Health Indicators

UNIT 2 FAMILY PLANNING PROGRAMME

Structure
2.1 Introduction
2.2 Population Policy
2.3 Development of Family Planning Programme
2.4 Family Planning Methods
2.5 Beyond Family Planning Measures
2.6 Determinants of Family Planning Programme
2.7 Effect of Family Planning on Health and Nutrition
2.8 Let Us Sum Up
2.9 Glossary
2.10 Answers to Check Your Progress Exercises

2.1 INTRODUCTION
The need for family planning assumed importance during the middle of the
20th century because of a number of factors. Among these factors rapid
decline of mortality in developed as well as in developing countries is the
main factor, thanks to the scientific-cum-technological inventions and faster
socio-economic development. On the other hand, fertility correspondingly
did not decline, since there were no organised interventions initiated to
regulate fertility as in the case of mortality. Consequently population growth
reached staggering proportions much beyond the ability of developing
countries to support the welfare of their populations. Under these
circumstances, the United Nations took a lead through the World Health
Organisation and UNFPA to evolve programmes to control the rapidly
growing population in the developing countries. These efforts of the United
Nations agencies were formulated in this regard after the first major World
population conference held in Bucharest in 1974. The United Nations ‘Plan
of Action” gave guidance for the member countries to promote family
planning for improving the quality of life of their population. Now you may
be interested in finding out more about the details of the Indian family
planning programme including the national population policy, programmes,
various methods of family planning and beyond family planning measures,
major factors influencing contraception and the effect of family planning on
health and nutrition leading to better quality of life of the population. This
unit discusses these major issues.

Objectives
After studying this unit, you should be able to:

• describe perspectives on population policy;

• discuss the genesis and development of the family planing programme;
28 • list various methods of family planning;
• identify perspectives on beyond family planning measures; Family Planning
Programme
• describe major determinants of the family planning programme; and
• discuss the effect of family planning on health, nutrition and quality of
life.

2.2 POPULATION POLICY

The development of a population policy facilitates the scientific and speedy
advancement of a family planning programme in any country The importance
of regulating rapid growth of population was known to humanity ever since
Robert Malthus, the father of population sciences, wrote his famous essays on
population as early as in 1797 focusing on the need for accepting family
planning and beyond family planning measures. However, population policy
per se developed only after the middle of the 20th century. Definite policy
formulations for the control of rapid growth of population were adopted by
the United Nations as late as 1974. Nevertheless, you may be happy to hear
that a pioneering country, which adopted population policy as a part of
developmental programmes, as early as in 1952, was India. But our policy
developed into a comprehensive plan of action only from 1976.

Population policy outlines a series of specffic measures for regulating

fertility. It consists of immediate and long-term goals; several strategies like
information, education and communication; interventions like mother and
child health programmes; efforts for monitoring the programme and
managing the administrative set up; contraceptive technology; research and
development and promotion of the entire programme in terms of accessibility
and acceptability During the last four decades, several policy measures had
been introduced to promote this programme through legal reforms as well.
For instance, abortion was legalised in 1972 and age at marriage of girls and
boys was raised to 18 ad 21 years, respectively by 1978 in India. Now you
may ask a question “Is it sufficient for India?” since the mean age at marriage
was already 18 years for, girls and 23 years for boys in India by 1981.
Of course, there is still a need to raise their age at marriage further. This has
been successfully done in China, where legal minimum age at marriage has
been fixed at,20 years for girls and 22 years for boys; The latest population
policy is the “National Population Policy 2000” (NPP). The new NPP of
Government of India deals with women education and empowerment, child
health and survival, specific needs of slum, tribal and hill area population and
those of disabled and migrant population, increased participation of men in
planned parenthood and collaboration with NGOs.

