Family planning india

Family planning class for MBBS students based on Park textbook including details on MTP, abortion, Family planning infrastructure and delivery systems in India and National Family Welfare Programme.

1. Family Planning Dr Mamta Gehlawat MBBS MD PGDHHM PGDG Asst Prof Comm Med GMC SDPT

2. Methods for Termination of pregnancy/ post-conception

3. Menstrual regulation Aspiration of uttering content post 1-2 weeks of a missed period Complications- Uterine perforation/trauma Risk for abortion/preterm labour Infertility, menstrual disorders Ectopic pregnancy, Rh-immunisation Its different from abortion (Its early, not restricted, safer)

4. Menstrual induction Intrauterine application of 1-5mg Prostaglandin F2 under sedation Induces contractions and bleeding Oral abortifacient ( upto 9weeks) 200mg oral 800mcg vag .

5. Contra-indications of Oral abortifacients h/o allergy /hypersensitivity to prostaglandins Suspected ectopic pregnancy IUD in situ Chronic adrenal failure Hemorrhagic disorder/Anticoagulant use Porphyria disorders No access to medical facility

6. Abortion (termination before viability of fetus ) Spontaneous Abortion (one in 15 pregnancies) 2. Induced Abortion Legal/ safe Illegal/ unsafe

7. Abortion Hazards Around 25% of all pregnancies are unintended Yearly 14 unsafe abortions per 1000 women of rep. age Low contraceptive use High unsafe abortion rate India- 33% safe and 66% unsafe abortions Complications of abortion- Hemorrhage , shock, sepsis, Uterine perforation, cervical injury, Thromboembolism, anaesthetic, psychiatric problems Later- Infertility, ectopic preg , spont . abortion risk, LBW

8. MTP/ Medical Termination of Pregnancy Act passed in 1971, revised in 1992 To reduce illegal abortion- reduce MMR and morbidity MTP act states- When pregnancy can be terminated? Who is qualified to terminate the pregnancy? Where to terminate the pregnancy?

9. Abortion- when allowed? Medical- danger to mothers life physically/mentally Eugenic- risk of abnormality in fetus Humanitarian- pregnant by rape Socio-economic- social/economic envt . not support pregnancy Failure of contraceptive devices- allows abortion on request

10. Abortion- who can perform? < 12 weeks = 1 RMP with experience in OG/abortion 12- 20 weeks = 2 RMP with experience in OG/abortion Abortion- where to perform? Government Hospital Govt. permitted clinic for MTP Patient Details to be kept confidential

11. The Bill seeks to extend the termination of pregnancy period from  20 weeks to 24 weeks,  making it easier for women to safely and legally terminate an unwanted pregnancy. MTP (Amendment) Bill 2020 approved

12. MTP (Amendment) Bill 2020 approved Requirement of opinion of one RMP  for termination of pregnancy up to 20 weeks of gestation – Earlier two RMP Requirement of opinion of two RMPs for termination of pregnancy of 20 to 24 week Raising the upper gestation limit from 20 to 24 weeks  for special categories of women, including include rape survivors, victims of incest, differently-abled women and minors Name and other particulars of a woman  whose pregnancy has been terminated shall not be revealed, except to a person authorised in any law Extend the contraceptive-failure clause for termination to include  “any woman or her partner” from the present provision for “only married woman or her husband”.

13. Take home message Abortion deaths constitute 8% of all maternal deaths per year in India The best abortion is still less safer than an effective contraceptive

14. National Population Policy 2000 The following major Objectives had been set in the National Population Policy till the year 2010 : 1. The 'total fertility rate' to be reduced to 2.1. 2. The high class birth control services had to be made available publically so that the standard of two children could be adopted. 3. The infant mortality rate had to be reduced to 30 per thousand. 4. The mother mortality rate had also to be reduced to below 100 per one lakh. 5. The late marriage of girls had to be encouraged.

15. Statistics NPP goal by 2010 What India has achieved TFR 2.1 (Replacement level) 2.3 (2014) CPR >60% 55% (2015) IMR <30 per 1000 live births 38 (2015) MMR <100 per lakh live births 174 (2015) Age of marriage girls Not before 18 and preferably after 20 19.2 (2011)

16. National Health Policy 2017 4.8 Population Stabilization : The National Health Policy recognises that improved access, education and empowerment would be the basis of successful population stabilization. The policy imperative is to move away from camp based services with all its attendant problems of quality, safety and dignity of women, to a situation where these services are available on any day of the week or at least on a fixed day . Other policy imperatives are to increase the proportion of male sterilization from less than 5% currently, to at least 30% and if possible much higher.

