems and programs

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Measures of Mortality
• Crude Death Rate
• Specific Death Rate
• Case Fatality Rate
• Proportion Mortality Rate
• Survival Rate
• Adjusted/Standardized Rates
Formula and Calculations

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Crude Death Rates
• It is the number of death (from all cause) per 1000 estimated mid
year population in one year, in a given place
• It measures the rate at which death are occurring from various causes
in a given population,during specific period
CDR =
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ 𝑓𝑟𝑜𝑚 𝑎𝑙𝑙 𝑐𝑎𝑢𝑠𝑒𝑠 𝑑𝑢𝑟𝑖𝑛𝑔 𝑡ℎ𝑒 𝑦𝑒𝑎𝑟
𝑀𝑖𝑑 𝑦𝑒𝑎𝑟 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛
𝑥 1000
Example
• There were 3200 death from all causes in a population of 150000,
Calculate CDR
CDR = 3200/150000 X 1000
= 9.3 per thousand per year

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Specific Death Rates
• It can be case specific or age specific
… 𝑆𝐷𝑅 =
𝑁𝑜. 𝑜𝑓 𝑑𝑒𝑎𝑡ℎ …𝑐𝑎𝑠𝑒 … 𝑜𝑟 … 𝑎𝑔𝑒 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 … 𝑖𝑛 𝑎 𝑦𝑒𝑎𝑟
𝑀𝑖𝑑 𝑦𝑒𝑎𝑟 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛
𝑥 1000
Example
• Calculate ASDR for the age group 20 – 30 years and compare with
CDR
Age group Population No of death
0 – 10 200 4
10 – 20 300 3
20 – 30 300 2
30- 40 350 3
40 – 50 400 5
50 – 60 250 7
60 – 70 150 5
70 – 80 50 7
Total 2000 36

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Solution
• ASDR =
• CDR =
Infant Mortality Rate
• It is an age specific RATIO of the number of death of infants (under 1 year)
to the number of live birth occurring in an area during a given year
IMR =
𝑁𝑜.𝑜𝑓 𝑑𝑒𝑎𝑡ℎ 𝑜𝑓 𝑖𝑛𝑓𝑎𝑛𝑡𝑠 𝑎𝑚𝑜𝑛𝑔 𝑎 𝑝𝑜𝑝.𝑜𝑓 𝑎 𝑔𝑖𝑣𝑒𝑛 𝑎𝑟𝑒𝑎 𝑖𝑛 𝑎 𝑦𝑒𝑎𝑟
𝑁𝑜.𝑜𝑓 𝒍𝒊𝒗𝒆 𝒃𝒊𝒓𝒕𝒉𝒔 𝑖𝑛 𝑠𝑎𝑚𝑒 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑖𝑛 𝑠𝑎𝑚𝑒 𝑎𝑟𝑒𝑎 𝑖𝑛 𝑠𝑎𝑚𝑒 𝑦𝑒𝑎𝑟
𝑥 1000

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Example
• There were 270 death of under 1 years children among 3200 live
births, calculate IMR
IMR = 270/3200 X 1000
84.4 per thousand live births
Difference MM Rate and MM Ratio
MM Rate =
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑾𝑶𝑹𝑨 𝑖𝑛 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛
𝑖𝑛 𝑟𝑒𝑓𝑒𝑟𝑒𝑛𝑐𝑒 𝑝𝑒𝑟𝑖𝑜𝑑
𝑥 𝟏, 𝟎𝟎,𝟎𝟎𝟎
MM Ratio =
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝒍𝒊𝒗𝒆 𝒃𝒊𝒓𝒕𝒉𝒔 𝑜𝑐𝑐𝑢𝑟𝑖𝑛𝑔
𝑤𝑖𝑡ℎ𝑖𝑛 𝑡ℎ𝑒 𝑟𝑒𝑓𝑒𝑟𝑒𝑛𝑐𝑒 𝑝𝑒𝑟𝑖𝑜𝑑
𝑥 𝟏, 𝟎𝟎, 𝟎𝟎𝟎

