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Family Planning in Community Medicine

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1. 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."

• (a) Avoid unwanted births
• (b) Bring about wanted births
• (c) Regulate intervals between pregnancies
• (d) Control the time at which births occur in relation to parental age
• (e) Determine the number of children in the family

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2. Family Planning as a Basic Human Right

• The UN Conference on Human Rights at Tehran (1968) first recognized family planning as a basic human right.
• The Bucharest World Population Conference (1974) stated: "All couples and individuals have the basic human right to decide freely and responsibly the number and spacing of their children."
• The World Conference of the International Women's Year (1975) reinforced the right of women to decide on the number and spacing of their children.

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3. Scope of Family Planning Services

1. Proper spacing and limitation of births
2. Advice on sterility
3. Education for parenthood
4. Sex education
5. Screening for pathological conditions (e.g., cervical cancer)
6. Genetic counselling
7. Premarital consultation and examination
8. Pregnancy tests
9. Marriage counselling
10. Preparation of couples for their first child
11. Services for unmarried mothers
12. Teaching home economics and nutrition
13. Providing adoption services

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4. Health Aspects of Family Planning

Benefits to Mother's Health

• Reduction in maternal mortality (spacing prevents high-risk pregnancies)
• Reduced anaemia, exhaustion from repeated childbirth
• Reduction in complications of unintended pregnancy

Benefits to Child's Health

• Adequate birth spacing (minimum 2 years) reduces neonatal/infant mortality
• Better nutrition and breastfeeding opportunity
• Reduced risk of prematurity and low birth weight

Benefits to Family and Society

• Better resource allocation per child
• Improved maternal and child nutrition
• Reduced population pressure

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5. Contraceptive Methods (Fertility Regulating Methods)

I. Spacing Methods

A. Barrier Methods

• Made of latex rubber; trade name in India: NIRODH (Sanskrit: "prevention")
• Failure rate: 3-15 per 100 woman-years (HWY) under typical use
• Only contraceptive that also protects against STIs/HIV
• Should be used with every act of intercourse; unroll before use
• Supplied free through government programmes

• A dome-shaped rubber cap placed over the cervix before intercourse
• Must be used with spermicidal cream/jelly
• Failure rate: 6-16 per HWY
• Requires fitting by a trained provider; must remain in place for 6 hours post-coitus
• Not widely used in India

• Smaller than diaphragm; fits over the cervix
• Failure rate slightly higher than diaphragm

• Creams, jellies, foams, tablets, suppositories containing surfactants (e.g., nonoxynol-9)
• Kill or immobilize sperm
• Failure rate: 6-20 per HWY when used alone
• Best used in combination with barrier methods

• Condom + spermicide
• Diaphragm + spermicide
• More effective than either alone

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B. Intra-Uterine Devices (IUDs)

• Inhibit sperm transport and fertilization
• Copper ions have a direct toxic effect on sperm
• Alter the endometrium to prevent implantation
• Stimulate local foreign body inflammatory reaction in the uterus

• Best during menstruation or within 10 days of period onset
• Post-puerperal: 6-8 weeks after delivery
• Immediate postpartum (first week) - higher expulsion risk
• Not recommended immediately after 2nd trimester abortion

• Menorrhagia and dysmenorrhoea (common, especially with inert IUDs)
• Expulsion (highest in first year)
• Pelvic inflammatory disease (PID)
• Ectopic pregnancy risk if device fails
• Perforation of uterus (rare, ~1 per 1000 insertions)
• Not suitable as first choice for nulliparous women (higher expulsion and PID rates)

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C. Hormonal Contraceptives

• Primary: Suppression of ovulation (via inhibition of LH and FSH)
• Secondary: Thick cervical mucus impeding sperm
• Altered endometrium reducing implantation probability

• Monophasic pills: Fixed dose in each pill
• Biphasic/triphasic pills: Varying oestrogen/progestogen ratios across cycle
• Low-dose pills: Ethinyl oestradiol 20-35 mcg (current standard)