17. Translation- Responsible couples do family planning

18. Evaluation of contraceptive methods To measure contraceptive efficacy: 1.Pearl Index 2. Life table analysis

19. Pearl Index=usually based on specific exposure hence fails to accurately compare methods at various durations of exposure

20. Life table analysis: Calculates failure rate for each month of use Cumulative failure rate calculated later Thus can compare methods for any specific duration of use

21. What is the drawback of Pearl index and how does ‘life table analysis address it? http://www.ihatepsm.com/blog/pearl-index-and-life-table-analysis The drawback of the Pearl index is that it assumes a constant failure rate over time. This assumption is incorrect due to two reasons: 1. The most fertile couples will get pregnant in the beginning of the study and will no longer be counted in the denominator. Couples remaining later in the study, are, on average, of lower fertility. 2. With most birth control methods the effectiveness increases with experience. The longer a couple is in the study, the better it gets at using the method. So the longer the study length, the lower the Pearl Index will be. Hence comparisons of Pearl Indexes from studies of different lengths cannot be accurate ‘Life table analysis’ calculates cumulative failure rates over a specified timeframe. They present failure rate as number of pregnancies per 100 women years, standardized by yearly cut-off points (usually 1, 3 or 5y) e.g. “life-table rates for long-acting hormonal methods were reported as 0–0.6 per 100 HWY at one year”

22. Success element in NFPP… The key points are as follows : (1) Make services accessible (2) Make services affordable (3) Offer client- centered care (4) Rely on evidence based technical guidance (5) Communicate effectively (6) Assure contraceptive security (7) Work for supportive policies

23. (8) Coordinate (9) Build a high-performing staff (10) Secure adequate budget, use it well (11) Base decisions on evidence (12) Lead strongly, manage well (13) Integrate services appropriately …Success element in NFPP

24. Unmet need for family planning in 1960s, when data from surveys of contraceptive knowledge attitude and practices (KAP) showed a gap between some women' s reproductive intention and their contraceptive behaviour. The term that came to popular use describing this group was "KAP-gap". Many women who are sexually active would prefer to avoid becoming pregnant, but nevertheless are not using any method of contraception (including use by their partner). These women are considered to have an "unmet need" for family planning. Among the most common reason for unmet need are inconvenient or unsatisfactory services, lack of information, fears about contraceptive side effects and opposition from husband or relatives. Unmet need is defined on the basis of women's response to survey questions.

25. The National Family Health Survey-4 results show that although current use of contraception has increased and the extent of unmet need has declined in most of the states in India, there is a need for considerable improvement in the coverage and quality of family planning services. especially in the four large states of Uttar Pradesh, Bihar, Madhya Pradesh and Rajasthan.

26. Contraception and adolescence For the year 2014, WHO puts the global adolescent birth rate at 49 per 1000 girls of that age Adolescents are ambivalent about family planning: to request contraception is to reveal one's sexuality. For this reason. adolescent girls sometimes choose the risk of an undesired pregnancy and of an abortion. BARRIER METHODS : Condoms HORMONAL CONTRACEPTION perfectly suitable for adolescents trimestrial or monthly injections are also appropriate.

27. Contraception and adolescence IUD : IUD are theoretically contraindicated , because of the risk of pelvic infection and of secondary sterility. However. an adolescent is better protected by an IUD than by illegal repeated abortions. OTHER METHODS : Periodic abstinence is not easy when cycles are irregular and intercourse is unforeseen, and with new partners. Spermicides are not contraindicated. but have two disadvantages - they are costly, and are not effective against STD and AIDS

28. Delivery System Levels Centre Planning and Financial Management Administration and Implementation Administration, mass edu ., media All FP services with Lap. and abortion MTP, sterilization, Cu T insertion Awareness, Nirodh , OCP supply

29. Browse for https://humdo.nhp.gov.in/ for updates on family planning data/services

30. New Initiatives in Family Planning Programme Home Delivery of Contraceptives (HDC) a. Since 2011 -ASHA to deliver contraceptives at the doorstep of beneficiaries Charge- Rs. 1 for 3 condoms. Rs.1 for 1 cycle OCPs and Rs. 2 for 1 ECP 2. Ensuring spacing at birth (ESB) ASHAs -counselling newly married couples to ensure spacing of 2 years after marriage and spacing of 3 years after the birth of 1st child. The scheme is operational in 18 States (EAG, North-Eastern and Gujarat and Haryana).

