FERTILITY AND ITS INDICATORS OF MOETALITY.pptx

INDICATIOES

1. FAMILY WELFARE Dr. E. Yogeshwaran, Assistant Professor, Department of Community Medicine Government Kallakurichi Medical College

2. FERTILITY

3. FACTORS INFLUENCING FERTILITY Age at marriage Sarada Act, 1929 – Forbids child marriage Census data, prior to 1951 – avg age at marriage for girls – 13 yrs The Child Marriage Restraint Act,1978 – raises legal age at marriage from 15 to 18 years for girls, from 18 to 21 years for boys. Duration of married life – 50-55% of all births – within 5 – 15 years of marriage. Spacing of children – decrease fertility rates. Education – Inverse association between fertility and educational status.

4. Economic status – inverse relationship with fertility. World Population conference at Bucharest – economic development - best contraceptive. Nutrition – all well fed societies – low fertility Family planning – declines fertility. Other factors: Physical, biological, social, cultural factors (local community involvement, industrialization, urbanization, housing, breastfeeding, customs, beliefs, opportunities for women, place of women in society, widow remarriage) FACTORS INFLUENCING FERTILITY

5. FAMILY PLANNING "Family planning refers to practices that help individuals or couples to attain certain objectives : to avoid unwanted births to bring about wanted births to regulate the intervals between pregnancies to control the time at which births occur in relation to the ages of the parent; and to determine the number of children in the family.

6. WHO Definition - "a way of thinking and living that is adopted voluntarily, upon the basis of knowledge, attitudes and responsible decisions by individuals and couples, in order to promote the health and welfare of the family group and thus contribute effectively to the social development of a country” Present approach - to provide "cafeteria choice” ie., to offer all methods from which an individual can choose according to his needs and wishes and to promote family planning as a way of life. FAMILY PLANNING

7. Health aspects of family planning Women's health : M aternal mortality, morbidity of women of child-bearing age, nutritional status (Hb level,weight changes etc.) preventable complications of pregnancy and abortion. Foetal health : Foetal mortality (early and late foetal death); abnormal development. Infant & child health : Neonatal, infant and pre-school mortality, health of infant at birth (birth weight), vulnerability to diseases. FAMILY PLANNING

8. WOMEN’S HEALTH In developing countries risk of dying due to pregnancy is much greater than in developed countries. Risk increases as the mother grows older and after she has had 3 or 4 children Health impact of family planning occurs through: 1. avoidance of unwanted pregnancies 2. limiting the number of births and proper spacing 3. timing of births in relation to the age of mother

9. WOMEN’S HEALTH 1. avoidance of unwanted pregnancies : - Unwanted pregnancy – most dangerous complication – criminal abortion. - Higher incidence of mental disturbances among mothers who had unwanted pregnancies. 2. limiting the number of births and proper spacing: increase incidence of uterine rupture, uterine atony, toxemia, eclampsia, placenta previa , anemia, still births cancer cervix associated with high parity. 3. Timing of births: - mothers - <20 years and >30 years – greater risk of dying.

10. FOETAL HEALTH: - with increases in advancing age , congenital anomalies in newborn also increases. CHILD HEALTH: - birth interval of 2 to 3 years - desirable to reduce child mortality. - child receives his/her full share of love and care, when the family size is small and births are properly spaced. - children living in large- sized families have an increase in infection.

11. ELIGIBLE COUPLES Currently married couple wherein the wife is in the reproductive age,which is generally assumed to lie between the ages of 15 and 45. There will be at least 150 to 180 such couples per 1000 population in India. These couples are in need of family planning services. 20% of eligible couples are in age group 15 -24 years. “Eligible couple register” – for organizing family planning work.

12. TARGET COUPLES Couples who have had 2-3 living children and family planning was largely directed to such couples. The definition of a target couple has been gradually enlarged to include families with one child or even newly married couples with a view to develop acceptance of the idea of family planning from the earliest possible stage. The term eligible couple is now widely used.

13. COUPLE PROTECTION RATE (CPR) Indicator of prevalence of contraceptive practice in the community Defined as percent of eligible couples effectively protected against childbirth by one or the other approved methods of family planning Attaining 60% CPR equals cutting off almost all third or higher order births CPR is a dominant factor in reduction of NRR Demographic goal of NRR=1 can be achieved only if CPR exceeds 60%

14. NATIONAL POPULATION POLICY 2000 First NPP – formed in April 1976- increased the legal age for marriage for girls from 15 to 18 years and for boys from 18 to 21years and emphasized on small family norm 1977 – Policy was modified and changed the title to “family welfare programme ” - small family norms without compulsion. 1983- National Health Policy- long term demographic goal – NRR of 1 by 2000 (not achieved) National Population Policy (NPP) – launched in 2000- to accelerate fertility reduction – by target free approach and population norms.