2.3 DEVELOPMENT OF FAMILY PLANNING

PROGRAMME
Although the Indian Government adopted family planning as a part of Five
Year Plans right from the First Plan onwards, this programme had many ups
and downs during the last four decades. During the first three Five Year Plan
periods it received the least financial support. Relatively more political
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Health Indicators commitment, supported by increased allocation of finance and seriousness in
implementation of this programme was noticed subsequently upto the mid
70s. Nevertheless, even during this period financial allocation made for this
programme was less than 3 per cent of the total budget of the Central
Government. However, a sudden spurt in promotion of family planning
programme was observed during the emergency period (1976-77), followed
by an equally indifferent attitude to this programme during the period 1978-
80. Subsequently from 1980 onwards, this programme received greater
impetus as it advocated the two child norm. The current emphasis is on three
elements: “Sons or daughters — two will do”“Second child after three
years”, and “Universal Immunization”. However, this programme continues
to progress very slowly in India as compared to many other developing
countries in the Asian region such as China, Taiwan, South Korea, Thailand,
Sri Lanka and Malaysia.

In India, the family planning programme initially came into being as a

unipurpose vertical programme fully financed by the Central Government but
implemented by the State Governments. After knowing the problem of
implementing this programme, it was initially integrated with maternal and
child health programmes and later on with total health programmes and made
as a part of the multipurpose programme. It has an administrative set up at the
National Level (Department of Family Planning), State level (Department of
Health and Family Planning), District and PHC (Primary Health Centre)
levels. For every three thousand population in hill/tribal areas and for every
five thousand population in plain areas, one health sub-centre have been
envisaged to promote health and planning at the peripheral level. Within each
PHC, doctors, male and female supervisors, multipurpose male and female
health workers, dais/community health volunteers are promoting this
programme. Although we have a uniform administrative set up for this
programme, it has been successfully promoted in certain states like Kerala,
Tamil Nadu, Maharashtra and Punjab and poorly implemented in states like
Madhaya Pradesh, Uttar Pradesh, Bihar and Rajasthan. In all the other states
this programme been developed with varying success. The details of the
differential promotion of the family planning programme in India can be seen
from the succeeding sections.

2.4 FAMILY PLANNING METHODS

The last few years have witnessed a contraceptive revolution, that is, man
trying to control the reproductive cycles.

It is now generally recognised that there can never be an ideal contraceptive

— a contraceptive that is safe, effective, acceptable, inexpensive, reversible,
simple to administer, independent of coitus, long-lasting enough to obviate
frequent administration and requiring little or no medical supervision.
Further, a method which may be quite suitable for one group maybe
unsuitable for another because of different cultural patterns, religious beliefs
and socio-economic milieu. As there is no single method likely to meet the
social, cultural, aesthetic and service needs of all individuals and
communities, the search for an ‘ideal contraceptive’ has been given up. The
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present approach in family. planning programmes is to provide a “cafeterial Family Planning
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choice”, that is 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. Use of family planning methods ranges from 27% to 74% in India
(NFHS 5 data).

The term conventional contraceptives is used to denote those methods that

require action at the time of sexual intercourse, e.g. condoms, spermicides
etc. Each contraceptive method has its unique advantages and disadvantages.
The success of any contraceptive method depends not only on its
effectiveness in preventing pregnancy but on the rate of continuation of its
proper use.

Check Your Progress Exercise 1

1) Why do you think a family planning programme is essential in India?
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2) Identify four reasons why the number of children may be high in a poor
rural Family Planning family Programme
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The contraceptive methods may be broadly grouped into two classes —
Spacing methods and Terminal methods as shown here:
I) SPACING METHODS
1) Barrier Methods
a) Physical methods (condom and diaphragm)
b) Chemical methods (spermicidal agents)
c) Combined methods.
2) Intra-Uterine Devices (IUD)
3) Homional methods (pills)
4) Post conceptional methods (Abortion)
5) Miscellaneous methods
II) TERMINAL METHODS
1) Male sterilization
2) Female sterilization

Let us now discuss each category in detail.

Spacing methods as we have already mentioned are the methods which help
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Health Indicators to space children i.e. those which arc reversible. On the other hand, terminal
methods are irreversible.

