Demography Demography

Demography Demography

Study of the demographic processes and their consequences for population distributions

Demographic Processes: • Natality • Mortality • Marriage • Migration • Social mobilisation

Demographic Indicators

Population density The number of people living per square kilometer of land area 382/sq. km (Census 2011)

India population – 130 crores Rural- 69%, urban – 31%

Literacy

• A person above the age of seven years who can read and write is considered literate.

Crude literacy rate = No. of literates X 100 Midyear population

Effective literacy rate = No. of literates ______X 100 Midyear population above seven years of age Literacy rate 74% Male literacy rate 82% Female Literacy rate 65% Highest Literacy Kerala- 94% Highest female literacy Kerala- 92% Lowest Literacy Bihar- 64% Lowest female literacy Rajasthan- 53% Economic dependency

Those under 15 and those over 65

Proportion of person < 15yrs of age and >65yrs of age % Age Dependency ratio = ------X 100 Proportion of persons 15-64 yrs. age

% Age dependency ratio- 53.3%

Life expectancy

• Life expectancy is the average number of years, which a person of that age may be expected to live according to the mortality pattern prevalent in that country. • India- 67.8 years • Male life expectancy – 66.7 years • Female life expectancy – 69.1 years

Crude birth rate

• The number of live births in an area during one year per 1000 midyear population

Number of live birth which occurred in a year in a specific area CBR = ------X 1000 Midyear population of the area in the same year

India- 20.4

Crude Death rate

Number of deaths which occurred in a year in a specific area CDR = ------X 1000 Midyear population of the area in the same year

Crude Death Rate (per 1000 mid-year population)  India- 6.5 Total fertility rate

Completed family size Completed Family Size is defined as total number of children borne by a woman during her entire reproductive period.

• Total Fertility Rate (per woman in reproductive age) India- 2.2

GRR & NRR

Gross reproductive rate- • The gross reproduction rate (GRR) is the average number of daughters that would be born to a woman (or a group of women) if she survived at least to the age of 49 and conformed to the age-specific fertility rate of a given year. Net reproductive rate • The average number of female live births that will occur to a newborn female as she grows up and passes through her entire reproductive age group provided she was subjected to the current rates of fertility as well as mortality.

Sex Ratio Number of females Sex ratio = ------X 1000 Number of males

Number of females live births Sex ratio at birth = ------X 1000 Number of males live births

Number of females (0-6 years) Child Sex ratio = ------X 1000 Number of males (0-6 years) Sex Ratio 940 (933 in 2001)

Child sex ratio 914 (927 in 2001)

Sex Ratio at Birth 908 Eligible couples

• It refers to currently married couple wherein the wife is in the reproductive age group, between 15 and 49 years. • There are 170 such couples per 1000 population (17%)

Contraceptive Prevalence Rate Total no. of eligible couples protected by any of approved methods CPR = ------X 100 Total no. of eligible couples in the community

Contraceptive prevalence rate is the proportion of women of reproductive age who are using (or whose partner is using) a contraceptive method at a given point in time NRR=1 can be achieved only when CPR exceeds 60. Population pyramid

Population pyramid

• The symmetry of the pyramid will indicate the sex distribution of the population. • The height of the pyramid indicates the life expectancy/ survival of the population • The age dependency ratio can also be calculated. • The shape of the pyramid can indicate whether it’s a High- income (developed), Middle-income (developing) or Low- income country (under-developed).

