Population Problem

Small differences in the family size will make big differences in the birth rate. The difference of only one child per family over a decade will have a tremendous impact on the population growth.

The objective of the Family Welfare Programme in India is that people should adopt the "small family norm" to stabilize the country's population at the level of some 1,533 million by the year 2050 AD. Symbolized by the inverted red triangle, the programme initially adopted the model of the 3-child family. In the 1970s, the slogan was the famous Do Ya Teen Bas. In view of the seriousness of the situation, the 1980s campaign has advocated the 2-child norm. The current emphasis is on three themes: "Sons or Daughters - two will do"; "Second child after 3 years", and "Universal Immunization".

A significant achievement of the Family Welfare Programme in India has been the decline in the fertility rate from 6.4 in the 1950s to 2.2 in 2018. The national target was to achieve a Net Reproduction Rate of '1' by the year 2006, which is equivalent to attaining approximately the 2-child norm, which could not be attained. All efforts are being made through mass communication that the concept of small family norm is accepted, adopted and woven into lifestyle of the people.

An "eligible couple" refers to a 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. About 20 percent of eligible couples a found in the age group 15-24 years. On an average 2.5 million couples are joining the reproductive group every year. The "Eligible Couple Register" is a basic document organizing family planning work. It is regularly updated each functionary of the family planning programme for area falling within his jurisdiction.

In order to pin-point the couples who are a priority group within the broad definition of "eligible couples", the term "target couple" was coined. Hitherto, the term target couple was applied to 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 (34) with a view to develop acceptance of the idea of family planning from the earliest possible stage. In effect, the term target couple has lost its original meaning. The term eligible couple is now more widely used and has come to stay.

Couple protection rate (CPR) is an indicator of the prevalence of contraceptive practice in the community. It is defined as the per cent of eligible couples effectively protected against childbirth by one or the other approved methods of family planning, viz. sterilization, IUD, condom or oral pills. Sterilization accounts for over 60 per cent of effectively protected couples (35). Demographers are of the view that the demographic goal of NRR=1 can be achieved only if the CPR exceeds 60 per cent.

Couple protection rate is based on the observation that 50 to 60 per cent of births in a year are of birth order 3 or more. Thus attaining a 60 per cent CPR will be equivalent to cutting off almost all third or higher order births, leaving 2 or less surviving children per couple (35). Therefore, in India, the previous National Population Policy was to attain a CPR of 42 per cent by 1990 (end of Seventh Five Year Plan), and 60 per cent by the year 2000. In short CPR is a dominant factor in the reduction of net reproduction rate.

CONTRACEPTIVE METHODS

Contraceptive methods are, by definition, preventive methods to help women avoid unwanted pregnancies. They include all temporary and permanent measures to prevent pregnancy resulting from coitus.

The last few years have witnessed a contraceptive revolution, that is, man trying to interfere with the ovulation cycle.

It is now generally recognized that there can never be an ideal contraceptive- that is, 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 may be 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 present approach in family planning programmes is to provide a "cafeteria, 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.

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. The contraceptive methods may be broadly grouped into two classes spacing methods and terminal methods, as shown below:

I. Barrier methods  Physical methods  Chemical methods  Combined methods II. Intra-uterine devices III. Hormonal methods IV. Post-conceptional methods V. Miscellaneous.

I. 1 Male sterilization II. 2 Female sterilization.

BARRIER METHODS

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 associated with the "pill" and IUD. 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 (37). Barrier methods require a high degree of motivation on the part of the user. In general they are less effective than either the pill or the loop. They are only effective if they are used consistently and carefully.

a. PHYSICAL METHODS

Condom is the most widely known and used barrier device by the males around the world. 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, condom protects both men and women from sexually transmitted diseases.

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 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.

Condoms can be a highly effective method of contraception, if they are used correctly at every coitus. Failure rates for the condom vary enormously. Surveys have reported pregnancy rates varying from 2-3 per 100 women-years to more than 14 in typical users (40). Most failures are due to incorrect use.

The ADVANTAGES of condom are: (a) they are easily available (b) safe and inexpensive (c) easy to use; do not require medical supervision (d) no side effects (e) light, The compact and disposable, and (f) provides protection not only against STD. but also against pregnancy 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 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 of unwanted pregnancy or sexually transmitted disease is high. Condoms are manufactured in India by the Hindusthan Latex in Trivandrum, London Rubber Industries in Chennai and others. Besides commercial outlets, condoms are supplied under social marketing programme.

The female condom is a pouch made of polyurethane, which lines the vagina. An internal ring in the close end of the pouch covers the cervix and an external ring remains outside the vagina. It is prelubricated with silicon, and a spermicide need not be used. It is an effective barrier to STD infection. However, high cost and acceptability are major problems. The failure rates during the first year use vary from 5 per 100 women-years pregnancy rate to about 21 in typical users (41).

2. Diaphragm

The diaphragm is a vaginal barrier. It was invented by a German physician in 1882. Also known as "Dutch cap", the diaphragm is a shallow cup made of synthetic rubber or plastic material. It ranges in diameter from 5-10 cm (2-4 inches). It has a flexible rim made of spring or metal. It is important that a woman be fitted with a diaphragm of the proper size. It is held in position partly by the spring tension and partly by the vaginal muscle tone. This means, for successful use, the vaginal tone must be reasonable. Otherwise, in the case of a severe degree of cystocele, the rim may slip down.