SPACING METHODS
BARRIER METHODS
The use of condoms, diaphragm, spermicidal agents and a combination of the
physical and chemical barriers fall under this group.
A variety of barrier or “occlusive” methods, suitable for both men and
women are available. The aim of these methods is to prevent live sperm from
meeting the ovum. Barrier methods have increased in popularity quite
recently because of certain contraceptive and non-contraceptive advantages.
The main contraceptive advantage is the absence of side effects of the barrier
methods. The non-contraceptive advantages include some protection from
sexually transmitted diseases, a reduction in the incidence of pelvic
inflammatory disease and possibly some protection from the risk of cervical
cancer, Barrier methods require a high degree of motivation on the part of the
user. They are only effective if they are used consistently and carefully.

a) Physical Methods
1) Condom: Condom is the most widely known and used barrier device by
males around the world and in India. It is better known by its trade name
NIRODH, a Sanskrit word meaning prevention. Condom is receiving
new attention today as an effective, simple “spacing” method of
contraception, without side effects. In addition to preventing’ pregnancy,
condoms protect both men and women from sexually transmitted
diseases.
There are basically two kinds of condoms — latex and skin. Latex
condoms are by far the most widely used. The condom is fitted on the
erect penis before intercourse. The air must be expelled from the teat end
to make room for the ejaculate. The condom must be held carefully when
withdrawing it from the vagina to avoid spilling seminal fluid into the
vagina after intercourse. A new condom should be used for each sexual
act.

Condom prevents the semen from being deposited in the vagina. The
effectiveness of a condom may be increased by using it in conjunction
with a spermicidal jelly inserted into the vagina before intercourse. The
spermicide serves as additional protection in the unlikely event that the
condom should slip off or tear. A condom is now available in the UK,
packed with spermicidal lubricant already in contact with the condom.
This seems a real step forward in barrier technology.

The advantages of the condom are: a) they are easily available, b) safe
and inexpensive, c) easy to use and do not require medical supervision,
d) no side effects, e) light, compact and disposable, and f) provides
protection not only against pregnancy but also against STD. The
disadvantages are: a) it may slip off or tear during coitus due to incorrect
use, and b) interferes with sex sensation locally about which some
32 complain while others get used to it. The main limitation of condoms is
 that many men do not use them regularly or carefully, even when the risk Family Planning
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of unwanted pregnancy or sexually transmitted diseases is high.
Condoms are available widely and at a very low price. It has been
estimated that 72 condoms per year may be needed to protect a couple.
Besides commercial outlets, condoms are supplied under social
marketing programme.

2) Diaphragm: The diaphragm is inserted before sexual intercourse and

remains in place for not less than 6 hours after sexual intercourse. A
spermicidal jelly is always used along with the diaphragm. A small
amount of the jelly is smeared around the edge of the diaphragm and on
both sides and a teaspoonful of the same is placed inside the cup. The
diaphragm holds the spermicide over the cervix. Side effects are
practically nil. Failure rate for the diaphragm with spermicide vary
between 6 to 12 per 100 woman.

Advantages: The primary advantage of the diaphragm is the almost total

absence of risks and medical contraindications.

Disadvantages: hitially a physician or other trained person will be needed

to demonstrate the technique of inserting the diaphragm into the vagina
and to ensure a proper fit. After delivery it can be used only after
involution of the uterus is completed. Practice of insertion, privacy for
this to be carried out and facilities for washing and storing the diaphragm
precludes its use in most Indian families, particularly in the rural areas.
Therefore the extent of use has never been great. Variations of the
diaphragm includes the cervical cap, vault cap and vimule cap. These
devices are not recommended in the National Family Welfare
Programme.

Chemical Methods
In the 1960s before the advent of IUDs and oral contraceptives, spermicides
(vaginal chemical contraceptives) were used widely. They comprise the
following categories viz.
a) Foam tablets / foam aerosols
b) Creams, jellies and pastes — squeezed from a tube
c) Suppositories — inserted manually
d) Soluble films— film inserted manually.