15. CONTRACEPTIVE METHODS Includes preventive measures to reduce the likelihood of the fertilisation of ovum by a spermatazoa & help women avoid unwanted pregnancies Must be (Mnemonic): S afe S E ffective E R eversible R I nexpensive I A cceptable A L ong lasting L S imple to administer S

16. CONTRACEPTIVE METHODS (Fertility Regulating Methods) SPACING METHODS Barrier methods Physical methods Chemical methods Combined methods Intra uterine devices Hormonal methods Post- conceptional methods Miscellaneous TERMINAL METHODS Male sterilization Female sterilization

17. BARRIER / OCCLUSIVE METHODS Aim: To prevent live sperm from meeting the ovum. Advantages: Absence of side effects of ‘pills’ and IUD. Protection from sexually transmitted diseases, Reduction in incidence of pelvic inflammatory disease, protection from the risk of cervical cancer . Disadvantages: High degree of motivation on the part of the user. - Less effective than either the pill or the IUD.

18. PHYSICAL METHOD - MALE CONDOM Most widely known and used. Trade name – NIRODH meaning ‘prevention’ Effective , simple ‘spacing’ method of contraception without side-effects. Fitted on erect penis before intercourse. Air must be expelled from teat end to make room for ejaculate.. A new condom should be used for each sexual act. Effectiveness – may increased when used with spermicidal jelly inserted into vagina before intercourse Pregnancy rate varies from 2 – 3/ 100 women years.

19. Advantages: Easily available , Safe and inexpensive Easy to use No side effects and easily disposable Provides protection against STD also Disadvantages: May slip off or tear during coitus Interferes with sex sensation locally Condoms manufactured by Hindusthan Latex in Trivandrum, London Rubber Industries in Chennai. PHYSICAL METHODS-MALE CONDOM

20. PHYSICAL METHODS- FEMALE CONDOMS Invented by Danish MD Lasse Hessel Pouch made of Polyurethane which lines the vagina is worn by the receptive partner An internal ring in closed end of pouch covers cervix and external ring remains outside vagina Prelubricated with silicon. Spermicide- not needed. Effective barrier to STD Infection D isadvantage : High cost and acceptibility Failure rate - 5 / 100 women years

21. PHYSICAL METHODS DIAPHRAGM Known as Dutch cap , It is a shallow cup made of synthetic rubber or plastic material. D iameter 5 to 10 cm. It has a flexible ring made of spring or metal . Held in position by spring tension and vaginal muscle tone. It is inserted before sexual intercourse . Must remain in place not less than 6 hours after sexual intercourse. S permicidal gel is always used on the diaphragm. Failure rate varies from 6 – 12/ 100 women years

22. Advantage: It has no risks & medical contraindications Disadvantage: Initially a physician or trained person needed to insert the diaphragm into vagina After delivery, it can be used only after involution of uterus is completed. If diaphragm is left for an extended period, there is possibility of Toxic Shock Syndrome V ariation - cervical cap, vault cap, and vimule cap Not recommended in the NFWP PHYSICAL METHODS DIAPHRAGM

23. PHYSICAL METHODS VAGINAL SPONGE Small polyurethane foam sponge measuring 5 × 2.5 cm saturated with spermicide, nonoxynol – 9 Less effective than diaphragm ‘TODAY” is the commonest brand name Failure rate Parous women - 20 – 40/ 100 women years Nulliparous women - 9 – 20/ 100 women years

24. CHEMICAL METHODS OF CONTRACEPTION Foams - foam tablets and aerosols Creams, jellies and pastes Suppositories - inserted manually Soluble films S permicides are “surface active agents” which attach themselves to spermatozoa  inhibit oxygen uptake and kill sperms. Drawbacks: High failure rate , Repeated before each sex act , causes burning, irritation and messiness , not safe and possible teratogenicity. So, not recommended.