Demographic Transition model

High stationary / Pre-transitional (first stage): • Very high birth rates and very high death rate (30-50 per 1000)` Early expanding / early transitional (second stage): • Decline in the death rate while the birth rate remains unchanged Late expanding / Middle transitional (third stage): • Further decline in the death rate while birth rate tends to fall Low stationary / Late transitional (fourth stage): • Low birth rate and low death rate Declining / post-transitional (fifth stage): • Birth rate lower than death rate

Growth rate

The growth rate of a population refers to the number of individuals growing per year per 100 individuals of that population

Annual growth rate = CBR-CDR 10

In calculating Dependency ratio, the numerator is expressed as- (AIIMS-2003) a) Population under 10 years and 60 and above b) Population under 15 years and 60 and above c) Population under 10 years and 65 and above d) Population under 15 years and 65 and above

The number of live births per 1000 women in the reproductive age group in a year refers to- (AIIMS 2003) a) Total fertility rate b) Gross reproductive rate c) Net reproductive rate d) General fertility rate The age and sex structure of a population may be described by a (AIIMS 2003, 2005) a) Life table b) Correlation coefficient c) Population pyramid d) Bar chart True about late expanding phase of demographic cycle- (AIPGME 2009) a) Birth rate is lower than death rate b) Death rate begins to decline, while the birth rate remains unchanged c) Death rate declines still further and the birth rate tends to fall d) High birth rate and high death rate WHO defines adolescent age between- (AIPGME-2005) a) 10-19 years b) 10-14 years c) 10-25 years d) 9-14 years The net reproduction rate of 1 can be achieved only if the following rate exceeds 60% (UPSC CMS 2013) a) Total fertility rate b) Total marital fertility rate c) Age specific marital fertility rate d) Couple protection rate The best indicator of “completed family size”, that is the number of children a woman would have through her reproductive years is (UPSC CMS 2011) a) General fertility rate b) Total fertility rate c) Gross reproduction rate d) Net reproduction rate At what point in time is the population assessed for calculation of the crude birth rate? (AIIMS 2001) a) 1st January b) 1st May c) 1st July d) 31st December Contraception Ideal Contraceptive

An ideal contraceptive is safe, effective, acceptable, inexpensive, reversible, simple to use, independent of coitus, long lasting, requiring minimum medical supervision. There is no Ideal contraceptive Natural Family Planning methods

Natural family planning is family planning without use of any drugs or contraceptives. Basis of Natural methods: • A woman ovulates at only one time during her cycle, and an ovum can survive for only 12–24 hours. • Cervical mucus is necessary for fertility • Spermatozoa live only one to three days • Menstruation will occur about 2 weeks after ovulation.

Calendar method

It is based on the fact that ovulation occurs 14 days before the onset of menstruation. The days on which conception is likely to occur is calculated as- Shortest cycle minus 18 days gives the first day of the fertile period Longest cycle minus 10 days gives the last day of the fertile period

Basal Body Temperature Method

• Normal BBT is between 96 and 98 degrees, and after ovulation rises to 97 to 98 degrees. • A rise in temperature that persists for at least 3 days indicates that ovulation has occurred. • The safe period begins from the fourth day (first day being the day of ovulation) to the last day of the next period. Cervical mucus method

• Based on the observation of changes in the characteristics of cervical mucus • At the time of ovulation, cervical mucus becomes watery clear • After ovulation under the influence of progesterone, the mucus thickens and lessens in quantity.

Lactational Amenorrhoea Method

• Frequent intense suckling disrupts the pattern of pulsatile release of GnRH from the hypothalamus and thus LH from pituitary. This disrupts follicular development in the ovary and suppresses ovulation. • Three criteria for effectiveness • Exclusively breastfeeding • Up to six months after delivery • Menstruation have not resumed after delivery Failure rate:0-6months-2/HWY

Male Condom

Types of Condoms: • Latex Condoms • Polyurethane Condoms • Vytex • Polyisoprene • Natural membrane Condoms

Advantages of condom

• Easily and freely available • Safe • Inexpensive or free of cost • Can be used easily without any medical supervision • No side effects • Light, compact and disposable • Also protects against STI

Disadvantages of condom

• Slippage or tearing is common due to improper use or inappropriate size. • Interferes with sexual pleasure in some cases. • May cause allergy in those sensitive to latex.

Failure rate of condom With perfect use- 3 per HWY With typical use – 10-14 per HWY

Consistent and correct use of condoms Consistent use means using a new condom during every sexual interaction.

