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53Preventive Healthcare
TFR was minimum (1.5) in Switzerland, intermediate (4.5)
in India, and maximum (7.8) in Kenya.
Factors, affecting TFR and fertility in India are low age at
marriage, universality of marriage, low level of literacy, poor
standard of living, less popularity of family planning programs,
limited use of contraceptives, and traditional ways of living.
High fertility rate in India can be brought down through
various measures, which are related to the following factors:
a. Age at marriage: Age at marriage is the age at which a
female marries and enters the reproductive life. It has a
direct impact on the fertility. A female marrying before
18 years of age can give birth to a greater number of
children than a female getting married at the age of
25 years. The average age at marriage of both men and
women is now increasing in India. This can bring down
fertility and help in controlling the population.
b. Duration of married life: Nearly 50 to 55% of births occur
within 5 to 15 years of married life while 10 to 25% of births
occur within 1 to 5 years. These figures indicate that if the
family planning efforts are concentrated within the first
few years of married life, the number of births can be easily
controlled.
Fig. 2.1: Stages in the demographic cycle
54 Social Pharmacy
c. Spacing of children: Fertility rates can be brought down by
proper spacing of the children. The greater the gap
between the births of the children lower the fertility rate.
Postponement of all births just by one year will reduce the
fertility rate tremendously.
d. Education: It is well established that the fertility rates are
low in the case of educated people. Thus educational status
of people is inversely related to the fertility rates. This is
the reason for high fertility rates in illiterate than literate
people and similarly high fertility rates in rural popu-
lations than in urban populations where more people are
educated. Educated people are aware of family welfare
and hence the importance of a small family and less
number of children.
e. Economic status: Economic status also plays an important
role in fertility. Thus, fertility is lower in populations with
higher economic status. Improving the economic status of
the people is considered to be an effective method of
controlling fertility, i.e. population growth.
f. Caste and religion: Caste and religion also play an
important role in fertility. Fertility rates are higher in
Muslims as compared to Hindus. Similarly, amongst
Hindus, fertility rates are lower in higher castes as
compared to lower castes.
g. Nutrition: Nutrition has an indirect effect on fertility.
Poorly fed societies exhibit high fertility rates whereas fed
societies show lower fertility rates.
h. Family planning: Family planning programs and their
effective implementation are important in fertility
reduction. These are more important in developing
countries like India. Family planning programs are
economical and have long-term beneficial effects.
i. Other factors: These factors are related to physical,
biological, social, and cultural aspects like the health status
of people, place of women and children in society, housing
and health conditions, sanitation, hygiene, industriali-
zation, medical facilities, etc.
55Preventive Healthcare
Birth control is an umbrella term for several techniques and
methods used to prevent fertilization or to interrupt pregnancy
at various stages. Birth control techniques and methods include:
a. Contraception: It is the prevention of fertilization. Contra-
ception includes barrier methods, such as condoms or
diaphragm, hormonal contraception, also known as oral
contraception, and injectable contraceptives.
b. Contragestion: It is the prevention of the implantation of
the blastocyst. Contragestives, also known as post-coital
birth control, include intrauterine devices (IUDs) and
emergency contraceptives.
c. Abortion: It is the removal or expulsion of a fetus or
embryo from the uterus.
Family Planning
Growing population is a major problem in India and is the
major obstacle in the all-round development of the country.
The main reasons for an increase in population are:
1. Decrease in death rate.
2. Decline in infant mortality rate (IMR).
3. Decline in maternal mortality rate (MMR).
4. Provision of good health facilities.
Family planning is one of the measures to check the growing
population. It refers to practices that help individuals to:
1. Avoid unwanted births and bring about wanted births.
2. Regulate the spacing between children.
3. Control the time at which births occur concerning the age
of parents.
4. Determine the number of children in the family.
Pharmacists are members of the healthcare team who deal
directly with the public and hence they are in a better position
to educate the people about the drawbacks of uncontrolled
population growth, the importance of family planning, and
family planning methods. They are aware of the dangers of
population and its explosion. Unfortunately, the concept of
family planning is not properly understood by many people.
56 Social Pharmacy
These people are not aware of the benefits of family planning.
Some people have a psychic fear that family planning methods
are painful, and harmful to health. The pharmacist can play a
vital role in alleviating such fears. Pharmacists can do a great
job by making the public understand the scope and benefits of
family planning. They can provide information, advice, and
motivation to people for family planning.