The spermicides contain a base into which a spermicide is incorporated. The

commonly used modern spermicides are “surface active agents’ which attach
themselves to spermatozoa and inhibit oxygen uptake and kill sperms.

The main drawbacks of spermicides are: a) they have a high failure rate, b)
they must be used almost immediately before intercourse and repeated before
each sex act, c) they must be introduced into those regions of the vagina,
where sperms are likely to be deposited and d) they may cause mild burning
or irritation besides messiness. The spermicide should be free from potential
systemic toxicity. It should not have an inflammatory or carcinogenic effect
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Health Indicators on the vaginal skin or cervix. No spermicide which is safe to use has yet been
found to be really effective in preventing pregnancy when used alone.
Therefore, spermicides are not recommended by professional advisers. They
are best used in conjunction with barrier methods. Recently there has been
some concern about possible teratogenic effects on foetuses, following their
excessive use. However, this risk is yet to be confirmed.

INTRAUTERINE DEVICES (IUDs)

The control of conception by introducing a foreign body into the uterus is not
new. This principle was known to the Arabs in the Middle East, who were
controlling conception in camels by introducing a small round stone into each
horn of the uterus. The Japanese were the first to utilise plastic material in the
manufacture of IUDs, which led to the development of our modern IUDs.
The rapid increase in the world population led to a reawakening of interest in
intrauterine contraception. The percentage of married women using lUDs in
the age group of 15-49 years is 47% in Korea, (DPR) 26.2% in China and
only 1.2% in India. (2019, un-2019-contraceptive use by method). In India,
during 2011 about 5.6 million IUD insertions were reported.

Lippes Loop
Lippes Loop is double-S shaped device made of polyethylene, a plastic
material that is non-toxic, non-tissue reactive and extremely durable. It
contains a small amount of barium sulphate to allow X ray observation. The
loop has attached threads or “tail” made of fine nylon, which projects into the
vagina after insertion. The tail can be easily felt and is a reassurance to the
user that the loop is in its place. The tail also makes it easy to remove the
loop when desired.

The Lippes loop exists in four sizes, A,B,C and D; the latter being the largest.
A larger sized device usually has a greater anti-fertility effect and a lower
expulsion rate but a higher removal rate because of side effects such as pain
and bleeding. The larger loops (C and D) are more suitable for multiparous
women. The loop is manufactured in India in two sizes 27.5 mm and 30 mm.
For purposes of identification the tail of the smaller loop is black and that of
the larger loop yellow. The device has now been given a slightly bulbous tip
to reduce the risk of perforation. The loop may be left in the uterus as long as
desired if there are no major problems. The Government of India in 1965
introduced the loop in the National Family Planning Programme.
a) Copper T: Most widely used in the UK and USA. It is shaped like a
numeral seven and has 200 sq.mm. surface area of copper wire around
the plastic stem. The metallic copper was found to have a strong anti-
fertility effect. The manufacturer recommends that it be replaced every
three years. A number of copper bearing devices are now available
commercially. The new variants of the T device are TCu-220C, TCu-
380A or Ag and Nova T. Nova T and TCu-380Ag are distinguished by a
silver case over which is wrapped the copper wire.

b) Multiload devices : The Multiload (ML) device, widely used in Western

Europe and in Indonesia, has two arms made of flexible plastic that bow
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 out and around from the top of the stem and point towards the stem’s Family Planning
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midpoint, each arm has five short fins on its outer surface. The Multiload
comes in two presentations. ML CU-250 and MI CU-375. The former
has a recommended life span of three years and the latter five years.

Advantages of Copper Devices:

• Low expulsion rate

• Lower incidence of side-effects e.g., pain and bleeding
• Easier to fit even in nulliparous women (women without children)
• Better tolerated by nullipara
• Increased contraceptive effectiveness
• Effective as post-coital contraceptives, if inserted within 3-5 days of
unprotected intercourse.