Female Condom

• These are sheaths or lining made that fit loosely inside a woman's vagina. • They have flexible rings at both ends, one ring at the closed end helps to insert the condom. • The ring at the open end holds part of the condom outside the vagina. • It is lubricated with a silicone-based lubricant on the inside and outside. • It can be kept inside the vagina up to 8 hours.

Failure rate: Perfect use: 5/HWY Typical use: 21/HWY

Contraindication: The female condom should not be used with simultaneously with male condom

IUD First generation These are inert or non-medicated devices. IUDs Lippe’s loop Second It consists of copper or silver containing IUDs generation IUDs Cu T 380- A, Cu 375

Third generation This consists of hormone releasing IUDs. IUDs Levonorgestrel releasing IUD- Mirena Mechanism of action of IUCD

Foreign body reaction- cellular and biochemical changes in the endometrium and the uterine fluids, which in turn impairs the viability of the products of conception.

Copper containing - Copper enhances the cellular response of endometrium. It hampers sperm survival.

Hormone releasing IUDs- They increase the viscosity of cervical mucus making the entry of sperm difficult. Advantages of IUCD

• Simple procedure • Longer continuation period • Inexpensive • Reversible • Free of systemic side-effects • High compliance

Absolute contraindications

Pregnancy / Suspected pregnancy Pelvic inflammatory disease Undiagnosed irregular vaginal bleeding Pelvic malignancy History of ectopic pregnancy Wilson's disease or a known allergy to copper Still retains a previously inserted IUD Genital Actinomycosis Immunodeficiency Relative Contraindications

Anemia (non-hormone releasing devices) Menorrhagia Leucorrhoea Uterine malformations Ideal time for insertion

• Within 12 days of start of menstrual cycle. • Post-partum insertion- within 2 days of delivery • It can be inserted after vaginal delivery or at the time of caesarean section • Post puerperal insertion- 6 weeks after delivery • Post-MTP insertion- immediately following a 1st trimester pregnancy, after four weeks of second trimester MTP

Effectiveness

• Cu-T- 0.6-0.8/HWY • LNG-IUS- 0.2/HWY

OC Pills

Advantages • Convenient to use • No interruption with sex • Lighter and shorter periods • Periods get regulated and occur every 28 days • As it prevents ovulation, it also eliminates mid-cycle pain • No effect on fertility after stopping pills

Non-contraceptive health benefits

• Protects against ovarian and endometrial cancer • Protects against functional ovarian cyst • Decreases the risk of ectopic pregnancy • Symptomatic PID is decreased • Iron deficiency anemia • Endometriosis

Disadvantages of O C Pills

• No protection against STI • May interfere with other oral medications • Regular use is mandatory • Slightly increased chances of increased coagulation of blood, cardiovascular diseases, hypertension, strokes or hepatic tumors

Relative contraindications

• Breastfeeding between six weeks and six months after delivery • Non-breastfeeding and less than 21 days postpartum • Blood pressure of 140–159/90–99 mm Hg • Migraine without aura • Symptomatic gallbladder disease • Taking barbiturates, carbamazepine, oxcarbazepine, phenytoin, primidone, topiramate, rifabutin or rifampicin, or lamotrigine. • Prolonged immobility

Absolute Contraindications

• Breastfeeding during the first six weeks postpartum • Blood pressure of 160/100 mm Hg or higher • Migraines with aura • Cardiovascular diseases • Complicated diabetes • Current breast cancer • Liver Diseases

Constituent of Mala-N/ Mala-D • Levonorgestrel 0.15 mg (progesterone) • Ethinyl estradiol 0.03 mg (estrogen)

• Mala N is the OCP provided free of charge by the Government of India through health and family welfare centers and government hospitals. • Whereas, Mala D is made available through social marketing and retailed by chemists/ drug shops as OTC drug

Mechanism of Action

• Suppression of ovulation • If ovulation has occurred, then it can prevent fertilization. • The progestin component of OC pills causes the cervical mucus to become thick and prevents sperm penetration.

