Family Planning

Dr Saleem Adil
Assistant Professor of Community Medicine
• Family planning is defined as a way of
thinking & 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
 Scope of FP services
• Family planning is not synonymous with birth control
• FP includes
1. Proper spacing and limitation of births
2. Advice on sterility
3. Education for parenthood
4. Sex education
5. Screening for pathological conditions related to reproductive system
6. Genetic counseling
7. Premarital consultation and examination
8. Carrying out pregnancy test
9. Marriage counseling
10. Preparation of couple for arrival of 1st child
11. Teaching home economics and nutrition
12. Adoption services
 Health aspects of family planning
• Woman’s health; reduction in maternal morbidity and
mortality by:
– Avoidance of unwanted pregnancies,
– limiting the number of birth and
– proper spacing and timing of pregnancy
• Fetal health
– Certain congenital malformations are associated with advanced
maternal age
• Infant and child health; effect of birth spacing and family size
on:
– Child mortality
– Child growth, development and nutrition
– Infectious diseases
 Eligible couples
• Eligible couples are the
married couples in which the
wife is in reproductive age
(15-45 yrs). These couples
are in need of family
planning services
 Target couples
• (An older term than eligible couple)
• Target couples are the priority couples among
eligible couples, typically those with 2-3 living
children
 Couple protection rate
• Percent of eligible couples effectively
protected against childbirth by one of the FP
methods
• An indicator of prevalence of contraceptive
use in a community
• Demographic goal is a CPR of at least 60%
 CONTRACEPTIVE METHODS
• Preventive methods against unwanted pregnancies
• Include temporary and permanent methods
• Several methods of contraception are available. The
method you choose will depend on your general
health, lifestyle and relationships.
• An ideal method is that which is effective, safe,
acceptable, inexpensive, reversible, simple to
administer, long lasting enough to avoid frequent
administrations, requiring little or no medical
supervision
 Ideal contraceptive method
• There is no ideal contraceptive method
• The use is effected by
– Culture
– Religious beliefs
– Socioeconomic factors

“Cafeteria choice”
 Contraceptive methods
Spacing methods Terminal methods
• Barrier methods • Male sterilization
– Physical methods • Female sterilization
– Chemical methods
– Combines methods
• Intrauterine devices
• Hormonal methods
• Post conceptional methods
• Misc
 Physical barrier methods
• Barrier methods of contraception stop sperm from
getting into the womb (uterus). Options include:
• Male condom
• Female condom
• Diaphragm.
• Male and female condoms also decrease the risk of
STIs. Barrier methods can be very effective if used
correctly. However, they can have high failure rates if
they are not used consistently and correctly.
• Main advantage is absence of side effects of IUDs or
hormonal methods
• Male condom
This is a latex (or polyurethane)
sheath that covers the penis and
prevents semen entering the
vagina. This is an effective (98
per cent) form of contraception
when used correctly. Male
condoms are relatively cheap
and are available over the
counter from supermarkets,
pharmacies and sexual health
clinics. They are more effective if
used alongwith spermicidal jelly
• Advantages of condoms
– Easily available, cheap, safe, easy to use, no
medical supervision required, no side effects, light,
disposable, also prevent against STDs
• Disadvantages
– May tear or slip off
– Reduce sensation
– Have to wear every time
• Female condom
This is a loose polyurethane
sheath with a flexible ring at
each end that sits in the
vagina and collects semen.
• Advantages: it protects
against STDs and has no siode
effects
• Disadvantages: It has to be
inserted several hours before
intercourse, insertion and use
need some practice, it is
expensive
Diaphragm
This is a shallow rubber cup
with a flexible ring that fits in
the vagina, covers the cervix
and stops sperm from
entering the uterus.
Advantages: no side effects
and no medical
contraindication, reduce risk
of STDs
Disadvantages: The diaphragm
must stay in place for at least
six hours after intercourse. It
is 94 per cent effective, have
to be fitted by a suitably
trained personnel, effective
only if muscle tone of vagina
is normal
 Vaginal sponge
• A foam sponge saturated
with spermicide, inserted
deep in vagina
• Much less effective than
other barrier methods
 Chemical methods
• Spermicide chemicals; including
– Foams
– Creams
– Suppositories
– Soluble films
Disadvantages: high failure rate, have to be applied
immediately before intercourse, local side effects of
chemicals which include irritation and even teratogenecity
Not much in use now; used only to increase the effects of
physical barrier methods
Intrauterine
contraceptive devices
(IUCD) 
2 types; non-medicated
and medicated.
1st generation
non-medicated/ inert
IUDs. Lippes loop (can
remain in uterus
indefinitely)
2nd generation
copper (5-10 yrs)
3rd generation
hormone – releasing (1-7
yrs)
An IUD, with added copper or hormones is inserted into
uterus. It can stay in the uterus for five to ten years
(depending on the type used) and can easily be removed.

