Community Medicine

Dr. Isha Amatya

MBBS (IOM), MD Community Medicine (KMC)
 DEMOGRAPHY
AND
FAMILY PLANNING
 DEMOGRAPHY
Demography: Is the scientific study of human population. It focuses
on:
– Changes in population size
– Composition of population
– Distribution of population in space

Demographic Processes: 5 processes continuously on work in a

population, thus determining its’ size, composition and
distribution
1. Fertility
2. Marriage
3. Mortality
4. Migration
5. Social mobility
DEMOGRAPHIC CYCLE

Demographic cycle Parameters

Stages Phases CBR CDR

Stage I High stationary High High

Stage II Early expanding High Starts declining

(Rapidly)

Stage III Late expanding Starts Continue declining

declining (Slowly)

Stage IV Low stationary Low Low

Stage V Declining CDR>CBR

 IMPORTANT DEFINITIONS IN DEMOGRAPHY
■ Crude birth rate (CBR): No. of live births per 1000 mid year population

■ General fertility rate (GFR): Annual number of live births per 1000 mid-
year population of women in childbearing age (15–49 years old)

■ General marital fertility rate (GMFR): Number of live births per 1000 mid-
year population of married women in childbearing age

■ Age-specific fertility rates (ASFR): Number of live births per 1000 women
in particular age groups

■ Crude death rate (CDR): Annual number of deaths per 1000 people

■ Expectation of life (Life expectancy): The number of years which an

individual at a given age could expect to live at present mortality levels
 IMPORTANT DEFINITIONS IN DEMOGRAPHY

■ Total fertility rate (TFR): Number of live births per woman completing
her reproductive life, if her childbearing at each age reflected current
ASFRs.

■ Gross reproduction rate (GRR): Average number of girls that would be

born to a woman if she experiences the current fertility pattern
through her reproductive span assuming nil mortality.

■ Net reproduction rate (NRR): Defined as “the number of daughters a

newborn girl will bear during her life time assuming fixed age specific
fertility and mortality rates”. It is most significant indicator of fertility.
 NRR=1 is also known as replacement rate (For NRR= 1, CPR
should be 60%)
 SEX RATIO AND DEPENDENCY RATIO
Sex Ratio
■ Sex Ratio: Is defined as number of females per thousand males
■ Sex Ratio = No. of Females * 1000
No. of Males
■ Sex ratio is an important and sensitive indicator of status of
women
Dependency Ratio
■ The proportion of persons above 65 years of age and children
below 15 years of age are considered to be dependent on
economically productive age group (15 – 64 years)
– DR is ratio of the economically dependent part of the
population to the productive part
– DR is the ‘age-wise’ ratio of non-earning to earning
population.
– DR is also known as ‘Societal Dependency ratio (SDR)’
 FAMILY PLANNING AND CONTRACEPTION
Pearl Index: The number of failures per 100 women years of exposure
measures contraceptive efficacy
■ Pearl index= Total accidental pregnancies X 1200
Total months of exposure

Couple Protection Rate (CPR):

■ CPR is percent of eligible couples protected against one or the other
approved methods of family planning, viz. condoms, OCPs, IUDs,
sterilization
■ Is an indicator of prevalence of contraceptive practice in a
community.

Eligible couples (ECs): A currently married couple with wife in

reproductive age group (15–45 years age)
■ ECs are in need of family planning services
COUPLE YEARS OF PROTECTION (CYP)

The estimated protection provided by contraceptive methods

during a one-year period, based upon the volume of all
contraceptives sold during that period.

CYP indicates the amount of time a couple will be protected

against an unwanted pregnancy based on the contraceptive
method used.

This provides an easy way to:

Estimate total CYP provided by all methods.
Compare contraceptive coverage provided by different
methods.
Monitor program results over time.
Calculate cost-effectiveness of a method.
COUPLE YEARS OF PROTECTION (CYP)
CONTD……

IUCD 8 CYP

2000-2008
COUPLE YEARS OF PROTECTION (CYP)
CONTD……

IUCD 8 CYP
Norplant 5 CYP
2000-2005
COUPLE YEARS OF PROTECTION (CYP)
CONTD……

IUCD 8 CYP
Norplant 5 CYP
pill
 COUPLE YEARS OF PROTECTION (CYP)
CONTD……

IUCD 8 CYP
Norplant 5 CYP
13 pill cycles 1 CYP
COUPLE YEARS OF PROTECTION (CYP)
CONTD……