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Example
• There were 271 death of mothers in 2018 where, WORA were 216800
who gave 189700 live birth. Calculate Maternal Mortality ratio and
maternal mortality rate
CW
Neonatal and post neonatal mortality ratio Rate
• NMR is defined as the number of death of neonates (0 – 28 days) during a year
per 1000 live birth in same area in same year
• PNMR is defined as the number of death of infants between 29 days to 364 days
during a year per 1000 live births in the same area in the same year
NMR =
𝑁𝑜.𝑜𝑓 𝑑𝑒𝑎𝑡ℎ 𝑜𝑓 𝑛𝑒𝑜𝑛𝑎𝑡𝑒𝑠 𝑎𝑚𝑜𝑛𝑔 𝑎 𝑝𝑜𝑝.𝑜𝑓 𝑎 𝑔𝑖𝑣𝑒𝑛 𝑎𝑟𝑒𝑎 𝑖𝑛 𝑎 𝑦𝑒𝑎𝑟
𝑁𝑜.𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠 𝑖𝑛 𝑠𝑎𝑚𝑒 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑖𝑛 𝑠𝑎𝑚𝑒 𝑎𝑟𝑒𝑎 𝑖𝑛 𝑠𝑎𝑚𝑒 𝑦𝑒𝑎𝑟
𝑥 1000
PNMR =
𝑁𝑜.𝑜𝑓 𝑑𝑒𝑎𝑡ℎ 𝑜𝑓 29 −365 𝑑𝑎𝑦𝑠 𝑐ℎ𝑖𝑙𝑑 𝑎𝑚𝑜𝑛𝑔 𝑎 𝑝𝑜𝑝.𝑜𝑓 𝑎 𝑔𝑖𝑣𝑒𝑛 𝑎𝑟𝑒𝑎 𝑖𝑛 𝑎 𝑦𝑒𝑎𝑟
𝑁𝑜.𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ𝑠 𝑖𝑛 𝑠𝑎𝑚𝑒 𝑝𝑜𝑝𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑖𝑛 𝑠𝑎𝑚𝑒 𝑎𝑟𝑒𝑎 𝑖𝑛 𝑠𝑎𝑚𝑒 𝑦𝑒𝑎𝑟
𝑥 1000

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Fetal mortality rates (Ratio)
• FMR is the number of resident fetal death in a specified geographic area
divided by the number of resident live births plus fetal deaths for the same
geographic area for same period of time in same year and expressed in per
1000
• Eg. 820 fetal death in 2008 in Kathmandu
• 130000 live births in 2008 in Kathmandu
• 820/(130000+ 820) X 1000 = 6.3 fetal death per 1000 live births plus fetal
death in 2008 among state residents
FMR =
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑓𝑒𝑡𝑎𝑙 𝑑𝑒𝑎𝑡ℎ
(𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ+𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑓𝑒𝑡𝑎𝑙 𝑑𝑒𝑎𝑡ℎ) 𝑖𝑛 𝑠𝑎𝑚𝑒 𝑎𝑟𝑒𝑎 𝑎𝑛𝑑 𝑦𝑒𝑎𝑟
𝑥 1000
Prenatal mortality rates (Ratio): Mistake content in curriculum
• Perinatal and prenatal are used interchangeably, but they are different
• It can be measured earlier to or during implantation to embryonic stage (upto
10 weeks)
• Eg.
PMR =
(𝑁𝑜. 𝑜𝑓 𝑝𝑟𝑒𝑛𝑎𝑡𝑎𝑙 𝑑𝑒𝑎𝑡ℎ)
𝑁𝑜.𝑜𝑓 (𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ+𝑆𝐵𝑠) 𝑖𝑛 𝑠𝑎𝑚𝑒 𝑎𝑟𝑒𝑎 𝑎𝑛𝑑 𝑠𝑎𝑚𝑒 𝑦𝑒𝑎𝑟
𝑥 1000

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Perinatal mortality rates (Ratio)
• It includes both late fetal death (stillbirths) and early neonataldeath
• It is defined as the ratio between sum of the still births and the infants death
under 1 week , and total number of live birth and Still birth in same area in
same year
• Eg.
PMR =
(𝑁𝑜. 𝑜𝑓 𝑆𝐵𝑠+𝑑𝑒𝑎𝑡ℎ 𝑢𝑛𝑑𝑒𝑟 1 𝑤𝑒𝑒𝑘 𝑜𝑓 𝑎𝑔𝑒)
𝑁𝑜.𝑜𝑓 (𝑙𝑖𝑣𝑒 𝑏𝑖𝑟𝑡ℎ+𝑆𝐵𝑠) 𝑖𝑛 𝑠𝑎𝑚𝑒 𝑎𝑟𝑒𝑎 𝑎𝑛𝑑 𝑠𝑎𝑚𝑒 𝑦𝑒𝑎𝑟
𝑥 1000
Standardized death rate and its importance
• Set of technique used to remove as far as possible effects of
difference in age or other confounding variables when comparing two
or more variables
• Age and sex are two most common variables used for standardization
– called standardized rates
• It is a weighted average of age sex specific mortality rates of a
particular population under observation, the weights being the
proportions in each age – sex group of a standard population (not the
particular population under observation)
• Everything same, just replace birth by death in previous
standardization slides. No to TFR