31. ASHA would be paid following incentives under the scheme : Rs. 500/- to ASHA for delaying first child birth by 2 years after marriage. - Rs. 500/- to ASHA for ensuring spacing of 3 years after the birth of 1st child. - Rs.1000/- in case the couple opts for a permanent limiting method upto 2 children only. b. Ministry of Health & Family Welfare has introduced short term IUCD (5 years effectively). Cu IUCD 375 under the National Family Planning programme. Training of State level trainers has already been completed and process is underway to train service providers upto the sub-centre level. c. A new method of IUCD insertion (post-partum IUCD insertion) has been introduced by the Government. d. Promoting Post-partum Family Planning services at district hospitals by providing for placement of dedicated Family Planning Counsellors and training of personnel.

32. 3. Pregnancy Testing Kits Nischay - Home based pregnancy test kits (PTKs) was launched under NRHM in 2008 across the country. The PTKs are being made available at sub-centres and to the ASHAs to facilitate the early detection and decision making for the outcomes of pregnancy.

33. 4. Mission Parivar Vikas (MPV) https://www.pradhanmantriyojana.co.in/mission-parivar-vikas-family-planning-scheme/ “Greater the Total Fertility Rate , the more will be the Maternal Mortality Rate and Infant Mortality Rate . Hence, reducing the Total Fertility Rate would lead to decrease in maternal mortality and morbidity and infant mortality and morbidity.” A programme launched in 146 high total fertility rate districts to accelerate the use and awareness of family planning methods.

34. Nayi pehal kit= encourage family planning decisions in newly weds

35. Saas bahu sammelan = bridge the gap in attitudes-beliefs

36. Saarthi = Awareness on wheels

37. 5. New contraceptive launch Injectable MPA under "Antara programme" Oral contraceptive pill centchroman " chhaya " Government of India is promoting "Fixed Day Static Services" (FDS) approach in sterilization services within the public health system with the aim of increasing access to sterilization services. District hospital - twice a week Sub-district hospital - weekly CHC/Block PHC - fortnightly 24x7 PHC/PHC - monthly

38. https://humdo.nhp.gov.in/new-contraceptives/

39. Community Needs Assessment Approach There were many drawbacks in the top down target approach in which types and quantity of contraceptive need to be canvassed was decided by the higher authorities. Firstly, the user preference was not reflected in the targets . There was no authentic system of feedback regarding which type of contraceptive was to be promoted in a particular area or among a particular age group. Secondly, the quality of the services became secondary . For example, if in an attempt to fulfil targets for the number of IUD insertions, the quality of care is compromised, the acceptability of IUD programme would receive a serious setback and discontinuation rate will be high. Thirdly. people may be tempted to resort to false reporting to claim fulfilment of the target to get incentives

40. …A Target free manual The practice of fixing up targets for each contraceptive method was removed in 1996. This does not mean a licence to do no work. The population goals remain the same as before. Health workers are expected to consult families and local community in the beginning of the year in order to assess their needs and preference and then work-out for themselves the programme and workload for the coming year. The requirement for each village needs to be worked out to arrive at the workload for the ANM, this becomes the target for the ANM for the year. The workload of different ANMs under one PHC when added up would determine the workload for the PHC. Similarly requirements at the district level would be worked out by adding up the requirements at all the PHCs. The target free manual was renamed as Community Needs Assessment Approach (CNAA) Manual.