IUCD 8 CYP
Norplant 5 CYP
13 pill cycles 1 CYP
depo
COUPLE YEARS OF PROTECTION (CYP)
CONTD……

IUCD 8 CYP
Norplant 5 CYP
13 pill cycles 1 CYP
4 depo 1 CYP
COUPLE YEARS OF PROTECTION (CYP)
CONTD……

IUCD 8 CYP
Norplant 5 CYP
13 pill cycles 1 CYP
4 depo 1 CYP
condoms
COUPLE YEARS OF PROTECTION (CYP)
CONTD……

IUCD 8 CYP
Norplant 5 CYP
13 pill cycles 1 CYP
4 depo 1 CYP
150 condoms 1 CYP
 UNMET NEED
 Refers to the condition of wanting to avoid or postpone
childbearing but not using any method of contraception.
Types:
1. Unmet need for spacing :
It refers to fecund women,
who want to wait for two or more years before having a child, or
who say they are unsure whether they want another child, or
 who want another child but are unsure when to have the child
but are not using any family planning method .

2. Unmet need for Limited:

 It refers to fecund women , who do not want any more children,
but are not currently using any family planning method.
Contraceptive prevalence rate

■ Percentage of target couples using modern

contraceptives
■ CPR= total no. women (15-49)using contraceptive
× 100
total no. women (15-49)
 CONTRACEPTIVES
TYPE COMPOSITION CPR CYP

•Oral Contraceptive 1. Levonorgestrel 0.15 mg 4.6% 13 Pill

Pills (Combined) 2. Ethinylestradiol 0.03 mg Cycle=1
3. Ferrous Fumarate 75 mg CYP

•Norplant Levonorgesterol 3.3% 5

36mg/Cap-6
75mg/Cap-2
•Intrauterine Copper 380mm2 1.4% 8
device(IUD)
Cu T 380 A
•Condom Made of Latex or Skin 4.2% 150
Male Polyurethrene Condom
Female Polyisoprene =1 CYP
•Depo-Provera Medroxyprogesterone 8.9% 4 Depo=1CYP
Acetate
 NATURAL METHODS
■ Safe period (Rhythm method/Calendar method):
– Fertile period: Shortest cycle minus 18 days (Last day of fertile
period: Longest cycle minus 10 days)
■ Basal Body Temperature (BBT) Method:
– Depends on: Rise of temperature (0.3° – 0.5° C) at ovulation
– Occurs due to: Increased progesterone production
– Measurement: Before getting out of bed in morning (preferably)
■ Cervical Mucus Method:
– Also known as ‘Billing’s Method’ or ‘Ovulation Method’
– Based on: Changes in characteristics of cervical mucus
■ Sexual abstinence:
■ Coitus interruptus/ Withdrawal method:
■ Lactation amenorrhoea method (LAM):
 COMBINED OCPS (EVERYDAY PILLS):
 Levonorgestrel 0.15 mg + Ethinylestradiol 0.03 mg +Ferrous
Fumarate 75 mg
 1 month supply has 28 pills ( 21 hormone containing and 7
Iron tablets)
 Mode of Action:
 Oestrogen: Inhibits ovulation.
 Progestogen:
 Inhibit ovulation by inhibiting the secretion of
gonadotropins(FSH and LH)
 Also thickens the cervical mucus & forming a barrier to
sperms.
 Also induce a thin endometrial lining, less suitable for
implantation.
 COMBINED OCPS (EVERYDAY PILLS):
 Duration of Effectiveness: As long as it is taken
regularly it is 99.9 % effective

 Failure Rate: 0.1-0.3 %

 Contraceptive Prevalence Rate: 4.6% (NDHS

2016)
OCPS: SIDE EFFECTS

 Breast tenderness
 Nausea
 Weight gain/bloating
 Headaches
 Mood changes
 Inter-menstrual bleeding
 Amenorrhea
OCPS: CONTRAINDICATIONS
1.Active thrombophlebitis or venous thromboembolic disorder

2. Acute or chronic obstructive liver disease with elevated liver enzyme levels
or compromised liver function

3. Known or suspected breast cancer

4. Undiagnosed genital bleeding

5. Women over 35 who smoke cigarettes

6. Arterial Thrombosis/Ischemic heart disease

7. Migraines with focal neurologic signs

 NORPLANT
It is a type of sub-dermal contraceptive implant
Type 1: NORPLANT
 Six small silicon rubber soft capsules, each
containing 36mg of synthetic progesterone
(levonorgesterol)