HORMONAL CONTRACEPTIVES
Hormonal contraceptives when properly used are the most effective spacing
methods of contraception. Oral contraceptives of the combined type are
almost 100 per cent effective in preventing pregnancy. They provide the best
means of ensuring spacing between one childbirth and another. More than 65
million in the world are estimated to be taking the “pill” of which about 10
million are estimated to be in India.

Oral Pills
The pill is given orally for 21 consecutive days beginning on the 5th day of
the menstruaI cycle (for a few preparations of 20 or 22 days are advised),
followed by a break of 7 days during which period menstruation occurs.
When the bleeding occurs this is considered the first day of the next cycle.

The bleeding which occurs is not like normal menstruation but is an episode
of uterine bleeding from an incompletely formed endometrium caused by the
withdrawal of exogenous hormones. Therefore, it is called “withdrawal
bleeding” rather than menstruation. Further, the loss of blood which occurs is
about half that occurring in a woman having an ovulatory cycle. If bleeding
does not occur the woman is instructed to start the second cycle one week
after the preceding one. Ordinarily, the woman menstruates after the second
course of pill intake.

The pill should be taken every day at a fixed time, preferably before going to
bed at night. The first course should be started strictly on the 5th day of the
menstrual period, as any deviation in this respect may not prevent pregnancy.
If the user forgets to take a pill, she should take it as soon as she remembers
and then she should take the next day’s pill at the usual time.

The Department of Family Welfare, in the Ministry of Health and Family

Welfare, Family Planning Government of India, has made available oral pills
under different brand names to the consumers free of cost and under social
marketing scheme.

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Health Indicators Emergency Contraceptive
Emergency contraceptive pill has been introduced for the first time under
Family Welfare Programme during 2002-03. The emergency contraceptive is
the method that can be used to prevent unwanted pregnancy after an
unprotected act of sexual intercourse — including sexual assault, rape or
sexual coercion or contraceptive failures. Emergency contraceptive is to be
taken on prescription of Medical Practitioners.

Post-Conceptional Methods (Abortion)

Menstrual Induction
This is based on disturbing the normal progesterone, prostaglandin balance
by intrauterine application of 1-5 mg. solution (or 2.5 -5 mg. pellet) of
prostaglandin F2. Within a few minutes of the prostaglandin impact,
performed under sedation, the uterus responds with a sustained contraction
lasting about 7 minutes followed by cyclic contractions continuing for 3-4
hours The bleeding starts and continues for 7-8 days.

MISCELLANEOUS METHODS

SAFE PERIOD
In order to use this method, the couple should know when the woman’s body
produces an ovum. Around this time, they should avoid sexual relations if
they want to avoid conception. Ovulation (release of ovum in the woman’s
body) occurs from 12 to 16 days before the onset of menstruation. The first
day of bleeding is taken as the number one day of the menstrual cycle. So the
safe days for intercourse would be before 8th day and after 21st day of any
menstrual cycle. Disadvantages of the method are that the woman’s
menstrual cycle is not always regular. It needs a high degree of motivation
and discipline. There are high failure rates.

TERMINAL METHODS
Voluntary sterilization is a well-established contraceptive procedure for
couples desiring no more children. Currently female sterilizations account for
85 per cent and male sterilizations for 10-15 per cent of all sterilizations in
India inspite of the fact that male sterilization is simpler, safer and cheaper
than female sterilization.

Sterilization offers many advantages over other contraceptive methods. It is a

one-time method, it does not require sustained motivation of the user as it
provides the most effective protection against pregnancy, the risk of
complications is small if the procedure is performed according to accepted
medical standards and it is most cost effective. It has been estimated that each
procedure averts 1.5 to 2.5 births per woman.