IUD are more than 99 per cent effective. They work by

changing the lining and environment of the uterus,
effectively killing off sperm. If any sperm survive and
fertilize an egg, the egg is unable to stick to the wall of the
uterus, preventing a pregnancy from continuing. 

The hormonal IUD also slowly and continuously releases

progesterone or levonorgestral, which thickens the mucus
made by the cervix to further block sperm.
 Advantages of IUDs
• Simplicity
• Insertion takes only few minutes
• Cheap
• Reversible
• Regular motivation is not required
• Remain for years
• Less systemic side effects
 Contraindications to IUDs
• Absolute
– Pregnancy, PID, vaginal bleeding, cancer of cervix
or uterus etc, previous ectopic pregnancy
• Relative
– Anemia, menorrhagia, distortion of uterus due to
congenital malformation, fibroids
 Ideal candidate for IUD
• At least one child
• No H/O pelvic disease
• Normal menstruation
• Access to follow up
• Can check IUD tail
 Timings of insertion
• First 10 days of menstrual cycle
• 6-8 weeks postpartum
 Side effects of IUD
• Bleeding
• Pain
• Pelvic infection
• Uterine perforation
• Pregnancy
• Ectopic pregnancy
• Expulsion
• Mortality; very rare
 Follow up
• Provide motivation
• Confirm presence of IUCD
• Diagnose any side effect or complication
• Advices:
– Check the presence of IUCD
– Consult doctor if
• period is missed
• Any side effect
• Hormonal
contraceptives
– Oral pills
• Combined pill
• POP (progestogen only
pill)
• Post coital pill
• Once a month pill
• Male pill
– Depot (slow release)
formulations
• Injectables
• Subcutaneous implants
• Vaginal rings
• Hormones
– Synthetic estrogens
– Synthetic progestogens
• Combined pill 
This is made up of synthetic
forms of the hormones
estrogen and progesterone.
The combined pill prevents
ovulation, thickens cervical
mucus to make it harder for
sperm to enter the uterus and
changes the lining of the
uterus to make it less suitable
for a fertilized egg. 
There are many types of
combined pills with different
dose and hormone
combinations. This form of
contraception is generally not
recommended for women
who are at risk of heart
disease, such as smokers aged
over 35 years.
They are taken from 5th day of
cycle till 20-22 days
• POP (norethisterone and levogorgestrel)
This contains only a synthetic form of the
hormone progesterone. It makes the cervical
mucus thicker, which prevents sperm from
entering the uterus. The mini pill must be
taken every day at the same time and is not as
effective as the combined pill. It’s usually
suitable for women who either experience
side effects from estrogen or shouldn’t take it
for health reasons. 
 Post coital contraception
• Within 72 hrs of unprotected sex
• Levonorgestrel or ehthinyl estradiol or
mifepristone
 Adverse effects
• Cardiovascular effects (mainly due to estrogen
component): MI, DVT, cerebral thrombosis
• Carcinogenesis: not yet fully proved
• Metabolic effects: Hypertension, reduction of high
density lipoproteins, increase in CHO and insulin levels
• Liver disorders: benign tumors
• Early Cessation of lactation
• Breast tenderness
• Wt gain
• Headache and migraine
• Breakthrough bleeding
 Contraindications to pills
Absolute Relative
• Breast or genital cancer • Age above 40
• Liver disease • Smoking
• Thromboembolislm • Renal disease
• Cardiac anomalies • Epilepsy
• Congenital hyperlipidemia • Migraine
• Abnormal uterine bleeding • DM
• GB disease
• amenorrhea
 Mode of action
• Prevention of release of ovum from ovary by
blocking pituitary secretion of gonadotropin
• Progestogen makes cervical mucus thick, ihibit
tubal motility and delay transport of sperm
and ovum to uterus
• Depot formulations: injectables, subdermal
implants and vaginal rings 
Hormonal contraceptives for women are also
available as implants and injections. These
methods are more effective than other
hormonal methods, but may produce side
effects and don’t protect against STIs.
• DPMA injections (Depo-Provera;
medroxyprogesterone) 
These are long-acting (12 to 14 weeks) injectable
contraceptives containing the hormone
progestogen. They prevent ovulation, block sperm
by thickening the mucus and cause changes in the
lining of the uterus to make it unsuitable for a
fertilized egg to stick. (deep intramuscular)
• Norethisterone enanthate: given every 8 weeks
• Vaginal ring
contains levonorgestrel. Worn
in vagina for 3 weeks of the
cycle and then removed. Low
dose required than oral
• Subdermal implants/
Norplant:
This is a hormone implant
that is inserted under the skin
at the inner side of the upper
arm in the form of capsules or
rods containing a total of 210
mg of contains levonorgestrel.
It is effective for 5 years, fully
reversible after removal and is
almost 100% effective
• Sterilization:
Sterilization is a permanent surgical
procedure that requires referral to a
specialist. Female and male
sterilization are highly effective
methods of contraception.
• Female sterilization 
This procedure blocks the
fallopian tubes, preventing
an egg from passing down
the tube and being fertilized.
There are two types of
Female Sterilization: Tubal
Ligation, a one-time
outpatient surgery to cut,
burn or tie the fallopian
tubes, or placement
of Essure (spring-like coils)
inserted into the fallopian
tubes through the vagina.
Tubal ligations are 99.5%
effective as birth control.
Vasectomy (male
sterilization):
A surgical procedure in
which the vasa deferentia
are severed, tied or sealed.
It involves numbing of the
scrotum with local
anesthetic after which one
or two small incisions are
made and vasa deferentia
are cut or sealed by
ligating, cauterizing or
clamping
 Advice after sterilization
• Male:
– there can be pain and swelling and if the wound is not
taken care of, there can be infection
– Man can remain fertile upto 3 months or 30
ejaculations after the procedure
– Should use contraceptives till aspermia
– Don’t take bath for 24 hrs
– Wear t bandage for scrotal support for 15 days
– Avoid cycling or heavy wt lifting for 15 days
– Stitches to be removed after 5 days
• Natural methods
Natural family planning is based on an understanding
of the menstrual cycle. Methods include monitoring
cervical mucus changes, body temperature changes
and rhythm or cycle calculations to help determine
when a woman is most likely to be fertile each
month. 
• Calendar Method
Standard Days Method
(Developed by Georgetown University's
Institute for Reproductive Health).
The Standard Days Method may
only be used by women whose
cycles are always between 26 and
32 days in length. In this system:
– Days 1-7 of a woman's menstrual
cycle are considered infertile
– Days 8-19 are considered fertile
– From Day 20, infertility is
considered to resume
– This Method has a perfect-use
failure rate of 5% per year
 Coitus interruptus
• Withdrawal before ejaculation
 Evaluation of Contraceptive methods