 Slowly releases hormone over a long period of time

Contraceptive protection for 5 years
Type 2: NORPLANT II (Jadelle)
 Same as above

 The only difference is that there are only 2 capsules

each containing 75mg of levonorgesterol
 NORPLANT CONTD…..
 Mode of Action:
 Synthetic progestogens inhibit ovulation by inhibiting the secretion of
gonadotropins(FSH and LH)

 They also thicken the cervical mucus thereby forming a barrier to sperms.

 They also induce a thin endometrial lining, less suitable for implantation.

 Duration of Effectiveness: 5 years approximately

 Failure Rate: 0.2-1.2 %

 Contraceptive Prevalence Rate(CPR): 3.3% (NDHS 2016)

NORPLANT: SIDE EFFECTS

 Irregular menstrual periods

 Breast discomfort

 Fluid retention

 Increase in acne
 INTRAUTERINE CONTACEPTIVE DEVICE
(IUCD/IUD)
■ A small, T-shaped plastic device that is wrapped in copper or
contains hormones.
Types of IUD

Copper IUD Hormonal IUD

 Hormonal IUD Copper IUD
Mode of Action

It makes the cervical mucus thick Copper is toxic to sperm

and
sticky, so sperm can't get through to
the uterus.
 It also prevents endometrial growth
and makes it non-receptive for the
fertilized egg
It makes the uterus and fallopian
tubes produce a fluid that kills sperm
-This fluid contains white blood cells,
copper ions, enzymes,&
prostaglandins.

Duration of Effectiveness
3-5 years 5-12 years
Failure Rate
0.2 % 0.8%
Contraceptive Prevalence Rate (CPR): 1.4%(NDHS 2016)
 IUCD: SIDE EFFECTS
 The hormonal IUD can cause hormonal similar to those
caused by Norplant
 DEPOPROVERA
 DEPOPROVERA a contraceptive method for women.
 It contains medroxyprogesterone acetate

 Mode of Action:
 Due to the action of progesterone

 Duration of Effectiveness: 3 months

 Failure Rate: 0.2 %- 6 %

 Contraceptive Prevalence Rate: 8.9% (NDHS 2016)

Depoprovera..
Contraindication:

 Breast cancer

 All genital cancers,

 Undiagnosed abnormal uterine bleeding

 High blood pressure

 Diseases of heart, blood vessel or liver

 CONDOM
 They are made of:- Latex sheath or skin(Males)

 Polyurethane(Females)

 Male: the condom is fitted on the erect penis before intercourse

 Females: Inserted in vagina

 Mode of Action:

 Forms a physical barrier between penis and vagina and prevents the
deposition of semen in the vagina
 Condom…
 Can be used in conjunction with spermicidal
agent

 Spermicide serves additional protection in the

unlikely event that the condom could slip off or
tears
 Failure rate: 2-3 %

 CPR: 4.2% (NDHS 2016)

 Emergency Contraception (EC)
■ Emergency postcoital contraception: Contraceptive measures that, if
taken after sex, may prevent pregnancy
■ Yuzpe and Lancee Method: Combined oral pills are generally accepted
as the preparation of choice for post-coital (emergency) contraception,
– Regimens:
■ pills with 30 mcg oestrogen: 4 pills immediately followed by 4
pills 12 hours later
■ Standard method (pills with 50 mcg oestrogen): 2 pills
immediately followed by 2 pills 12 hours later
■ Pills with 200 mcg oestrogen: 1 pill immediately followed by 1
pill 12 hours later
– Regimens have to be ‘completed within 72 hours of coitus’
– MC side effect reported by users of emergency contraceptive
pills: Nausea
 Emergency Contraception (EC)
■ Mini Pills (POP): Progesterone only Pill (POP) 0.75 mg
– Pill has to be ‘used within 72 hours of intercourse (LNG oral
tablet (0.75 mg): 1st tablet within 72 hours of intercourse and
2nd tablet after 12 hours of first dose)
– Reduces risk of pregnancy by 89%
– Use in first 24 hours prevent 95% of expected pregnancies
– POP as an Emergency Contraceptive has showed greater efficacy
with reduced side effects and has therefore superseded Yuzpe &
Lancee method
■ IUD Insertion: Must be ‘inserted within 5 days of coitus’
– Insertion of IUD is more effective than use of Emergency OCPs
■ High dose estrogens: Estrogen 5mg OD X 5 days
■ Antiprogestogen (Mifepristone RU 486): 600 mg stat within 72 hours
of coitus
 I-pill…
 Each Pill contains Levonorgestrel 1.5mg

 Used to prevent pregnancy But it cannot be used as a

regular contraceptive method

 Unhealthy if taken more than twice a month.