Male Sterilization
Male sterilization or vasectomy being a comparatively simple operation can
be performed even in primary health centres by trained doctors under local
anaesthesia. When carried out under strict aseptic technique, it should have
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no risk of mortality in vasectomy. It is customary to remove a piece of vas at Family Planning
Programme
least 1 cm. after clamping. The ends are ligated and then folded back on
themselves and sutured into position so that the cut ends face away from each
other. This will reduce the risk of recanalisation (rejoining) at a later date. It
is important to stress that the acceptor is not immediately sterile after the
operation Health Indicators usually until approximately 30 ejaculations have
taken place. During this intermediate period another method of contraception
must be used. If properly performed, vasectomies are almost 100 per cent
effective.

Following vasectomy, sperm production and hormone output are not affected.
The sperm produced are destroyed intraluminally by phagocytosis. This is a
normal process in the male genital tract, but the rate of destruction is greatly
increased after vasectomy. Vasectomy is a simpler, faster and less expensive
operation than tubectomy in terms of instruments, hospitalization and doctors
training-cost-wise, the ratio is about 5 vasectomies for one tubal ligation.

Female Sterilization
Female sterilization can be done as an interval procedure, postpartum or at
the time of abortion. Two procedures have become most common, namely
laparoscopy and minilaparotomy.

Laparoscopy
This is a technique of female sterilization through abdominal approach with a
specialised instrument called a “laparoscope”. The abdomen is inflated with
gas (carbon dioxide, nitrous oxide or air) and the instrument is introduced
into the abdominal cavity to visualise the tubes. Once the tubes are accessible
the falope rings (or clips) are applied to occlude or block the tubes. This
operation should be undertaken only in those centres where specialist
obstetricians/ gynaecologists are available. The short operating time, shorter
stay in hospital and a small scar are some of the attractive features of this
operation.
Minilap Operation

Minilaparotomy is a modification of abdominal tubectomy. It is a much

simpler procedure requiring a smaller abdominal incision of only 2.5 to 3 cm.
conducted under local anaesthesia. The minilap/pomeroy technique is
considered a revolutionary procedure for female sterilization. It is also found
to be a suitable procedure at the primary health centre level and in mass
campaigns. It has the advantage over other methods with regard to safety,
efficiency and ease in dealing with complications. Minilap operation is
suitable for postpartum tubal sterilization.

2.5 BEYOND FAMILY PLANNING MEASURES

The term “Beyond family planning” was popularised by Bernar Berelson and
Philip M. Hauser. According to these authors, certain non-family planning
measures can also regulate the growth of population. In this context they
focused on the importance of raising the age at marriage of boys and girls,
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Health Indicators medical termination of pregnancy (MTP); voluntary and involuntary
separation are examples of beyond family planning measures. Now you may
be wondering as to how they can regulate the population growth.

Raising Age at Marriage

Females in India traditionally marry soon after puberty. Such women have a
prolonged fertile reproductive period of 30-35 years for conception. This is
because the mean age at puberty in India ranges from 12 to 14 years. The
mean age at effective marriage of females of all ages in India in 2006 was
19.8 years resulting in a total fertility rate of 2.8. When female age at
marriage is legally raised to 20 years or more, the probability of averting the
future births may go up to 20-25 per cent. When it is further raised to 23
years, it may have still greater scope to prevent more births. However, our
present minimum legal age of marriage of 18 years for girls is not adequate
because of primary sterility existing for 1-2 years after puberty. In addition, if
age at marriage is raised to 20 years or more, several advantages will be
there. For example girls will have opportunity to get education, develop
physical and mental maturity and a sense of planning in life besides
minimising the risk of infant and maternal mortality When age at marriage
for girls is raised, maternal and child health can be assured and their
longevity can become a reality. Therefore, education/counselling for raising
age at marriage of girls forms a powerful beyond family planning measure to
regulate population growth.