25. INTRAUTERINE DEVICES

26. INTRAUTERINE DEVICES Types of IUD: - Non medicated - Medicated F irst generation IUDS - non medicated or inert IUDS Second generation IUDS - Copper IUDS Third generation IUDS - Hormone releasing IUDS Medicated IUDs – Reduce incidence of side effects, increase contraceptive effectiveness, expensive. Under NFWP - Cu T 200 B was used - From 2002, Cu T 380 A is used.

27. FIRST GENERATION IUD Inert. Made of polyethylene or other polymers D ifferent shapes & sizes-loops, spirals, coils and rings. Lippes loop Double S shaped device made of polyethylene - non toxic, non tissue reactive, extremely durable Contains small amount of barium sulphate for X-ray observation Has attached threads or tail made of fine nylon, projects into vagina after insertion Exists as 4 sizes. Larger size  Greater anti fertility effect and lower expulsion rate.

28. Copper containing IUD – Metallic copper - Strong anti fertility effect. Smaller devices, easy to fit. N ewer devices are Cu-T-220 C Cu-T-380 A Nova-T ML( multiload )- Cu-250 ML-Cu-375 SECOND GENERATION IUD

29. SECOND GENERATION IUD Number in the device refers to the surface area of the copper in sq.mm Nova T and Cu- T- 380 Ag – distinguished by silver core over which the copper wire is wrapped.

30. ADVANTAGES OF COPPER IUDS Low expulsion rate Lower incidence of side effects like pain and bleeding Easier to fit even in nulliparous women Better tolerated by nullipara Increased contraceptive effectiveness Effective as post coital contraceptives, if inserted within 3-5 days of unprotected intercourse.

31. THIRD GENERATION IUD PROGESTASERT LNG-20 (MIRENA) Filled with 38 mg of progesterone. Filled with 52 mg of progesterone. Released at the rate of 65 mcg daily Releasing 20 mcg of levonorgesterol Direct local effect on the uterine lining, cervical mucus and sperms. Direct local effect on the uterine lining, cervical mucus and sperms. Replaced every year Replaced every 10 years Higher failure rate Low pregnancy rate and ectopic pregnancies Most widely used Lower menstrual blood loss More expensive

32. THIRD GENERATION IUD Progestasert Mirena

33. MECHANISM OF ACTION OF IUD Foreign body reaction in uterus  Cellular & biochemical changes in endometrium & uterine fluids  Impair viability of gamete  chance of fertilization. Copper IUD - Affects enzymes in the uterus, enhances cellular response in endometrium. By altering the composition of cervical mucus  affects sperm motility, capacitation and survival. Hormones releasing devices - increase viscosity of cervical mucus  prevent sperm from entering cervix. High progesterone and low oestrogen in endometrium (Hormonal imbalance)  makes endometrium unfavourable to implantation.

34. EFFECTIVENESS OF IUD “Theoretical effectiveness” of IUD is less than that of oral and injectable hormonal contraceptives. “Overall effectiveness” of IUD and oral contraceptives remain same, because of longer continuation rates than pills or injections. Effectiveness of copper devices is directly related to the amount of copper surface area.

35. INTRAUTERINE DEVICES Advantages of IUD: Simplicity in insertion (no complex procedures and no hospitalization) Stays in place as long as required Inexpensive Contraceptive effect reversible on removal of IUD free of systemic metabolic side effects Highest continuation rate, Continuous motivation not needed

36. CHANGE OF IUD Lippes loop may be left as long as need, if there are no side effects. Copper and hormone releasing devices have to be replaced periodically. Cu-T-380 A approved for 10 years, Cu-T-200 approved for 4 years, Nova T and Cu-T-375 approved for 5 years. Progesterone releasing IUD replaced every year Levonorgesterol IUD can be used for probably 10 years

37. INTRAUTERINE DEVICES CONTRAINDICATIONS Absolute: Suspected pregnancy Pelvic inflammatory disease (PID) Vaginal bleeding Cancer of cervix, uterus, adnexa and other pelvic tumors Previous ectopic pregnancy Relative Anaemia Menorrhagia History of PID since last pregnancy Purulent cervical discharge Distortion of uterine cavity due to congenital malformations, fibroids Unmotivated person

38. THE IDEAL IUD CANDIDATE A woman Who has borne at least one child Has no history of pelvic disease Has normal menstrual periods Willing to check IUD tail Has access to follow-up & treatment of potential problems In a monogamous relationship

39. IUD CANDIDATE IUD is not method of choice for nulliparous women – increased risk of expulsions, lower abdominal pain and pelvic infection. IUDs (Copper-T) – smaller and more pliable are better suited for small uterus of nulliparous women, if they cannot use or accept alternative methods of contraception. IUDs are “not recommended for women who have not had children or who have multiple sex partners, because of the risk of PID and infertility”.