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Factors affecting mortality
• Biological factors
• Birth weight
• Age of the mother
• Birth Order
• Birth Spacing
• Multiple birth
• Family size
• High fertility
• Economic factors
• Governmental factors
• Preventive level related factors
• Nutritional factor
• Genetic factor
• Cultural and social factors
• Religion and caste
• Early marriage
• Health care seeking behavior
• Child sex
• Quality of mothering
• Maternal education
• Quality of health care
• Broken families
• Illegitimacy
• Brutal habits and customs
• Indegenous Dhai Ama
• Bad environment
Actors and population change (Organizations)
• UNFPA
• Population Media Centre
• Population ReferenceBureau
• Population EnvironmentResearchNetwork
• Worldwatch
• World Population Balance
• Population Institute
• Population Council
• Population Action International
• Partners in Population and Development
• InternationalPlanned ParenthoodFederation
• Population and SustainabilityNetwork
• Rutgers WPF (World Population Fund)
• DSW (DeutscheStiftung Weltbevoelkerung)
• ………..
• Family Planning 2020
• Population Communication
• Bixy Centre forGlobalReproductiveHealth
• TransitionEarth
• Population and SustainableDevelopmentAlliance
• OurCarbon Footprint
• BOCS Foundation
• Population Matters
• Ten million club foundation
• Rientrodolce
• MinderMensen
• NumbersUSA
• Center for Biology Diversity
• Scientists and EnvironmentalistforPopulation
Stabilization
• ……………..

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United Nations Population Fund (UNFPA)
• It was formed in 1969, after UN declaration
• UNFPA is UN sexual and reproductive health agency
• Mission: Deliver a world where every pregnancy is wanted, every childbirth
is safe and every young person potential is fulfilled
• It supports in more than 150 countries, providing 20 million women with
modern contraceptives
• Prevention of GBV which effects 1 in 3 women
• Abandonment of FGM which harms 3 million girls annually
• Ending child marriage
• ……….
Migration (concept)
• Migration is a way to move from one place to another in order to
live and work.
• Movement of people from their home to another city, state or
country for a job, shelter or some other reasons is called migration
• UN Migrateion Agency (IOM) defines a migrant as any person who is
moving or has moved across an international border or within a State
away from his/her habitual place of residence, regardless of:
• The persons legal status
• Whether the movement is voluntary or involuntary
• What ever the cause for the movement are
• What the length of the stay is

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Contd…
• Migration is a form of geographic or spatial mobility involving a
change of usual residence between clearly defined geographic units.
It involves two areas, place of origin and place of destination
• Two specific lacuna in the definition, i.e, excludes -
• Short – term or cyclical or Circulatory or temporary movements
• Non – comparative overtime due to change of boundry
• Migrants: Person who has changed his/her usual place of residence
from one migration – defining area to another at least once during
the migration interval (usually, interval may be one year, five years, or
ten years, or inter – censal period)
Contd …
• The 2030 Agenda for Sustainable Development recognizes for the first time
the contribution of migration to sustainable development.
• 11 out of the 17 Sustainable Development Goals (SDGs) contain targets and
indicators relevant to migration or mobility. The Agenda's core principle is
to "leave no one behind," not even migrants.
• There are two types of migration : Voluntary and Forced migration
• Migration can also be classified as Internal/Domestic migration and
External Migration (Rural – Urban, Seasonal, Planned)
• Some theories regarding migration are:
• Contemporary Labor Migration Theories: Neoclassical economic theory, Dual labor
market theory, New Economics of labor migration, Relative deprivation theory, World
systems theory, Osmosis theory
• Social – scientific theories: Sociology, Political Sciences