• Cardiovascular: Increased risk of venous thromboembolism, myocardial infarction, cerebral thrombosis - especially with smoking and increasing age. Risk markedly higher in women >35 who smoke.
• Hypertension: Occurs in ~5% of users
• Headache, nausea, breast tenderness (minor effects)
• Depression, libido changes
• Metabolic: Altered glucose tolerance, lipid changes
• Breakthrough bleeding: More common with low-dose pills

• Reduced risk of endometrial and ovarian cancer
• Reduced dysmenorrhoea and menorrhagia
• Protection against PID and benign breast disease
• Improvement in acne

• Contains only progestogen; taken daily without a pill-free interval
• Suitable for breastfeeding mothers and those with contraindications to oestrogen
• Works mainly by thickening cervical mucus

• DMPA (Depo-Provera): 150 mg medroxyprogesterone acetate every 3 months (12 weeks)
• NET-EN (Noristerat): 200 mg norethisterone enanthate every 2 months
• Highly effective; failure rate < 1 per HWY
• Side effects: Menstrual irregularities (most common), amenorrhoea, weight gain, delay in return of fertility after stopping
• Suitable for women who forget daily pills

• Cyclofem/Cycloprovera, Mesigyna - given monthly
• Failure rate: <0.2% for Cyclofem; <0.4% for Mesigyna

• 6 silastic (silicone rubber) capsules each containing 35 mg levonorgestrel, inserted subdermally in forearm/upper arm
• Provides contraception for >5 years; reversible on removal
• Failure rate: ~0.2 per HWY
• Norplant-2: 2 rods, easier insertion and removal
• Side effects: Menstrual irregularities, local reactions at insertion site

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D. Post-Conceptional Methods (Emergency Contraception)

• Levonorgestrel 1.5 mg single dose OR 0.75 mg × 2 doses 12 hours apart
• Must be taken within 72 hours of unprotected intercourse (the sooner, the more effective)
• Reduces risk of pregnancy by ~75%
• Does NOT induce abortion if implantation has already occurred

• Antiprogesterone; used for medical termination of early pregnancy
• Given with misoprostol for complete expulsion

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E. Natural Family Planning Methods (NFP)

1. Calendar (Rhythm) Method (Ogino-Knaus method): Calculate fertile period based on previous cycle lengths (ovulation ~14 days before next period). Failure rate: 14-47 per HWY. Unreliable with irregular cycles.
2. Basal Body Temperature (BBT) Method: Temperature rises 0.2-0.5°C after ovulation due to progesterone effect. Record temperature every morning before activity; avoid intercourse until 3 days after sustained rise.
3. Cervical Mucus Method (Billings/Ovulation Method): Fertile period identified by clear, slippery, stretchable cervical mucus ("spinnbarkeit"). Peak day = last day of clear mucus. Avoid intercourse until 4th day after peak.
4. Symptothermal Method: Combines BBT + cervical mucus + calendar.

• Breastfeeding suppresses ovulation through prolactin-mediated inhibition of GnRH
• Effective only if: fully breastfeeding + amenorrhoeic + <6 months postpartum (all three must be present)
• No more than 5-10% of women conceive during lactational amenorrhoea
• Once menstruation returns, breastfeeding no longer provides protection

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II. Terminal Methods (Sterilization)

• Does not require sustained motivation
• Most effective contraceptive protection (failure rate < 0.5%)
• Most cost-effective method
• Each procedure averts 1.5-2.5 births per woman

A. Female Sterilization (Tubectomy)

• Laparoscopic sterilization - most common; done under general anaesthesia
• Minilaparotomy - small incision below navel; done under local anaesthesia; suitable in postpartum period
• Colpotomy (vaginal approach) - less common

• Pomeroy's method: Loop of fallopian tube ligated and cut (most common)
• Fimbriectomy: Removal of fimbriated end
• Hulka clip, Filshie clip, Fallope rings (reversible to some degree)
• Electrocoagulation (via laparoscope)

• Interval (any time in menstrual cycle, ideally luteal phase)
• Postpartum (within 7 days or after 6 weeks)
• Post-abortion (immediately after)

B. Male Sterilization (Vasectomy)

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6. Effectiveness of Contraceptive Methods (Pearl Index)

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7. The Medical Termination of Pregnancy (MTP) Act 1971