The diaphragm is inserted before sexual intercourse and must remain in place for not less than 6 hours after sexual intercourse. A spermicidal jelly is always used along with the diaphragm. The diaphragm holds the spermicide over the cervix. Side-effects are practically nil. Failure rate for the diaphragm with spermicide vary between 6to12 per 100 women-years (40).

ADVANTAGES: The primary advantage of the diaphragm is the almost total absence of risks and medical contraindications. DISADVANTAGES: Initially 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 at 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 its use has never been great.

If the diaphragm is left in the vagina for an extended period, there is a remote possibility of a toxic shock syndrome, which is a state of peripheral shock requiring resuscitation (42).

Variations of the diaphragm include the cervical cap. Vault cap and the vimule cap. These devices are not recommended in the National Family Welfare Programme.

3. Vaginal sponge

Another barrier device employed for hundreds of years is the sponge soaked in vinegar or olive oil, but it is only recently one has been commercially marketed in USA under the trade name TODAY for the sole purpose of preventing conception. It is a small polyurethane foam sponge measuring 5 cm x 2.5 cm, saturated with the spermicide, nonoxynol-9. The sponge is far less effective than the diaphragm, but it is better than nothing (43). The failure rate in parous women is between 20to 0 per 100 women-years and in nulliparous women about 9 to 20 per 100 women-years (41).

b. CHEMICAL METHODS

In the 1960s, before the advent of IUDs and oral contraceptives, spermicides (vaginal chemical contraceptives) were used widely. They comprise four categories (44):

a) Foams: foam tablets, foam aerosols b) Creams, jellies and pastes - squeezed from a tube c) Suppositories - inserted manually, and d) Soluble films - C-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 (45).

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 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 (44). 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 use. However, this risk is yet to be confirmed (42).

4. Natural family planning methods

The term "natural family planning" is applied to three methods:

(a) Basal body temperature (BBT) method (b) Cervical mucus method (c) Symptothermic method.

The principle is the same as in the calendar method, but here the woman employs self-recognition of certain physiological signs and symptoms associated with ovulation as an aid to ascertain when the fertile period begins. For avoiding pregnancy, couples abstain from sexual intercourse during the fertile phase of the menstrual cycle; they totally desist from using drugs and contraceptive devices. This is the essence of natural family planning.

The BBT method depends upon the identification of a specific physiological event the rise of BBT at the time of ovulation, as a result of an increase in the production of progesterone. The rise of temperature is very small, 0.3 to 0.5 degree C. When no ovulation occurs (e.g., as after menarche, during lactation) the body temperature does not rise. The temperature is measured preferably before getting out of bed in the morning. The BBT method is reliable if intercourse is restricted to the post-ovulatory infertile period, commencing 3 days after the ovulatory temperature rise and continuing up to the beginning of menstruation. The major drawback of this method is that abstinence is necessary for the entire pre-ovulatory period. Therefore, few couples now use the temperature method alone (100).

This is also known as "billings method" or "ovulation method". This method is based on the observation of changes in the characteristics of cervical mucus. At the time of ovulation, cervical mucus becomes watery clear resembling raw egg white, smooth, slippery and profuse. After ovulation, under the influence of progesterone, the mucus thickens and lessens in quantity. It is recommended that the woman uses a tissue paper to wipe the inside of vagina to assess the quantity and characteristics of mucus: To practice this method the woman should be able to distinguish between different types of mucus. This method requires a high degree of motivation than most other methods. The appeal and appropriateness of this method in developing countries such as India, especially among lay people, is dubious.

This method combines the temperature, cervical mucus and calendar techniques for identifying the fertile period. If the woman cannot clearly interpret one sign, she can "double check" her interpretation with another. Therefore, this method is more effective than the "Billings method”. To sum up, natural family planning demands discipline and understanding of sexuality. It is not meant for everybody. The educational component is more important with this approach than with other methods. The opinion of the Advisory Group to WHO's Special Programme of Research in Human Reproduction is that the current natural family planning methods have very little application particularly in developing countries (101).

5. Breast-feeding

V Field and laboratory investigations have confirmed the traditional belief that lactation prolongs postpartum amenorrhoea and provides some degree of protection against pregnancy (102). No more than 5-10 per cent of women conceive during lactational amenorrhoea, and even this risk exists only during the month preceding the resumption of menstruation (103). However, menstruation returns, continued lactation no longer offers any protection against pregnancy (104). By and large, by 6 months after childbirth, about 20-50 per cent of women are menstruating and are in need of contraception (105).

6. Birth control vaccine

Several immunological approaches for men and women are being investigated. The most advanced research involves immunization with a vaccine prepared from beta sub-unit of human chorionic gonadotropin (hCG), a hormone produced in early pregnancy. Immunization with hCG would block continuation of the pregnancy. Antibodies appeared in about 4-6 weeks and reached maximum after about 5 months and slowly declined reaching zero levels after a period ranging from 6-11 months. The immunity can be boosted by a second injection. Two types of pregnancy vaccines employing variants of the beta sub-unit of hCG are now about to go into clinical trial (51). Research on birth control vaccines continues. The uncertainties are great (85).