The pharmacist can promote family planning by:
1. Displaying the family planning posters in hospitals,
dispensaries, drug stores, etc.
2. Motivating people to adopt the small family norm.
3. Encouraging the people to maintain spacing between
the children.
4. Distributing pamphlets on family planning.
5. Creating awareness in the community regarding the
availability of various family planning services.
6. Guiding people to hospitals and family planning
centers for vasectomy or tubectomy and laparoscopy.
7. Publicity of family planning programs.
8. Motivating people to use oral contraceptive drugs,
condoms, and various family planning techniques.
9. Social services.
10. Organizing educational programs and seminars that
highlight the problems associated with high popula-
tions.
11. Demonstrating comparative studies.
Scope of Family Planning Services
Family planning services are helpful in the following ways:
1. Proper spacing and limitation of births.
2. Education regarding contraceptive methods.
3. Investigation and advice on sterility and low fertility.
4. Education for wise parenthood.
5. Sex education.
6. Screening of the reproductive system for pathological
conditions, e.g. cervical cancer.
57Preventive Healthcare
7. Genetic counseling.
8. Pre-marital advice and examinations.
9. Maternal and child healthcare.
10. Carrying out pregnancy tests.
11. Marriage counseling.
12. Preparation of couples for the arrival of their first child.
13. Providing services for unmarried mothers.
14. Home science including home economics and nutrition.
15. Care of unmarried mothers and adoption services.
16. Early diagnosis of gynecological troubles such as cancer of
cervix.
17. Termination of pregnancy, if indicated.
Married couples can avoid unwanted pregnancies and
regulate the proper spacing by adopting family planning
measures.
METHODS OF FAMILY PLANNING
1. BARRIER METHODS
These methods act as a barrier to prevent the meeting of sperm
with the ovum. These are as follows.
i. Male Condom
A condom prevents the entry of semen into the vagina. Condom
meets the requirement of an ideal contraceptive. It is made from
latex and is applied to the erect penis before intercourse. The
condom must be withdrawn from the vagina carefully after
intercourse to avoid spilling of semen in the vagina.
Fig. 2.2: Male condom
58 Social Pharmacy
Various other types of condoms are also available in the
market like Nirodh, Kohinoor, Moods dotted condoms, Durex,
Masti, Climax, etc.
Advantages
1. Easily available, safe, and inexpensive.
2. Easy to use.
3. No side effects.
4. Disposable.
5. Protect against sexually transmitted diseases (STD)
including AIDS.
Disadvantages
It may (a) slip off or tear during coitus due to incorrect use,
and (b) may interfere with sex sensation locally in some cases.
ii. Female Condom
The female condom is worn by women 2 hours before
intercourse and should not be removed for 2 hours after
intercourse. The female condom has a small, flexible ring on
the closed end that covers the cervix, and a larger ring that
remains on the outside of the vagina. It is made of polyurethane.
It provides a higher degree of protection against sexually
transmitted diseases (STD) and AIDS as compared to male
condoms as it has two rings, which are longer and made of
polyurethane. Male condoms are shorter in length having one
ring at the end and are translucent because they are made from
latex.
The main disadvantages of female condoms are (i) high cost,
and (ii) poor acceptability.
Fig. 2.3: Female condom
59Preventive Healthcare
iii. Diaphragm
It is a barrier that covers the cervix during coitus and prevents
sperm from entering the uterus. Diaphragms are made up of
latex or silicone and are available in diameters of 50 to 105 mm
(about 2–4 inches). The diaphragm has to be inserted 4–6 hours
before sexual intercourse and must remain in place for at least
6 hours after intercourse. The diaphragm is reusable and must
be removed for cleaning at least once every 24 hours and can
be re-inserted immediately. Variations of the diaphragm
include the cervical cap, vault cap, and the vimule cap.
Fig. 2.4: Diaphragm
Advantages
No risks and medical contraindications.
Disadvantages
1. Require training before use.
2. This may result in a toxic shock syndrome in case the
diaphragm is left in the vagina for an extended period.