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Measures
• It can be measured either using formula
(… MR =
𝑁𝑜 𝑜𝑓 …. 𝑚𝑖𝑔𝑟𝑎𝑛𝑡𝑠
𝑴𝒊𝒅 𝒚𝒆𝒂𝒓 𝒑𝒐𝒑𝒖𝒍𝒂𝒕𝒊𝒐𝒏 𝑖𝑛 𝑠𝑎𝑚𝑒 𝑎𝑟𝑒𝑎 𝑎𝑛𝑑 𝑠𝑎𝑚𝑒 𝑦𝑒𝑎𝑟
𝑥 1000)
or
• By adding or subtracting
Contd …
• Direct Measurement:
• Estimation of lifetime from place of birth data
• Out migration (Going out)
• In migration (Coming in)
• Non Migration (No movement)
• Gross Migration (Total movement)
• Net migration (Difference of out and in migrants)
• Estimation of inter-censual Migration from place of birth data (Survival Ratio)
• Estimation of duration of residence data
• Estimation of Migration from place of residence at a fixed prior data – data

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Cont …
• Indirect Measurement:
• National Growth Rate Method
• Vital Statistics Method (Residual Method)
• Census Survival Method (CSR Method)
Calculations (Estimation of lifetimefrom place of birth data)
• Out migration from A, x1 = A12+A13+A14
• In – Migration to A, y1 = A21+A31+A41
• Non Migration, A = A11
• Gross Migration, A = (y1+x1)
• Therefore, net – migration for A = (y1-x1)
(We have calculated on the basis of A)
Place of Birth Place of Enumeration
A B C D
A A11 A12 A13 A14
B A21 A22 A23 A24
C A31 A32 A33 A34
D A41 A42 A43 A44

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Calculations (Estimation of Inter – censual Migration from place
of birth data - International)
• Estimating by subtracting the survival of migrants counted in the first census from
migrants counted in the second census
• Indirect estimate of inter – censual net – migration
NM = (It+n – Ot+n) – (StIt – SoOt)
Where, It – Number of lifetime inmigrants at a time t in particular area
It+n - Number of lifetime inmigrants at a time t+n in particular area
Ot - Number of lifetime outmigrants at a time t from particular area
Ot+n - Number of lifetime outmigrants at a time t+n from particular area
St and So are intercensal survival ratios indicating what proportions of It and Ot that will
survive during the inter – censual period
Example
Try yourself …. very easy

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Factors affecting migration and population change
Push Factors
Countries of origin
Migrants Pull Factors
Countries of destination
• Population growth, young age structure
• Inadequate educational institutions, medicare
and social security
Domestic factors and
social infrasturcutre
• Stable population, population decline,
population ageing
• Welfare state benefits, educational institutions,
medicare, social security
• Unemployment, low wages
• Poverty, low consumption and living standard
Economic factors
• Labour demand, high wages
• Welfare, high consumption and living standard
• Dictatorships, shadow democracy, bad
governance, political upheaval
• Conflict, (civil) war, terrorism, human rights
violation, oppression of minorities
Political factors
• Democracy, rule of law, pluralism, political
stability
• Peace, security, protection of human and civil
rights, protection of minorities
• Ecologic disaster, desertification, lack of
natural resources, water shortage, soil erosion,
lack of environmental policy
Ecological factors • Better environment, environmental policy,
protection of natural resources and
environmental protection
• Decision of the family or the clan
• Information flows, media, transferred picture
of a country of origin
• Possibilities of (ir)regular immigration, routes
of trafficking
Migrant flows and
migration stocks
• Diaspora, ethnic community
• Information flows, media transfererd picture of
destination country
• Possibilities of (ir)regular immigration (right of
residence)
Unit 6: Population projections
(6 hours)

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Concept
• Population projections are estimates of the population for future dates.
• It is an attempt to show how human population living today will change in
future
• They are typically based on an estimated population consistent with the most
recent decennial census and are produced using the cohort-component
method.
• Population projection can be done using the charts at early stages, and later it
need to be done using the formula if population growth is rapid using
Arithmetic, Geometric and Exponential
• Growing of human population exponentially is generally not possible
Estimation and Projection (Yearly)
2017 Population
Data available
2018 26000000 (Real)
2019 27500000 (Real)
2020 29000000 (Real)
2021 (August, 26 - Today) 30000000 (Real)
2022 32500000 (Estimated) Estimate
……
Projection
2045 40000000 (Estimated)
2046 42500000 (Estimated)
2047 45500000 (Estimated)
2048 48000000 (Estimated)
2049 51000000 (Estimated)
2050 53000000 (Estimated)

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