 The pill is to be taken soon after unprotected sex.

 It should be taken preferably within 24 hours and before

72 hours.

 It is taken by mouth and when taken correctly, it is up to

99.9% effective.
 INDICATION

 Contraceptive failure

 Unprotected sex

 Improper use of your regular birth control

method

 Forced sex
 MOA

 It may stop an egg being released from the ovary.

 If an egg has been released, i-pill may prevent the

sperm from fertilizing it.

 It prevents fertilization of an egg by affecting the

cervical mucus or the ability of sperm to bind to the
egg.

 If the egg is already fertilized, it may prevent it from

attaching itself to the lining of the womb.
 SIDE EFFECTS
 Nausea or vomiting.
 Dizziness.
 Fatigue.
 Headache.
 Breast tenderness.
 Bleeding between periods or heavier menstrual bleeding.
 Lower abdominal pain or cramps.
 Diarrhea.
 STERILIZATION (Vasectomy)
■ Procedure of Vasectomy: Remove ‘minimum 1 cm of vas deferens’
Ends are ligated and folded back to themselves
– Person is NOT sterile UNTIL after 30 ejaculations ( 3months)
– Open ended Vasectomy:
■ Seals only top end of vas deferens, Sperms are free to spill
out from the lower severed end of the vas
■ Likelihood of long-term testicular pain from ‘backup pressure’
seems to be eliminated using this method
– No Scalpel Vasectomy (NSV): vas is brought out through a tiny
puncture which does not require any stitches
■ Also known as ‘Key hole vasectomy’, Surgical hook (not
scalpel) is used to enter the scrotum
■ New safer, convenient technique acceptable to males
■ Nearly painless, less invasive and faster
■ Sterilization is the most cost-effective contraceptive measure
– Vasectomy is overall most cost-efective: Cost wise ratio is
5 vasectomies to 1 tubectomy

■ Failure of vasectomy:
– MCC: Mistaken identification of vas deferens
– Failure rate (Pearl Index): 0.15 per HWY
– Confirmation of successful vasectomy:
■ Histological confirmation
■ Smear of squeeze of vas by Wright’s stain
1) In demographic cycle, late expanding stage includes:
a) High BR and High DR
b) Decreasing BR and Decreasing DR
c) Stationary BR and decreasing DR
d) Low BR and Low DR
2) In calculating the dependency ratio, the numerator is expressed as:
a) Population under 10 years and 60 years and above
b) Population under 10 years and 65 years and above
c) Population under 15 years and 60 years and above
d) Population under 15 years and 65 years and above
3) The term “cafeteria choice” in relation to family planning indicates:
a) Provision of contraceptives at public places including toilets
b) Availability of contraceptives at cafeterias and canteens
c) Offering all method of contraception to an individual to make own
choice
d) Installation of condom vending machines at diff locations
4) The term family size refers to:
a) Total number of female children born to a woman
b) Total number of persons in a family
c) Total number of children a woman has born at a point in time
d) None of the above
5) Total fertility rate is indicative of :
a) Completed family size
b) Total number of married females in 15-45 years age group
c) Total number of female children in the family
d) Total number of females in 15-45 years age group.
6) Sex ratio is:
a) No of males per 1000 females
b) No of females per 1000 males
c) No males per 100 females
d) No of females per 100 males
7) “Number of live births per 1000 women in the reproductive age group in a
given year” is:
a) Birth rate b) GMFR c) GFR d) GRR

8) Mortality experiences are taken into consideration while defining:

a) GFRb) TFR c) GRR d) NRR

9) Failure rate of contraceptive methods is determined by:

a) Sullivan’s index
b) Number of accidental pregnancies
c) Pearl index
d) Half-life

10. CYP of Norplant is

a) 2 b) 3 c) 4 d)5
ANY QUESTIONS??