41. Involvement of private sector For family planning programme to be successful. Grants-in-aid are provided to voluntary organizations and industrial organizations for running family welfare centres and postpartum centres. Extended to practitioners of integrated medicine. Government has also created nation-wide retail outlets for selling subsidized condoms. Incentives and dis-incentives To encourage couples to practise family planning Financial compensation of individuals undergoing sterilization started in 1966 The acceptors now receive a one-time payment

42. National Family Planning Indemnity Scheme (NFPIS) From 2013, it has been decided that States/UTs would process and make payment of claims to accepters of sterilization in the event of death/failures/ complications/indemnity cover to doctors/health facilities. The States/UTs would make suitable budget provisions under the National Rural Health Mission (NRHM) and the scheme is renamed as "Family Planning Indemnity Scheme". Government of India has introduced a family planning insurance scheme for acceptors of sterilization and indemnity cover for doctors performing sterilization procedures The insurance scheme will be operated by the ICICI.

43. Rewards/ Incentives State government employees, who undergo sterilization after two or three children are eligible for a special increment (two increments after 2 children and one after 3 children). Central government employees get one increment after sterilization to promote small family norm, provided the employee is below 50 years of age and his spouse below 45 years. They get special leave (14 days for women and 7 days for men). No maternity leave is allowed after 3 children. The State Governments have been requested to : issue Green Cards to individual acceptors of terminal methods after two children as a mark of recognition and for priority attention in schemes where preferential treatment was feasible. Cash awards have been instituted for the best performing states, the amount of which will be spent on promoting family welfare activities

44. All India Hospital Postpartum Programme (AIHPP) -1969 It is a hospital-based maternity centred approach to family planning . The primary objective- to improve the health of the mother and children through MCH and Family Welfare programme which includes antenatal, neonatal, and postnatal services; immunization services to children and mothers; and prophylaxis against anaemia and blindness. The programme is based on the following rationale : a. That women who have recently delivered are of proven fertility, and are at risk to become pregnant again rapidly b. At the time of delivery and during the lying-in period. they are generally more receptive to adopt one or the other family planning method. The postpartum programme offers necessary facilities to such women. It has proved to be an efficient way of delivering family planning services. A scheme of PAP smear test facilities has been sanctioned for all medical colleges

45. Population education Population education has been defined as an educational programme which provides for a study of the population situation in the community, nation and world with the purpose of developing in the students rational and responsible attitudes and behaviour towards that situation‘’. In the Indian context, the concept of population education is to teach the students- the consequences of uncontrolled population growth the benefits of a small family norm the economics, sociology and statistics of population growth, its distribution and its relation to the levels of living

46. SOCIOLOGY OF FAMILY PLANNING Sociologists and economists have shown that it will be difficult to raise the living standards/ quality of life of the people while population growth continues unchecked -food, shelter, clothing, education and medical care. Attitude surveys have shown that awareness of family planning is very widespread and over 60 per cent people have attitudes favourable to restricting or spacing births . People are generally in favour of family planning, and there is no organized opposition to it. lnspite of this, the rate of contraceptive use by couples in the developing countries is very low. This is the crux of the family planning problem. Studies have shown that the population problem is complicated by deep- rooted religious and other beliefs , attitudes and practices favouring larger families (e.g., strong preference for male children). The common beliefs are - that children are the gift of God; the number of children is determined by God; children are a poor man's wealth; children are an asset to which parents can look forward in periods of dependency caused by old age or misfortune, etc. Most of these beliefs stem from ignorance and lack of communication . The problem of family planning is therefore, essentially the problem of social change. Contraceptive technology is no short cut to the problem. What is more important is to stimulate social changes affecting fertility such as raising the age of marriage, increasing the status of women, education and employment opportunities, old age security, compulsory education of children, accelerating economic changes designed to increase the per capita income, etc. It is now axiomatic that economic development is the best contraceptive- a desire to improve standard of living. The solution to the problem is one of mass education and communication , so that people may understand the benefits of a small family.

47. VOLUNTARY ORGANIZATIONS Complement governmental efforts to promote Family Welfare Programme. Apart from educational and motivational efforts, their activities include running of Family Welfare Centres, post-partum centres, ANM training schools, population research centres and other innovative projects. well-known voluntary agencies in India are the Family Planning Association of India, the Family Planning Foundation and the Population Council of India. Others include the Indian Red Cross, the Indian Medical Association, Rotary Clubs, Lions Clubs, Citizens Forum, Christian Missionaries and Private Hospitals. At the international level, the International Planned Parenthood Federation is the world's largest private voluntary organization supporting family planning services in developing countries. It is an international federation of independent Family Planning Associations with headquarters in London. Others include the United Nations Fund for Population Activities (UNFPA), the US Agency for International Development (USAID). the Population Council, Ford Foundation, the Pathfinder Fund and World Bank besides WHO and UNICEF. The international agencies are assisting in funding family planning research , services, training and information programmes designed to reduce the family size.

