Contraception: Historical Perspective

Views:
 
Category: Entertainment
     
 

Presentation Description

No description available.

Comments

Presentation Transcript

Contraceptives and family planning:

Contraceptives and family planning State Institute of Health & Family Welfare, Jaipur 1 SIHFW: an ISO 9001: 2008 certified institution

Slide 2:

Contraception 2 SIHFW: an ISO 9001: 2008 certified institution

Contraceptive methods :

Contraceptive methods Definition- “Methods & practices that allow intercourse yet prevent conception are called contraception” 3 SIHFW: an ISO 9001: 2008 certified institution

India population trends :

India population trends 4 SIHFW: an ISO 9001: 2008 certified institution

Rajasthan /India : Decade wise Population growth :

Rajasthan /India : Decade wise Population growth Year India Rajasthan 1901 2380 102 1911 2520 109 1921 2510 102 1931 2790 117 1941 3190 138 1951 3610 159 1961 4390 201 1971 5480 257 1981 6830 342 1991 8460 440 2001 10270 565 2011 12100 686 5 SIHFW: an ISO 9001: 2008 certified institution

Contraception: condus: a vessel to store:

Contraception: condus : a vessel to store F irst recorded -end of the 19th century, Onanism - as an act of sexual intercourse so performed that, with ejaculation, procreation cannot result. (biblical story of Onan (Gen. 38: 4-10) Intentional prevention of fertilization of an ovum by special devices or drugs 6 SIHFW: an ISO 9001: 2008 certified institution

Historical Perspective:

Historical Perspective 1850 BC , Greek & Egypt Bible, Genesis Chapter 38, 'coitus interrupts‘ Ebers Papyrus, 1550 BC mentioned lint tampons soaked in the fermented tips of acacia shrubs. Gabrielle-15 century- first used the condom 7 SIHFW: an ISO 9001: 2008 certified institution

Early developments:

Early developments Japan-tortoiseshell, horn or leather cover Romans- first century- goat's bladder Fallopius (Italian anatomist), male condom (Linen) in 1504 Dr. Condom- to King Charles-II: animal intestine sheaths 1918, Marie Stopes ,- rubber cap to be used with quinine pessaries or a pad of cotton wool smeared with petroleum jelly. Vulcanized rubber in the 1840’s, by Goodyear Rubber condoms became available in 1880, 1930 liquid latex 8 SIHFW: an ISO 9001: 2008 certified institution

Context and Quality changed:

Context and Quality changed 1990 Condom quality Sizes Colors Flavors 9 SIHFW: an ISO 9001: 2008 certified institution

Slide 10:

In 1950- Gregory Pincus -“ideal” oral contraception, tested on women from Haiti and Puerto Rico. 1960- first oral contraception, Enovid 10, launched in the US 10 SIHFW: an ISO 9001: 2008 certified institution

Ancient Practices:

Ancient Practices Tree Barks & Gums Excreta of animals Fruits and Vegetable juices (Lemon, Orange) Dates, Honey, Sugar Salt water douches Chemicals like lactic acid anhydride All oriented at 11 SIHFW: an ISO 9001: 2008 certified institution

Prevalence and Use:

Prevalence and Use 12 SIHFW: an ISO 9001: 2008 certified institution

Trends in Knowledge of Modern Contraceptive Methods:

Trends in Knowledge of Modern Contraceptive Methods Source : NFHS SIHFW: an ISO 9001: 2008 certified institution 13

Trends in Contraceptive Use by Method:

Trends in Contraceptive Use by Method Percent of currently married women age 15-49 Source : NFHS 14 SIHFW: an ISO 9001: 2008 certified institution

Trends in Contraceptive Use by Method :

Trends in Contraceptive Use by Method Source : NFHS 3 Rajasthan Percent of currently married women age 15 SIHFW: an ISO 9001: 2008 certified institution

Use of family planning methods :

Use of family planning methods Source : DLHS 16 SIHFW: an ISO 9001: 2008 certified institution

Modern Contraceptive Prevalence-:

Modern Contraceptive Prevalence- Source : DLHS 17 SIHFW: an ISO 9001: 2008 certified institution

Contraceptive methods :

Contraceptive methods 18 SIHFW: an ISO 9001: 2008 certified institution

Classification:

Classification Spacing methods: used for spacing between two children or to delay birth of first child. Terminal methods: used when family is completed & couples desire no more children . 19 SIHFW: an ISO 9001: 2008 certified institution

Spacing methods:

Spacing methods Barrier methods: Male condom, Female condom. Vaginal methods: Spermicides , Diaphragm, Cervical cap. Intrauterine devices (IUDs): Lippes loop, Cu T-200,ML-Cu-250. CuT-380A Hormonal methods: OCPs, POP, Injectable , Implants etc. 20 SIHFW: an ISO 9001: 2008 certified institution

Spacing methods: cont..:

Spacing methods: cont.. 5. Non hormonal contraceptive pill 6. Emergency contraception- Post-coital 7. Natural methods 8. LAM 21 SIHFW: an ISO 9001: 2008 certified institution

Terminal methods:

Terminal methods Male Sterilization (Vasectomy) 2. Female Sterilization ( Tubectomy ) 22 SIHFW: an ISO 9001: 2008 certified institution

Barrier Methods:

Barrier Methods 23 SIHFW: an ISO 9001: 2008 certified institution

A. Male Condom:

A. Male Condom Composition: Sheath or covering of latex rubber made to fit over a man’s erect penis before intercourse Mode of action: Prevents the semen from being deposited in vagina Advantages: Inexpensive, easily available Easy to use Protects against STDs/ HIV No hormonal side effects 24 SIHFW: an ISO 9001: 2008 certified institution

Male condom contd.:

Male condom contd. Disadvantages: Require high degree of motivation Interferes with sex sensation May slip off, tear during coitus due to incorrect use Contraindication: Only contraindication is severe allergy to latex 25 SIHFW: an ISO 9001: 2008 certified institution

B. Female Condom:

B. Female Condom Composition : Pouch made of polyurethane Mode of action: Prevents semen from being deposited in vagina Advantages: Prevents STDs No side effects, no allergic reactions Disadvantages: Expensive Less effective than male condom 26 SIHFW: an ISO 9001: 2008 certified institution

2.Vaginal Methods :

2.Vaginal Methods Contraceptives that a woman places in her vagina shortly before intercourse. 27 SIHFW: an ISO 9001: 2008 certified institution

A. Spermicides:

A. Spermicides Composition: Surface-active agents, in form of foams, cream, je l ly, suppositories, melting films. Most commonly used agent is nonoxynol-9. Mode of action: These attach themselves with spermatozoa & inhibit oxygen uptake & kill sperms. Advantages: 1. No hormonal side effects. 2. Easy to use. Disadvantages: 1. High failure rates. 2. May cause irritation and do not prevent STDs effectively. 28 SIHFW: an ISO 9001: 2008 certified institution

B. Diaphragm/Cervical cap:

B. Diaphragm/Cervical cap Composition: Shallow cup made of synthetic rubber or plastic Mode of action: Inserted in vagina to cover the cervix before intercourse & must remain in place for not less than 6 hrs after Advantages: No side effects & medical contraindication. Can be inserted up to 6 hours before sex Disadvantages: Requires medical supervision Should be washed with soap & water after each use. Needs careful storage. 29 SIHFW: an ISO 9001: 2008 certified institution

3. Intrauterine Devices (IUDs):

3. Intrauterine Devices (IUDs) An IUD usually is a small, flexible plastic frame, often has copper wire or sleeves on it & inserted into a woman’s uterus through her vagina. IUDs have 1 or 2 strings which hang through the opening of cervix into the vagina to check the presence of IUD 30 SIHFW: an ISO 9001: 2008 certified institution

History of IUCDs:

History of IUCDs Grafenberg-1929-Ring of silkworm gut & silver wire Ota of Japan-gold plated silver 1959—Oppenheimer reintroduced; this time– INERT devices 1962-2 nd IN Conf. On IUCDs MARGUILLES Rings & LIPPES Loop were presented In 1964 the 2 nd IN Conf. On IUCDs many devices of different shapes were presented The first medicated devices were developed in 1969 using Copper and there is no looking back since then 31 SIHFW: an ISO 9001: 2008 certified institution

Slide 32:

Global Use of IUCD Sub Saharan Africa 0% Oceania 0% Developed Countries 5% Latin America & Caribbean 5% Near East & North Africa 7% Eastern Europe & Central Asia 11% Other Asia 12% China 60% 32 SIHFW: an ISO 9001: 2008 certified institution

Types/ mode of action of IUD:

Types/ mode of action of IUD 1 st generation IUDs Inert or non medicated( lippes loop) foreign body reaction in the uterus 2 nd generation IUDs Contain copper wire or sleeve(CuT-200, CuT-220C, ML-375, Cu-T380A ) Foreign body reaction Plus alteration in composition of cervical mucus, reduced sperm motility and survival due to copper ions 3 rd generation IUDs Hormone releasing IUDs ( Progestasert and LNG 20) increased cervical mucus viscosity thus preventing sperm entry in cervix high level of progesterone and low level of estrogen thus making the endometrium unfavorable for implantation. 33 SIHFW: an ISO 9001: 2008 certified institution

Slide 34:

34 SIHFW: an ISO 9001: 2008 certified institution

Copper - T:

Copper - T CU T 200-B CU T 220-C NOVA T ML CU 250,375 CU T 380-A 35 SIHFW: an ISO 9001: 2008 certified institution

Slide 36:

36 SIHFW: an ISO 9001: 2008 certified institution

Lippes Loop :

Lippes Loop Polyethylene. Available in four sizes, designated A (left) through D (right ). Date first marketed: 1962. Length: A—26.2 mm; B—25.2 mm; C—27.5 mm; D—27.5 mm. Width: A—22.2 mm; B—27.4 mm; C—30.0 mm; D—30.0 mm. Strings: Two; A—blue, B—black, C—yellow, D—white Areas of major use: Formerly, worldwide except China; currently, Indonesia. 37 SIHFW: an ISO 9001: 2008 certified institution

TCu-200 and TCu-200B :

TCu-200 and TCu-200B Polyethylene with barium sulfate added for visibility on x-rays. 200 mm2 copper wire wrapped around stem. The TCu-200B (shown) has a ball at the tip Date first marketed: 1972. Length: 36 mm.          Width: 32 mm. Inserter type and diameter: Withdrawal; 4.4 mm. Approved lifespan: US, 4 years 38 SIHFW: an ISO 9001: 2008 certified institution

Multiload-250 (MLCu-250) and 375 (MLCu-375) :