1. Medical: Continuation endangers the mother's life or causes grave injury to physical/mental health
2. Eugenic: Substantial risk of child being born with serious physical/mental handicaps
3. Humanitarian: Pregnancy resulting from rape
4. Socio-economic: Environmental factors (social or economic) likely to injure mother's health
5. Contraceptive failure: Anguish of unwanted pregnancy from failure of any contraceptive method - unique to Indian law; virtually allows abortion on request

• Up to 12 weeks: One Registered Medical Practitioner (with gynaecology/obstetrics experience)
• 12-20 weeks: Requires opinion of two Registered Medical Practitioners
• Consent of guardian required for women <18 years and those of unsound mind

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8. National Family Welfare Programme (India)

Historical Evolution

National Population Policy 2000 (NPP 2000)

• Reduce IMR to <30 per 1,000 live births
• Reduce MMR to <100 per 100,000 live births
• Achieve universal immunization
• Reduce prevalence of anaemia
• Promote delayed marriage (girl > 18, boy > 20)
• Make school education up to Class 10 free and compulsory

RCH Programme (Reproductive and Child Health)

• Maternal health (ANC, safe delivery, postpartum care)
• Child health (immunization, nutrition, IMNCI)
• Family planning (all methods, quality of care)
• STI/RTI management
• Adolescent health

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9. Postpartum Programme

• Women are highly receptive
• Medical infrastructure is present
• It can be combined with post-delivery follow-up

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10. Couple Protection Rate (CPR)

• Target set in National Health Policy: 60% CPR by year 2000
• Used as the main indicator of family planning programme performance
• India's CPR was ~48% at the time of Park's writing

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11. Targets of the Family Planning Programme

• Reduce crude birth rate to 21 per 1,000
• Reduce crude death rate to 9 per 1,000
• Reduce IMR to <30 per 1,000 live births
• Reduce MMR to <100 per 100,000 live births
• Achieve NRR = 1 (Net Reproduction Rate of 1)

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12. Cafeteria Approach to Contraception

"There is no single method likely to meet the social, cultural, aesthetic and service needs of all individuals and communities. The present approach is to provide a cafeteria choice - to offer all methods from which an individual can choose according to his needs and wishes."

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13. Voluntary Agencies in Family Planning

• Family Planning Association of India (FPAI): Founded 1949, headquarters Mumbai; pioneering role in family planning propagation; member of International Planned Parenthood Federation (IPPF)
• Population Council of India
• Family Planning Foundation
• IPPF (International): World's largest private voluntary organization for family planning; headquarters London
• UNFPA: UN Fund for Population Activities; funds research, services, training
• USAID, Ford Foundation, Pathfinder Fund, World Bank: International funding bodies

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Summary Table: Classification of Contraceptive Methods

CONTRACEPTIVE METHODS
│
├── SPACING METHODS
│   ├── Barrier Methods
│   │   ├── Physical: Condom, Diaphragm, Cervical cap
│   │   ├── Chemical: Spermicides
│   │   └── Combined: Condom + spermicide
│   │
│   ├── Intra-Uterine Devices (IUDs)
│   │   ├── Inert: Lippes Loop
│   │   ├── Copper: Cu-T 380A, Multiload 375
│   │   └── Hormonal: Mirena (LNG-IUS)
│   │
│   ├── Hormonal Contraceptives
│   │   ├── Combined Oral Pills (COCPs)
│   │   ├── Progestogen-Only Pill (POP)
│   │   ├── Injectables: DMPA, NET-EN, Cyclofem
│   │   └── Implants: Norplant
│   │
│   ├── Post-Conceptional Methods
│   │   ├── Emergency pills (Levonorgestrel)
│   │   └── MTP (mifepristone + misoprostol)
│   │
│   └── Natural Methods
│       ├── Calendar/Rhythm method
│       ├── BBT method
│       ├── Cervical mucus (Billings) method
│       ├── Symptothermal method
│       └── Lactational amenorrhoea (LAM)
│
└── TERMINAL METHODS
    ├── Female sterilization (Tubectomy/Laparoscopy)
    └── Male sterilization (Vasectomy/NSV)

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