• Assessed by measuring unplanned/ unwanted

pregnancies which occur during specified
period of exposure and used of contraceptive
methods
• Two methods are used
– Pearl Index (Failure rate)
– Life-table analysis
 Pearl Index (Failure rate)
• Number of failures per 100 woman–years of
exposure (HWY)

Total accidental
Failure pregnancies
Rate = ---------------------------- x 1200
Per HWY Total months
of exposure
• Numerator (total accidental pregnancies)
include all conception, i.e, livebirths,
abortions, stillbirths, not terminated.
• Factor 1200 is the number of months in 100
years
• Denominator (total months of exposure)
period under review minus 10 months for a
full term pregnancy and 4 months for an
abortion
• In a study to determine the Failure Rate of
condom as contraceptive, 30 couples were
observed for 3 years, 40 couples for 2 years,
10 couples for 18 months, 30 couples for 6
months. During study period, conception
took place in 20 couples
1.Name denominator to be used to calculate
the failure rate
2.Calculate failure rate of condom as
contraceptive
Denominator: Total months of exposure
30 x 3 x 12 = 1080
40 x 2 x 12 = 960
10 x 18 = 180
30 x 6 = 180
1080 + 960 + 180 + 180 = 2400
Conceptions: 20 : 20 x 10 = 200
Denominator: 2400 – 200 = 2200
 Total accidental
Failure pregnancies
Rate = ---------------------------- x 1200
Per HWY Total months
of exposure

20
= ---------- x 1200 = 10.9 per HWY
2200
• Interpretation:
• 25 ÷ 10.9 = 2.3
• A failure rate of 10.9 means that in the
lifetime of an average woman using
condom as contraceptive, 2.3 accidental
pregnancies would result (fertile period
of a woman is 25 y)
 Life table analysis
• Failure rate for each month of use is
calculated. A cumulative failure rate can then
compare methods for any specific length of
exposure
• Life table methods are often used to study birth
control effectiveness. In this role, they are an
alternative to the Pearl Index. As used in birth control
studies, a decrement table calculates a separate
effectiveness rate for each month of the study, as well
as for a standard period of time (usually 12 months).
• Use of life table methods eliminates time-related
biases (i.e. the most fertile couples getting pregnant
and dropping out of the study early, and couples
becoming more skilled at using the method as time
goes on), and in this way is superior to the Pearl
Index.