Multiload-250 (MLCu-250) and 375 (MLCu-375) Polyethylene.The MLCu-250 has 250 mm2 copper wire on the stem and is available in 2 sizes. Date first marketed: 1974. Length: Standard (250 and 375)—35 mm; 375SL—29 mm; 250 Short—24 mm. Width: All types—18 mm. Approved lifespan: MLCu-250—3 years; MLCu-375—5 years. 39 SIHFW: an ISO 9001: 2008 certified institution

CuT-220C :

CuT-220C Polyethylene.220 mm2 copper in 7 copper sleeves—2 on the arms and 5 on the stem. Date first marketed: 1980. Length: 36 mm.          Width: 32 mm. Strings: Two Approved lifespan: Mexico, 3 years. 40 SIHFW: an ISO 9001: 2008 certified institution

CuT-380A & CuT-380 :

CuT-380A & CuT-380 Description: Polyethylene rays. 314 mm2 copper wire on vertical stem; two 33mm2 transverse arm. Length: 36 mm.          Width: 32 mm Strings: Two white (formerly blue). Inserter type and diameter: Withdrawal; 4.4 mm Approved lifespan: TCu-380A—US, 10 years 41 SIHFW: an ISO 9001: 2008 certified institution

Nova T and CuNovaT :

Nova T and CuNovaT Nova T (shown) has 200 mm2 copper wire with a silver core wrapped around the stem. CuNovaT has 380 mm 2 wire wrapped around the stem. Date first marketed: Nova T—1979; CuNovaT—1994 Length: 32 mm.          Width: 32 mm. Approved lifespan: Nova T and CuNovaT—5 years in various European countries 42 SIHFW: an ISO 9001: 2008 certified institution

Progestasert Intrauterine Progesterone Contraceptive System :

Progestasert Intrauterine Progesterone Contraceptive System Ethylene vinyl acetate copolymer. Vertical stem contains a reservoir of 38 mg progesterone and barium sulfate. Releases 65 micrograms progesterone per 24 hours. first marketed: 1976 Length: 36 mm.          Width: 32 mm Approved lifespan: US, one year; France, 18 months 43 SIHFW: an ISO 9001: 2008 certified institution

Levonorgestrel (LNG-20) Intrauterine System (Mirena/Levonova) :

Levonorgestrel (LNG-20) Intrauterine System ( Mirena / Levonova ) Polyethylene T frame surrounded by a levonorgestrel -containing cylinder. The cylinder is covered with a rate-controlling membrane. The release rate is 20 micrograms levonorgestrel per 24 hours. Date first marketed: 1990 in Finland. Length: 32 mm.          Width: 32 mm. Hormone cylinder: length 19 mm, outer diameter 2.8 mm, inner diameter 1.2 mm. Approved lifespan: UK, 3 years; other countries, 5 years 44 SIHFW: an ISO 9001: 2008 certified institution

New Frameless Design :

New Frameless Design Several copper cylinders strung together are anchored into the uterus. 45 SIHFW: an ISO 9001: 2008 certified institution

Timing of Insertion:

Timing of Insertion During menstruation or within 10 days of beginning of menstruation Postpartum insertion: a. Immediate postpartum: first week b. Post Puerperal: after 6 weeks (advisable as more safe and easy) After abortion insertion: Immediately after legal 1 st trimester abortion but not immediately after 2 nd trimester abortion 46 SIHFW: an ISO 9001: 2008 certified institution

Advantages :

Advantages Simple and inexpensive procedure Single partner motivation required Long term effect Reversible contraception Free from systemic side effects of hormonal contraceptives No interference with sex 47 SIHFW: an ISO 9001: 2008 certified institution

Disadvantages:

Disadvantages Side effects and complications Heavy/ abnormal menstrual bleeding Lower abdominal pain Pelvic inflammatory diseases Uterine perforation Ectopic pregnancy Expulsion Does not protect against STDs, HIV/AIDS Requires trained person for insertion & removal 48 SIHFW: an ISO 9001: 2008 certified institution

Slide 49:

Contraindications Absolute: Suspected pregnancy, PID, undiagnosed vaginal bleeding, Carcinoma cervix & uterus, previous ectopic pregnancy Relative: anemia, menorrhagia , Purulent cervical discharge, unmotivated person 49 SIHFW: an ISO 9001: 2008 certified institution

4.Hormonal methods:

4.Hormonal methods A. Oral Contraceptives pills (OCPs) Low dose combined oral contraceptives- Monophasic : Standard dose, low dose and very low dose pills Multiphasic : Biphasic, Triphasic pills Progestogen -only pill B. Depot methods Injectables Implants 50 SIHFW: an ISO 9001: 2008 certified institution

Content of pills:

Content of pills Estrogen as ethinyl estradiol Progesterone as Medroxyprogesterone acetate and megestrol Norethisterone group: orethisterone , norethynodrol , Norethysterone aceate , Ethinodiol diacetate Norgestrel group: d- Norgestrel , L- Norgestrel Newer Progesterones : Desogestrel gestodene , and norgestemate . Contraceptive effect similar to other progesterones but almost no androgenic or anabolic effect. 51 SIHFW: an ISO 9001: 2008 certified institution

Combined Oral Contraceptive pills:

Combined Oral Contraceptive pills Mechanism of action: Inhibition of ovulation by suppressing FHS and LH Alteration of endometrium to make it unsuitable for implantation even if the ovum is fertilized. Changes in cervical mucous which make it hostile for sperms 52 SIHFW: an ISO 9001: 2008 certified institution