3. Do not give protection against STDs.
iv. Vaginal Sponge
It is a small polyurethane foam sponge saturated with
spermicides. The sponge was first introduced to shelves in 1983
and immediately became the most popular over-the-counter
contraceptive on the market. It is less effective than the
diaphragm and is not used in India.
v. Spermicidal Jellies, Foams, and Creams
These products are used along with barrier methods to increase
their efficiency. These products kill sperm by creating acidic
60 Social Pharmacy
pH. However, these methods of contraception are not safe and
reliable.
2. HORMONAL CONTRACEPTIVES
Hormonal contraceptives are most popular all over the world,
including India. They are almost 100% effective in preventing
pregnancy and ensuring spacing between childbirths.
Hormonal contraceptives are used in two forms:
a. Oral pills
b. Depot formulations.
a. Oral Pills (Table 2.2)
There are two types of pills available
i. Steroidal
ii. Non-steroidal.
Emergency Contraceptives
i-pill is an emergency contraceptive pill that is effective within
72 hours of coitus. It contains 1.5 mg of Levonorgestrel
(a progestogen), which helps prevent the implantation of the
egg in the uterus and avoids the beginning of pregnancy. A
single dose of i-pill provides a safe and easy way to prevent an
unintended pregnancy after unprotected sex or contraceptive
failure.
Fig. 2.5: Vaginal sponge
61Preventive Healthcare
Table 2.2: Types of oral pills
Parameter Steroidal pills Non steroidal pills
Composition Contain either progestogen
alone or a combination of
estrogen and progesterone
hormones (30 to 35 μg of
estrogen plus 0.5 to 1 mg
progestogen)
Mode of 1. Inhibit ovulation (due Interfere with implan-
action to estrogen) tation by acting on
2. Make endometrium unsuit- estrogen receptors
able for implantation of
fertilized ovum
3. Make the cervical mucous
thick and scanty which
inhibits the entry of sperm
Dosage The pill is taken daily by oral Initially, the pill is
route for 21 days, starting on taken twice a week for
the fifth day of the menstrual the first 3 months and
period. then once a week.
Advantages 1. Highly effective. 1. Highly effective and
2. Low risk of pelvic infection, easy to use
breast cancer, ovarian and 2. No effect on sexual
uterine cancer. activity
3. No irregularity in periods 3. Free from the typi-
4. Decrease in menstrual cal side-effects of
blood loss hormonal contra-
ceptives
Disadvan- a. The high failure rate in case High failure rate
tages the pill is not taken regularly
b. Minor side effects are
common, such as headache,
loss, and inter-period spot-
ting
c. Increased risk of cardiovas-
cular disease (blood clots,
heart attacks, strokes, etc.)
d.Mild hypertension.
e. High risk of gallbladder
disease
Examples Mala-N, Mala-D Saheli
62 Social Pharmacy
(b) Depot Formulations
Unlike oral pills that are to be taken daily, a single
administration of depot preparations is sufficient for several
months or years. They are highly effective, reversible, long-
acting, and estrogen-free. They can be injected into the body
(injectable contraceptives), implanted beneath the skin
(implants), or worn in the vagina (vaginal rings).
A. Injectable contraceptives
i. DMPA: One intramuscular injection (150 mg) of DMPA
(Depot-Medroxy Progesterone Acetate or Depot-provera)
is sufficient for 90 days. DMPA suppresses ovulation. It is
a safe, effective, and acceptable contraceptive, which does
not affect lactation. It is suitable for spacing pregnancies.
Its disadvantages include weight increase, irregular
menstrual, and prolonged infertility after its use. Depot
Provera is the most controversial contraceptive in India.
ii. NET-EN: Norethisterone enantate (NET-EN) is given
intramuscularly in a dose of 60 mg every 60 days. It is less
popular than DMPA. It also inhibits ovulation like DMPA.
The initial injection of both DMPA and NET-EN (deep
intramuscular) should be given during the first five days
of menstrual period. Both contraceptives are reversible.
B. Subdermal implants
Subdermal contraceptive implants involve the delivery of a
steroid progestin from polymer capsules or rods placed under
the skin. Protection is ensured with a low drug dosage and no
estrogen, and fertility is readily reversible once the implants
are removed.
Advantages
1. Implanted subdermally, beneath the skin of the forearm or
upper arm by surgical procedure.
2. Inhibit ovulation and implantation.
3. Effective for a long-term period extending over 5 years.
4. Contain progesterone alone or a combination of proges-
terone and estrogens.