Medical Termination of Pregnancy

Abortion is theoretically defined as termination of pregnancy before the
foetus becomes viable (capable of living independently). This has been fixed
administratively at 28 weeks, when the foetus weighs approximately 1000
gm. Abortion is sought by women for a variety of reasons including birth
control. As referred to earlier, MTP was legalised in India by 1972. Through
voluntary abortion, many countries successfully regulated rapid growth of
population avoiding unwanted births. In fact, 75 per cent of the success of
Japan’s family planning programme has been attributed to induced abortion.
In addition, most of Scandinavian countries in Europe regulated their
population growth largely through induced abortion. However, in India it
remains as a taboo and those who resort to abortion use mostly indigenous
and unscientific methods which is affecting the health and longevity of
women. In India every year 6.7 million abortions take place and out of which
5.7 million are illegal abortions. No doubt it varies between rural and urban
areas, in different communities and states. But these abortions do not
contribute much in bringing down birth rate in India because most of the
women resorting to induced abortion afready have high parity.

2.6 DETERMINANTS OF FAMILY PLANNING

PROGRAMME
The success of the family planning programme in a developing country is
dependent upon multi-dimensional factors. When a country is developed,
38 negative factors of family planning get reduced in number. On the other
hand, in a developing country social backwardness and many cultural barriers Family Planning
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are detrimental to the progress of the family planning programme. The
success of a family planning programme in a developing country depends
upon 1) the type of management including change agents, training,
motivation, efficiency and availability, 2) resources-available for
contraceptives and medicines, 3) vehicles and transport facilities available on
a regular and timely basis, 4) out-reach of the programme through multiple
channels including Government and NGOs, 5) strategies effectively used for
the promotion of the programme including IEC programmes, incentives,
disincentives, etc., 6) developmental priorities given for the education of
females, 7) health and nutrition programmes, 8) involvement of community
and their participation in creating social support, etc These are only a few
determinants of the family planning programmes but many more factors at
micro-level are also equally important for the success of the family planning
programme.

2.7 EFFECT OF FAMILY PLANNING ON

HEALTH AND NUTRITION
Family planning programmes address important health problems. Maternal
and infant death rates are extremely high in the developing world. Reported
maternal mortality ratio for instance are about, 33 per 100,000 births in
Mexico and 342 in Kenya, about 19 in the US and 7 in UK (2017,
data.worldbank.org). The complications of pregnancy account or 10 to 30 per
cent of deaths among women of reproductive age.

Deaths among children also are shockingly frequent. The death rate is as high
as 31 in developing countries as compared to industriaized countries where it
is 3 for infants under age one. Mortality rate of children below 5 years is only
4 in industrialzed countries as compared to more than 71 in developing
countries (data.worldbank.org, 2019). Children under age five make up 14
per cent of the population in developing countries but account for up to 80
per cent of the deaths each year. By contrast, in developed countries children
under age five make up 8 per cent of the population but account for less than
3 per cent of deaths.

In African countries one out of every four children dies before reaching
adolescence, compared with one in 40 in developed countries.

Avoiding High-Risk Pregnancies: Family Planning is an effective way to

prevent maternal and infant mortality because family planning can help
couples avoid high-risk pregnancies. Evidence from around the world shows
that the risk of maternal or infant illness and death is highest in four specific
types of pregnancy:
1) pregnancies before age 18,
2) pregnancies after age 35,
3) pregnancies after four births, and
4) pregnancies less than two years apart.
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Health Indicators In other words, pregnancies can be considered high-risk if women are “too
young, too old” or “if children are too many, too close”. In parts of Europe
and North America as much as one-quarter of the decline in infant mortality
in recent decades occurred because fewer and fewer births took place among
older women with many children.

In developing countries today about 5.6 million infant deaths and 200,000
maternal deaths could be avoided if women chose to have their children
within the safest years with adequate spacing between births and completed
families of moderate size. This amounts to about half of the estimated 10.5
million infant deaths and 450,000 maternal deaths now occurring and
represents the combined effect of fewer births and lower death rates.

Family Planning: Effective and Safe Prevention

The wide choice of family planning methods now available allows health
programmes to offer an appropriate method to avoid each type of high-risk
pregnancy. For example, oral contraceptives, condoms, and spermicides are
particularly appropriate to postpone the first pregnancy and to space births,
whereas voluntary sterilization is highly effective for older couples who want
no more children.