Health Benefits:

Health Benefits Fertility related benefits Prevention of pregnancy Offers protection against ectopic pregnancy Menstrual benefits Menstrual cycle stabilization Reduced iron deficiency anaemia due to lighter menstrual cycles More regular menstrual cycles Less dysmenorrhea Less severe pre-menstrual symptoms 53 SIHFW: an ISO 9001: 2008 certified institution

Health Benefits:

Health Benefits Protection from some cancers e.g. endometrial and ovarian cancer Protection against benign diseases e.g. benign breast diseases like fibrocystic and fibroadenomatosis disease decreased by 50-70% Other possible health benefits Protection against pelvic inflammatory diseases Reduces risk of follicular cyst by 50% and corpus luteal cyst by 80%. Past contraceptive use protects women after they reach menopause; reduced risk of low bone mineral density was documented Reduction in acne 54 SIHFW: an ISO 9001: 2008 certified institution

Side effects:

Side effects Nausea , vomiting, decreased appetite; usually pass off after 2-3 months of use Breakthrough bleeding-common with low dose progesterone pills due to low or absent estrogen. Oligo and ammenorrhoea due to lack of proliferation of endometrium of cycle. Common among women who had menstrual problems before starting oral contraceptive pills. Breast changes- oedema , heaviness and tenderness. Vaginal discharge due to congestion and hypertrophy of cervical epithelium. Weight gain in some cases due to estrogen and progesterone. Chloasma 55 SIHFW: an ISO 9001: 2008 certified institution

Who can use COCs?:

Have no children Heavy, Irregular, painful menstrual periods or anemia Benign breast disease or ovarian tumor Diabetes without vascular, kidney, eye or nerve disease Mild headaches or Varicose veins Thyroid disease Pelvic inflammatory disease Endometriosis Uterine fibroids Past ectopic pregnancy Tuberculosis (unless taking Rifampicin ) Who can use COCs? 56 SIHFW: an ISO 9001: 2008 certified institution

Who cannot use COCs?:

Who cannot use COCs? Women who have Complicated pulmonary hypertension, risk of atrial fibrillation, history of subacute bacterial endocarditis Migraine with aura Current breast cancer Diabetes with neuropathy, retinopathy, nephropathy and other vascular disease Multiple risk factors for arterial cardiovascular disease Acute hepatitis or severe cirrhosis of liver or benign or malignant liver tumours 57 SIHFW: an ISO 9001: 2008 certified institution

Slide 58:

Hypertension with systolic BP 140-159 and diastolic 90-99 and those having vascular disease. Clear history of deep vein thrombosis (DVT), pulmonary thrombosis or current DVT or pulmonary thrombosis. Known thrombogenic mutations. Current history of ischemic heart disease or known hyperlipidaemias Women who are breastfeeding within 6 weeks postpartum Are age 35+ and smoke more than 15 cigarettes per day 58 SIHFW: an ISO 9001: 2008 certified institution

Major evidences and clarifications:

Major evidences and clarifications COC users who smoke were at increased risk of cardiovascular diseases, specially Myocardial infarction. Desirable to have blood pressure measured before initiation of COC use but the women should not be denied use of COCs simply because their blood pressure cannot be measured. Among women with proven hypertension, COCs should be not be used unless other more appropriate methods are not available or not acceptable 59 SIHFW: an ISO 9001: 2008 certified institution

Major evidences and clarifications:

Major evidences and clarifications COCs are not recommended for women having Known thrombogenic mutations, as there is higher risk of thrombosis than for non-users Migraine and age above 35 years and those having migraine with aura 60 SIHFW: an ISO 9001: 2008 certified institution

Major evidences and clarifications:

Major evidences and clarifications Women with depressive disorders can safely use COCs If there is heavy or prolonged bleeding/ unexplained vaginal bleeding, evaluate for pregnancy or underlying pathological condition (such as pelvic malignancy). No increased risk among women with dysmennoroea compared to women not using COCs . Safe for women having trophoblast disease, benign breast disease, family history of cancer, pelvic inflammatory disease, STIs and HIV. Women having diabetes without non-vascular disease can generally use COC 61 SIHFW: an ISO 9001: 2008 certified institution

Major evidences and clarifications:

Major evidences and clarifications If taking Rifampicin or certain anticonvulsants, COCs should be prescribed only if any other appropriate contraceptive is not available or acceptable. Interaction of these drugs with COCs is not harmful but is likely to reduce effectiveness of COCs. Use of other contraceptives should be encouraged for the women who are long-term users of any of these drugs. 62 SIHFW: an ISO 9001: 2008 certified institution

When can a woman start COCs?:

When can a woman start COCs? During a menstrual cycle Between 2 menstrual cycles Amenorrhoea Breastfeeding Switching to another hormonal method Switching from non-hormonal method Switching from IUD (including hormonal) After miscarriage or abortion 63 SIHFW: an ISO 9001: 2008 certified institution

Pills missed?:

Pills missed? WHAT TO DO IF YOU MISS ONE OR MORE PILLS Every time you miss one or more active pills (days 1-21): In these special cases, ALSO follow these special rules If you miss nay of the 7 inactive pills (in a 28–pill pack only) 1. Take a pill as soon as you remember 1. Take the next pill at the usual time 3. Keep taking active pills as usual, one each day Source: Johns Hopkins University Bloomberg School of Health, Population information program Started pack 2 or more days late? Missed 2–4 pills of first 7 pills days 1–7 Missed 5 or more active pills in a row days 1–7 Missed 2–4 pills of last 7 active pills days 15–21 Avoid sex or another method for 7 days Finish all active pills in the pack. Do not take last 7 (inactive) pills in 28–pill pack. Do not wait 7 days to start next 21– pill pack. Start a new pack. 1. Throw away missed pills 2. Keep taking one pill each day 3. Start new pack as usual 64 SIHFW: an ISO 9001: 2008 certified institution

B. Depot methods:

B. Depot methods 65 SIHFW: an ISO 9001: 2008 certified institution

A. Injectable contraceptives:

A. Injectable contraceptives Progestogen only: a. DMPA: IM injection of depot medroxy progesterone acetate, 150 mg given in every 3 months. b. NET-EN: IM injection of norethistetrone enantate , 200 mg is given in every 2 months. 66 SIHFW: an ISO 9001: 2008 certified institution

Injectable contraceptives contd.:

Injectable contraceptives contd. II. Combined injectable contraceptives: Contains both progestogen & estrogen Given at monthly interval, plus or minus 3 days. 67 SIHFW: an ISO 9001: 2008 certified institution

B. Implants (Norplant):

B. Implants (Norplant) Composition: A set of 6 small silastic (silicone rubber) capsules, containing 35 mg (each) of levonorgestrel . More recent device comprise of 2 small rods: Norplant (R)-2 Mode of action: same as POPs 68 SIHFW: an ISO 9001: 2008 certified institution

Implants Norplant) contd.:

Implants Norplant) contd. Advantages: Same as hormonal contraceptive pills with an additional advantage, that single motivation provides long term pregnancy prevention, up to 5 years, no daily pill taking. Disadvantages: Minor surgical procedures required to insert & remove capsules. Other disadvantages are same as hormonal contraceptive pills. 69 SIHFW: an ISO 9001: 2008 certified institution

5. Non hormonal contraceptive pill:

5. Non hormonal contraceptive pill Composition: Pills containing non hormonal contraceptive called “CENTCHROMAN” Mode of action: Prevents implantation through endometrial changes. It has a strong anti-estrogenic action at peripheral receptor level. 70 SIHFW: an ISO 9001: 2008 certified institution

Non hormonal contraceptive pill cont. :

Non hormonal contraceptive pill cont. Dose: 30 mg started on 1 st day of menses and taken twice weekly for 12 weeks an weekly thereafter Side effect: Prolonged cycles and oligomenorrhoea in 8% Advantages: No hormonal side effects 71 SIHFW: an ISO 9001: 2008 certified institution

6. Post-coital contraception (Emergency contraception) (ECPs):

6. Post-coital contraception (Emergency contraception) ( ECPs) Emergency contraception: Is method of contraception used before missing a period to prevent pregnancy. It is also called “morning after” or post-coital contraception. 72 SIHFW: an ISO 9001: 2008 certified institution

Indications for using Emergency Contraception :

Contraceptive Updates Seminar, October 2005 Indications for using Emergency Contraception A woman who had unprotected sex, and wants to prevent pregnancy. For example: She did not expect to have sex and was not using any contraception Sex was forced Condom broke or slipped She ran out of contraceptives, or was irregular in taking pills and did not use condoms or spermicide . She is late for a contraceptive injection. 73 SIHFW: an ISO 9001: 2008 certified institution

What pills can be used as ECPs?:

What pills can be used as ECPs? Progestin-only dedicated products: Levonorgesterol pills are generally used GOI emergency contraceptive pills also available through public systems Several commercial preparations available in market 74 SIHFW: an ISO 9001: 2008 certified institution

:

0.75 mg of tablets Levonorgestel available in India. The current recommendation: 1 pill of LNG 0.75 mg to be taken as soon as possible after unprotected coitus (within 72 hours) followed by another pill 12 hours later. Method highly effective, has only mild and less frequent side effects compared to other combinations/regimens. A single dose of LNG 1.5 mg was tried in a WHO multicentric randomized trial. Found as effective as 2 doses given 12 hours apart up to 120 hours after exposure. Levonorgesterol alone EC pills- A dedicated product 75 SIHFW: an ISO 9001: 2008 certified institution

GOI Guidelines:

GOI Guidelines The Government of India guidelines for Emergency Contraception recommend use of Levonorgestrel ( progestogen only) LNG 0.75 mg as a “dedicated product” for effective emergency contraception. The Drug Controller of India has approved only Levonorgestrel for use as ECP. 76 SIHFW: an ISO 9001: 2008 certified institution

How do ECPs work?:

How do ECPs work? Probable mechanisms are: Inhibition or delay of ovulation Thickening of cervical mucous Direct inhibition of fertilization Histological and biochemical alteration in endometrium leading to impaired endometrial receptivity to implantation of the fertilized egg Alteration in transport of egg, sperm and embryo Interference with corpus luteum function and luteolysis 77 SIHFW: an ISO 9001: 2008 certified institution

When should ECPs be taken?:

When should ECPs be taken? ECPs should be taken as soon as possible after unprotected intercourse. The first dose should be taken within 72 hours after intercourse 78 SIHFW: an ISO 9001: 2008 certified institution

Advice on common problems :