48. NATIONAL FAMILY WELFARE PROGRAMME India launched a nation-wide family planning programme in 1952 During the Third Five Year Plan (1961-66). family planning was declared as "the very centre of planned development"' . The emphasis was shifted from the purely "clinic approach"' to the more vigorous "extension education approach·· for motivating the people for acceptance of the " small family norm " . The introduction of the Lippes Loop in 1965 necessitated a major structural reorganization of the programme, leading to the creation of a separate Department of Family Planning in 1966 in the Ministry of Health. During the years 1966-1969, the programme took firmer roots. The family planning infrastructure (e.g., primary health centres, sub-centres, urban family planning centres, district and State bureaus) was strengthened. During the Fourth Five Year Plan (1969- 74), the Government of India gave " top priority " to the programme. The Programme was made an integral part of MCH activities of PHCs and their sub-centres. In 1970, an All India Hospital Postpartum Programme and in 1972, the Medical Termination of Pregnancy (MTP) Act were introduced.

49. In April 1976, the country framed its first "National Population Policy''. The disastrous forcible sterilization campaign of 1976 led to the Congress defeat in the 1977 election. Amendment of the Constitution made "Population control and Family Planning'' a concurrent subject . The acceptance of the programme is now purely on voluntary basis . The launching of the Rural Health Scheme in 1977 and the involvement of the local people (e.g., Health Guides, trained Dais, Opinion leaders) in the family welfare programme at the grass-root level for progress of the programme. India was a signatory to the Alma Ata Declaration in 1978. The acceptance of the primary health care approach to the achievement of HFA1 2000 AD led to the approval of National Health Policy in 1983. It laid down the long- term demographic goal of NRR= 1 by the year 2000 - which implies a 2-child family norm - through the attainment of a birth rate of 21 and a death rate of 9 per thousand population, and a couple protection rate-of 60 per cent by the year 2000 . The Universal Immunization Programme aimed at reduction in mortality and morbidity among infants and younger children due to vaccine preventable diseases was started in the year 1985-86. The oral rehydration therapy was also started to tackle diarrhoea -a leading cause of child death. During 1992 these programmes were integrated under Child Survival and Safe Motherhood (CSSM) Programme . During 1994 the International Conference on Population and Development in Cairo recommended implementation of Unified Reproductive and Child Health Programme (RCH). The Government of India evolved a more detailed and comprehensive National Population Policy 2000.

50. In the year 2005 Govt. of India launched National Rural Health Mission , initially for seven years (2005-2012) which was extended for 5 years up to 2017. Then came National Urban Health Plan and merging both these - National Health Mission . In the year 2013, RMNCH+A strategy was launched which was based on a continuum of care approach and defines integrated packages of services for different stages of life. In the year 2014, India Newborn Action Plan (!NAP) came with the goal to attain single digit neonatal mortality rate by 2030 and single digit stillbirth rate by 2030. The investment on family welfare programme -It can be seen that from a 0.65 crores during the first plan, the investment has reached Rs. 371,600 crores during the Twelfth Plan period.

51. EVALUATION OF FAMILY PLANNING The purpose of evaluation is to improve the design and delivery of family planning services. Five types of evaluation have been defined by a WHO Expert Committee in 1975 on evaluation of family planning in health services : Evaluation of need -health, demographic and socio-economic needs For example, the current status of maternal mortality in a given area 2. Evaluation of plans -assessment of the feasibility and adequacy. 3. Evaluation of performance Services : Clinic services, mobile services, postpartum services, contraceptive distribution, follow up services, education and motivation activities (b) Response : Number of new acceptors, characteristics of acceptors; (c) Cost analysis; (d) Other activities: Administration, manpower, data system, etc.

52. 4. Evaluation of effects Changes in knowledge, attitudes, motivation and behaviour. 5. Evaluation of impact (a) Family size (number of living children (b) desired number of additional children (c) birth interval (d) age of the mother at birth of first child and last child (e) birth order (f) number of abortions. Evaluation is a technical activity that requires trained personnel, statistical facilities and adequate flow of data and information.