Modern family planning methods are safe. Contraceptive products are not
toxic even if used incorrectly—an important consideration for community-
based or non-medical distribution. For some methods, such as condoms,
spermicides, and natural family planning, the only important risks are those
of accidental pregnancy. Other methods may pose only rare risks, many of
which can be reduced by following simple guidelines. With all methods,
family planning in developing countries is much safer than child-bearing.

Moreover, some methods provide benefits beyond the control of fertility.

Condoms and spermicides prevent the spread of venereal disease. Oral
contraceptives reduce some menstrual problems and help to protect against
pelvic inflammatory disease, cancer of the uterine lining, cancer of the
ovaries, anaemia, and rheumatoid arthritis.

Maternal and Child Health Family Planning

There has long been evidence from developed countries that pregnancies “too
young, too old, too many, too close” endanger maternal and infant health.
Now there is new evidence that meets more rigorous standards of modern
epidemiology — that these adverse effects are as strong or stronger in
developing countries. In all settings pregnancies among adolescents, women
over 35, and women with many previous births are more likely to involve
life-threatening complications such as haemorrhage and high blood pressure.
Closely spaced births may contribute to malnutrition and other maternal
health problems.

The infants born as a result of high-risk pregnancies are even more

vulnerable. Spacing of less than two years between births is especially
hazardous because it means lower birth weights and poorer nutrition, possibly
including a shorter period of breast-feeding or more competition for family
40 resources and care. From infancy to adolescence, children born into large or
closely spaced families experience more sickness, slower growth, and lower Family Planning
Programme
levels of academic achievement. Lower socio-economic status has similar
effects, but birth patterns also are important.

Family planning programmes cannot guarantee maternal and infant health,

but by protecting families against high-risk pregnancy, family planning saves
lives and reduces illness.

Check Your Progress Exercise 2

1) Fill in the blanks:
i) India’s family planning programme experienced success
before………. and problems during ……………………….periods.
ii) Temporary family planning methods are meant for……………
iii) The first country to adopt family planning in the world is…………
iv) Terminal methods of family planning are……………… and………
v) Failure of family planning is largely due to problems resulting from
the… ………….and………………….. factors.
vi) M.T.P. stands for………………………………………………….
vii) Abortion can be done upto the end of……………………… week.

2.8 LET US SUM UP

Now let us recapitulate in brief on what has been discussed so far. This unit
gave a resume of policy perspectives and emphasised the importance of
raising female age of marriage and liberalisation of induced abortion.
Subsequently, historical development of the family planning programme after
independence in India under different Governments, which gave varying
emphasis to this programme has been discussed. Family Planning methods—
spacing and terminal are discussed. These were followed by giving an
overview of major determinants of the family planning programme. At the
end, in brief, certain salient implications of family planning on health and
nutrition have been highlighted.

2.9 GLOSSARY
Abortion : Expulsion of product of conception from the
uterus before it is viable i.e., before the end of
the 28th week.
Beyond Family Planning : Measures other than family planning used to
regulate population growth like age at
marriage.
Menstrual Induction : Removal of fertilised ovum from uterus by
prostaglandins.
Population Policy : Deals with goals, strategies, short term and long
term-cum-direct and indirect developmental
measures, reforms, etc. adopted by the
41
Health Indicators Government for stabilisation of population.
Strategies : Refers to various effective measures used to
promote interventions/programmes.

2.10 ANSWERS TO CHECK YOUR PROGRESS

EXERCISES
Check Your Progress Exercise 1
Both questions require you to think carefully before you answer. The answers
are hinted at in the unit but not outlined in detail.

Check Your Progress Exercise 2

i) 1976; 1976-80
ii) Spacing of children
iii) India
iv Tubectomy and vasectomy
v) Programme and client’s background
vi) Medical Termination of Pregnancy
v) 28

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