40. Timing of insertion: Best - During menstruation or within 10 days of beginning of menstrual period  Diameter of cervical canal is greater, uterus is relaxed & less myometrial contractions. D uring 1 st week of delivery - Immediate postpartum insertion  Risk of perforation, higher expulsion rate. Convenient time is 6-8 weeks after delivery. (POST PUERPERAL INSERTION) Can be inserted immediately after a legally induced 1 st trimester abortion. Immediate insertion is not recommended after a 2 nd trimester abortion. INTRAUTERINE DEVICES

41. IUD INSERTION - FOLLOW UP Objectives of the follow up examination: To provide motivation & emotional support for the woman To confirm the presence of IUD To diagnose and treat any side effects or complications. IUD wearer should be examined : after 1st menstrual period – chances of loop expulsion are high during this period. after 2nd menstrual period – to evaluate the problems of pain and bleeding. Thereafter at six- month or one year interval

42. IUD INSERTION - FOLLOW UP I nstructions for the IUD wearer: C heck the threads or tail regularly to be sure that IUD is in uterus. If she fails to locate the threads, she must consult the doctor. V isit the clinic whenever she experiences side effects like fever, pelvic pain and bleeding. if she misses her period, she must consult the doctor.

43. IUD –SIDE EFFECTS AND COMPLICATIONS Vaginal Bleeding: C ommonest complaint. Accounts for 10 - 20 % of IUD removals. B leeding may be greater volume of blood loss during menstruation or longer menstrual periods or mid cycle bleeding – leads to IDA. Patient with bleeding episode should receive iron tablets (ferrous sulphate 200 mg, three times daily) Larger non-medicated > copper > hormone releasing devices. Heavy persistent bleeding or IDA despite iron supplements – IUD removed

44. IUD – SIDE EFFECTS AND COMPLICATIONS Pain: Second major side effect leading to IUD removal. Accounts for 15 – 40% of IUD removals. Experienced during IUD insertion and few days thereafter, also during menstruation. Manifests as low backache, cramps in lower abdomen, pain down thighs. Symptoms usually disappears at 3rd month . Severe pain – incorrect position, size disparity, perforation or infection. Most commonly observed in nulliparous and who have not had a child for number of years.

45. Pelvic infection: IUD users 2 to 8 times more at risk Organisms ascending the IUD tail from lower genital tract to uterus and tubes - Gardnerella , coliform bacilli, anaerobic streptococci, Bacteroides , and Actinomyces . PID risk – highest in 1 st few months after insertion C linical manifestations - vaginal discharge, pelvic pain & tenderness, abnormal bleeding, fever with chills & infertility. Treatment - Broad spectrum antibiotics & Prevention – Aseptic insertion techniques. No response to antibiotics within 24 – 48 hours – IUD removal. IUD –SIDE EFFECTS AND COMPLICATIONS

46. IUD – SIDE EFFECTS AND COMPLICATIONS Uterine perforation: I ncidence-1:150 -1:9000 insertions depending on time, technique, design of IUD and operators experience. Perforations more common when inserted between 48 hours & 6 weeks postpartum. Conclusive Diagnosis - pelvic X ray. IUD that has perforated the uterus must be removed (risk of peritoneal adhesions or perforation of organs within abdominal cavity > risks associated with removal)

47. IUD – SIDE EFFECTS AND COMPLICATIONS Pregnancy: About 50% uterine pregnancies occuring with device in situ  infection, spontaneous abortion, increased risk of premature births. Only 25% of the pregnancies will have a successful outcome if the IUD is left in place Cancer and teratogenesis : N o evidence Fertility after removal: over 70% of previous IUD users conceive within 1 year of stopping use.

48. Ectopic pregnancy: R ate/1000 women year – progesterone IUD > LNG-IUD & Cu-T-380A High risk cases (previous PID, tubal or other ectopic pregnancy) – DON’T USE Expulsion: R ate varies between 12 to 20%. Usually occurs during 1 st few weeks following insertion or during menstruation Expulsion common among young women, nulliparous women and women who have postpartum insertion. Mortality: E xtremely rare - 1 death per 1 lakh women years of use. IUD - SIDE EFFECTS AND COMPLICATIONS

49. Thank you