Advice on common problems Nausea: Eat something soon after taking the pills to reduce nausea.Take anti-emetic half an hour before taking emergency contraceptive pills and every 4-6 hours thereafter. Vomiting: If the woman vomits within 2 hours of taking the pills, she may take another dose. Otherwise she should not take any extra pills. Extra pills will not make the method more effective, and they may increase nausea. Her next monthly period may start a few days earlier or later than expected. Reassure her that this is not a bad sign. 79 SIHFW: an ISO 9001: 2008 certified institution

When should the user return to the healthcare provider :

When should the user return to the healthcare provider if her next period is quite different from usual for her, especially if: There is unusually light bleeding (possibly pregnancy) Bleeding does not start within 4 weeks (Possible pregnancy Unusually painful (possibly ectopic pregnancy). But emergency oral contraception does not cause ectopic pregnancy. If there are symptoms of sexually transmitted diseases. 80 SIHFW: an ISO 9001: 2008 certified institution

Some facts about ECPs:

Some facts about ECPs Will not disrupt an established pregnancy No medical conditions rule out ECPs. Do not provide continuing protection from pregnancy. Offer no protection against STIs. 81 SIHFW: an ISO 9001: 2008 certified institution

Providing ECPs: Key steps:

Providing ECPs: Key steps Help the client feel at ease. Ask when unprotected sex took place. Give the woman pills. Explain how to take them. She can take first dose at once. Tell her that if she vomits within 2 hours of taking pills, she may take another dose. Explain and discuss important points about ECPs. Discuss her ongoing need for contraception 82 SIHFW: an ISO 9001: 2008 certified institution

7. Fertility awareness-based methods:

7. Fertility awareness-based methods Various methods are: Calendar calculation: A woman can count calendar days to identify the start and end of fertile time. The shortest cycle minus 18 days gives the first day of fertile period and longest cycle minus 10 days gives the last day of fertile period Cervical secretions: Also known as “Billings method”: When a woman sees or feels cervical secretions, she may be fertile. 83 SIHFW: an ISO 9001: 2008 certified institution

Fertility awareness-based methods contd. :

Fertility awareness-based methods contd. Basal body temperature: A woman’s resting body temperature goes up slightly around the time of ovulation Feel of the cervix: As the fertile time begins, the opening of the cervix feels softer, opens slightly, and is moist. A combination of all these methods can also be used to be more effective. 84 SIHFW: an ISO 9001: 2008 certified institution

Advantages:

Advantages No physical side effects No cost required Once learned, may require no further help from health care providers. Immediately reversible No hormonal side effects No effect on breast feeding 85 SIHFW: an ISO 9001: 2008 certified institution

Disadvantages:

Disadvantages Not an effective method Takes time to learn the duration of menstrual cycle Can become unreliable or hard to use if the woman has a fever, has a vaginal infection or is breast feeding May not be effective for women with irregular menstrual cycles Does not protect against STDs, HIV/AIDS 86 SIHFW: an ISO 9001: 2008 certified institution

8. Lactational amenorrhea method :

8. Lactational amenorrhea method Use of breast feeding as a temporary family planning method. A female is naturally protected against pregnancy when: Her baby gets at least 85% of his or her feedings as breast milk and she breastfeeds her baby often, both day and night Her menstrual periods have not returned Her baby is less than 6 months old 87 SIHFW: an ISO 9001: 2008 certified institution

Advantages:

Advantages Effectively prevents pregnancy for at least 6 months Encourages the best breastfeeding practices No need to do anything at time of sexual intercourse No hormonal side effects No direct costs, supplies or procedures 88 SIHFW: an ISO 9001: 2008 certified institution

Disadvantages:

Disadvantages Effectiveness after 6 months is not certain No protection against sexually transmitted infections including HIV/AIDS. If the mother has HIV, there is a chance that breast milk will pass HIV to the baby 89 SIHFW: an ISO 9001: 2008 certified institution

2. Terminal Methods:

2. Terminal Methods Effective contraceptive procedure for couples who have completed their family size Currently female sterilization accounts for about 85 % and male sterilization 10-15% of all sterilizations in India 90 SIHFW: an ISO 9001: 2008 certified institution

Male Sterilization:

Male Sterilization Method: Done under LA, a small incision is made in scrotal skin and a piece of vas at least 1 cm removed after clamping and ends ligated and folded back on themselves and sutured into position. Mode of action: No sperm in semen. Precaution: Use additional contraceptive procedure until approx. 30 ejaculations or for 3 months after the procedure 91 SIHFW: an ISO 9001: 2008 certified institution

Slide 92:

92 SIHFW: an ISO 9001: 2008 certified institution

Advantages:

Advantages Very effective Permanent: a single, quick procedure leads to lifelong, safe, and very effective family planning No interference with sex. No apparent long term health risks. No supplies to get, and no repeated clinic visits required 93 SIHFW: an ISO 9001: 2008 certified institution

Disadvantages:

Disadvantages Complications: Common complications: pain in scrotum, swelling and bruising Sperm granules Spontaneous recanalization (0-6 %) Autoimmune response to sperm Psychosocial effects 2. Requires minor surgery by a specially trained provider 3. Reversal is difficult 4. No protection against STDs including HIV/AIDS 94 SIHFW: an ISO 9001: 2008 certified institution

No Scalpel Vasectomy:

No Scalpel Vasectomy Eliminates the need to cut the patient's skin in order to reach the vas deferens. Tubes under the skin are isolated with a specialized clamp - after the anesthesia Make a tiny puncture to reach vas deferens. The vas deferens from each side are pulled through the hole one at a time and cut and blocked. very little bleeding and scarring, no stitches 95 SIHFW: an ISO 9001: 2008 certified institution

Benefits of NSV: :

Benefits of NSV: No-incision and no-stitch is a popular option Less trauma, less complications Fast recovery period and early return to work During the whole operation testicles are not interfered with at all. What are the potential complications Infections Congestion Sperm Granuloma Recanalization Internal Bleeding (Hematoma) 96 SIHFW: an ISO 9001: 2008 certified institution

Female Sterilization:

Female Sterilization Two procedures: Laparoscopy: First the abdomen is distended with CO 2 or NO 2. A small sub naval incision is made and laparoscope is inserted, after accessing the tubes, they are closed by a clip, a ring, or by electro coagulation. 2. Minilap operation: A small incision (under LA) is made in abdomen just above pubic hair line, uterus is raised and turned with an elevator to bring fallopian tubes under the incision and then each tube is tied and cut, or else closed with a clip or ring. 97 SIHFW: an ISO 9001: 2008 certified institution

Female sterilization contd.:

Female sterilization contd. Mode of action: Prevents ovum from being fertilized by the sperm. “Postpartum tubal ligation” is one of the most effective female sterilization techniques. (failure rate: 0.05 pregnancies per 100 women during the first year after the procedure)” 98 SIHFW: an ISO 9001: 2008 certified institution

Advantages:

Advantages Very effective Permanent: a single procedure leads to lifelong, safe and very effective family planning Nothing to remember, no supplies needed, and no repeated clinic visits required No interference with sex No long term or hormonal side effects No effect on breast feeding 99 SIHFW: an ISO 9001: 2008 certified institution

Disadvantages:

Disadvantages 1. Complications: a: Pain after the procedure or local infection or bleeding b: internal infection or bleeding C: Injury to internal organs 2. Requires physical examination and minor surgery by a specially trained provider 3. Reversal surgery is difficult, expensive and not available in most areas 4. No protection against STDs including HIV/AIDS 100 SIHFW: an ISO 9001: 2008 certified institution

Slide 101:

Method Failure Rate Spacing Methods Barrier Method Condom-Male 14% Condom-Female 5-21% Vaginal Method Diaphragm / Cervical Cap 20% Spermicides 26% Intrauterine Device Intrauterine Device 2 % 101 SIHFW: an ISO 9001: 2008 certified institution

Slide 102:

Method Failure Rate Hormonal Method Combined Oral Contraceptive (estrogen/progestin ) 0.3% Oral Contraceptive progestin only pills (POPs) 5% Injectables Implants 0.3% Non Hormonal Contraceptive pills Non Hormonal Contraceptive pills 1.83 Post-coital contraception (Emergency contraception) 0% Fertility Awareness 25% LAM 2% 102 SIHFW: an ISO 9001: 2008 certified institution

Slide 103:

Method Failure Rate Terminal methods Male Sterilization- Vasectomy 0.15% No Scalpel Vasectomy 5-10% Female Sterilization Laproscopy 0.5% 103 SIHFW: an ISO 9001: 2008 certified institution

Family Planning (Currently Married Women, age 15–49) Indicators: India:

Family Planning (Currently Married Women, age 15–49) Indicators: India Family Planning (Currently Married Women, age 15–49) Indicators Urban Poor Urban Non Poor Urban Rural State Total Urban Poor NFHS-2 Any modern method (%) 48.7 58.0 55.8 45.3 48.5 43.0 Spacing method (%) 7.6 19.8 16.9 7.2 10.1 4.6 Permanent sterilization method rate (%) 41.1 38.2 38.9 38.1 38.3 38.4 Total unmet need (%) 14.1 8.3 10.0 14.6 13.2 16.7 a. For spacing (%) 5.7 4.1 4.5 6.9 6.2 8.5 b. For limiting (%) 8.4 4.2 5.2 7.2 6.6 8.2 Source : NFHS 2 104 SIHFW: an ISO 9001: 2008 certified institution

Family Planning (Currently Married Women, age 15–49) Indicators: Raj :

Family Planning (Currently Married Women, age 15–49) Indicators: Raj Family Planning (Currently Married Women, age 15–49) Indicators Urban Poor Urban Non Poor Urban Rural State Total Urban Poor NFHS-2 Any modern method (%) 53.1 63.7 62.0 38.0 44.4 28.9 Spacing method (%) 10.5 22.6 20.6 5.3 9.4 2.9 Permanent sterilization method rate (%) 42.6 41.0 41.3 32.7 35.0 26.2 Total unmet need (%) 16.1 8.5 9.8 16.3 14.6 23.9 a. For spacing (%) 6.2 5.0 5.2 8.0 7.3 10.3 b. For limiting (%) 9.9 3.5 4.6 8.3 7.3 13.6 105 SIHFW: an ISO 9001: 2008 certified institution

Marriage and fertility Indicator : Raj:

Marriage and fertility Indicator : Raj Marriage and Fertility-Indicator Urban Poor Urban Non Poor Urban Rural State Total Urban Poor NFHS-2 Women age 20-24 married by age 18 (%) 65.1 30.6 35.8 65.7 57.1 70.0 Women age 20-24 who became mothers before age 18 (%) 16.2 8.7 9.8 27.5 22.4 37.3 Total fertility rate (children per woman) 3.4 2.0 2.2 3.6 3.2 5.1 Higher order births (3+ births) (%) 39.0 11.2 17.8 36.0 33.9 85.6 Birth Interval (median number of months between current and previous birth) 29.5 29.0 29.0 30.0 30.0 31.0 Source : NFHS 2 106 SIHFW: an ISO 9001: 2008 certified institution

Marriage and fertility Indicator : India :

Marriage and fertility Indicator : India Marriage and Fertility-Indicator Urban Poor Urban Non Poor Urban Rural State Total Urban Poor NFHS-2 Women age 20-24 married by age 18 (%) 51.5 21.2 28.1 52.5 44.5 63.9 Women age 20-24 who became mothers before age 18 (%) 25.9 8.3 12.3 26.3 21.7 39.0 Total fertility rate (children per woman) 2.8 1.8 2.1 3.0 2.7 3.8 Higher order births (3+ births) (%) 28.6 11.4 16.3 28.1 25.1 29.5 Birth Interval (median number of months between current and previous birth) 29.0 33.0 32.0 30.8 31.1 31.0 Source : NFHS 2 107 SIHFW: an ISO 9001: 2008 certified institution

NRHM Initiatives :

NRHM Initiatives Rajiv Gandhi Population Mission PCTS: Eligible couple tracking for two child norm Post Partum-IUCD linked to institutional deliveries Static Centers strengthening –MOs to be trained for Mini lap Online complete monitoring system to make PCPNDT Act effective (hamaribeti.nic.in) IEC for Spacing methods to be promoted Strengthening of Jan Mangal program (38300 couples) 108 SIHFW: an ISO 9001: 2008 certified institution

Slide 109:

Expanding Contraceptive Choice in RCH –II Addition of new contraceptive choices Injectable contraceptives (DMPA-SC 104,NET- EN) Sub dermal implants (Norplant) Vaginal Rings The Lactation Amenorrhea Method (LAM) Standard Days Method (SDM) Centchroman 109 SIHFW: an ISO 9001: 2008 certified institution

Strategies to expand contraceptive choice in RCH II:

Strategies to expand contraceptive choice in RCH II One MO trained in one sterilization method at each CHC and PHC Improving and integrating RCH services in PHCs and Sub-centers Training of District hospital/CHC/PHC staff: Forging linkages with ICDS division Engaging the private sector to provide quality family planning services Involving Panchayati Raj Institutions, Urban local bodies and NGOs 110 SIHFW: an ISO 9001: 2008 certified institution

Slide 111:

Stimulating demand for quality Family Planning services Increasing compensation In case of failure of permanent methods eligibility for safe MTP & compensation of Rs. 5000 Using the media. Involving satisfied users. Increasing the gender awareness of providers and increasing male involvement. Social Marketing. Studies and Operational Research 111 SIHFW: an ISO 9001: 2008 certified institution

Slide 112:

Evaluation of Contraceptive methods 112 SIHFW: an ISO 9001: 2008 certified institution

Evaluation of Contraceptive methods:

Evaluation of Contraceptive methods Measuring the number of unplanned pregnancies that occur during a specified period of exposure and use of a contraceptive method. pearl index life- table analysis. 113 SIHFW: an ISO 9001: 2008 certified institution

Pearl index :

Pearl index Identified as the number of “failures per 100 women years of exposure (HWY)’’ Total accidental pregnancies Failure rate per HWY = X 1200 Total months of expenditure 114 SIHFW: an ISO 9001: 2008 certified institution

Slide 115:

Total Fertility Rate : Average number of children a women would have if she were to pass through her reproductive years bearing children at the same rate as the women in each age group Computed as : *ASFR : Age specific fertility rate 45-49 5 X  ASFR* 15-19 TFR= 1000 Total fertility rate 115 SIHFW: an ISO 9001: 2008 certified institution

Slide 116:

TFR : Total no. of children a women has borne at a point in time Fertility : Actual bearing of children India Total fertility rate Rural 2.06 Urban 2.98 Source : NFHS 3 116 SIHFW: an ISO 9001: 2008 certified institution

Major Issues: Reducing TFR:

Major Issues: Reducing TFR Early age of marriage (40% - DLHS III) and high adolescent fertility rate (16 %) Lack of motivation of the Couples to adopt limiting methods after having two children Son preference Meeting the unmet need of family planning through regular provision of FP services 117 SIHFW: an ISO 9001: 2008 certified institution

Slide 118:

Need to Shift from Camp Approach to Fixed Day approach Lack of service providers for fixed day approach at CHCs - 50% vacancy of Gynecologists and 53% vacancy of Surgeons at CHCs Need for focus on promoting spacing methods 118 SIHFW: an ISO 9001: 2008 certified institution

Slide 119:

S.No . States TFR (SRS) Average Reduction in TFR (04-08) 2004 2005 2006 2007 2008 All India 2.9 2.9 2.8 2.7 2.6 -0.075 TFR - Declining Trend 119 SIHFW: an ISO 9001: 2008 certified institution

Slide 120:

For more details log on to www. Sihfwrajasthan.com or contact : Director-SIHFW on sihfwraj@yahoo.co.in Thank You 120 SIHFW: an ISO 9001: 2008 certified institution

authorStream Live Help