• Effectiveness: • Perfect use: 0.3/HWY • Typical use: 8/HWY How to take OCP

• A woman can start taking COCs anytime a provider is reasonably sure she is not pregnant. • No backup method is necessary if a woman initiates COC use during the first five days • If a woman starts COCs after the fifth day of her menstrual cycle, she should use a backup method for seven days.

If a woman misses one or two active pills - • She should take one missed pill as soon as she remembers. • She should take the next pill in the pack at the regular time. • A backup method of contraception is not necessary

If a woman misses three or more active pills in a row- • She should take a pill as soon as she remembers and continue taking pills, one each day. • She should also either abstain from sex or use a backup form of contraception, until she has taken active pills for seven days in a row. • If she has at least seven active pills, she should complete the pack and take her standard hormone-free break. • If the woman does not have seven active pills remaining, she should finish the remaining active pills, discard the inactive pills, and start a new pack immediately. POP

• Progestin-only pills (POPs) are also called “mini-pills” and progestin-only oral contraceptives. • Do not contain estrogen, and so can be used throughout breastfeeding and by women who cannot use methods with estrogen.

Mechanism of action of Progestin-only pills • Thickening cervical mucus • Preventing ovulation

Failure rate of POP

In breastfeeding women • Typical usage-1/HWY In non-breastfeeding women- • Typical use: 3-10/HWY

• If a woman is 3 or more hours late taking a pill, or if she misses a pill completely, she should take a missed pill as soon as possible • She should use backup method for next two days

Progestin Only Injectables

• Depot Medroxy Progesterone Acetate (DMPA): 150 mg IM once in three months (13 weeks) • DMPA- subcutaneous formulation (Depo-subQ): 104 mg subcutaneously once in three months (13 weeks) • Norethisterone Enanthate (NET-EN): 200 mg IM once in 2 months (8 weeks)

• With DMPA she may come up to 4 weeks late and still get an injection. • With NET-EN she may come up to 2 weeks late and still get an injection. • With either DMPA or NET-EN, she can come up to 2 weeks early.

Effectiveness • Typical use: 3/HWY • For the first several months, irregular bleeding, prolonged bleeding, frequent bleeding. Later, no monthly bleeding. • POI is considered to be the most ‘private’ method of contraception • POI is the only contraceptive which delays the return of fertility. DMPA users become pregnant on average 10 months after their last injection and NET-EN users, 6 months after their last injection • POI is the only contraceptive which significantly but reversibly decreases Bone mass density

Centchroman

• Selective estrogen receptor modulators • Non-hormonal, non-steroidal oral contraceptive

• Centchroman is available as 30mg tablets. • A single tablet should be taken twice a week for the first three months and then weekly thereafter. Emergency Contraception

Methods of emergency contraception: • LNG: 1.5 mg in single dose or 0.75 mg in two doses 12 hours apart • IUCD insertion within 7 days of unprotected sex • Yuzpe’s Regime: 4 COC pills followed by 4 more after 12 hours • Ulipristal acetate 30 mg single dose • Mifepristone: 10-50 mg as a single dose

Medical Abortion

Termination of pregnancy up to 9 weeks period of gestation (63 days from the first day of the last menstrual period in women with regular cycle of 28 days)

• First Visit (day 1): to take Tab Mifepristone 200 mg orally, in the presence of a health functionary. • Second Visit (day 3): to take tablet Misoprostol, 400µg orally/vaginally • Third Visit (day 15): to ensure that abortion is complete. Female Sterilization

• Clients should be ever-married • Female clients should be below the age of 49 years and above the age of 22 years • The couple should have at least one child whose age is above one year • Clients or their spouses/partners must not have undergone sterilization in the past • Clients must be in a sound state of mind Timing of the Surgical Procedure

• Interval sterilization should be performed within 7 days of the menstrual period • Post-partum sterilization should be done after 24 hours up to 7days • Sterilization with MTP can be performed concurrently

Male Sterilization

• Clients should be ever-married. • Ideally be below the age of 60 years. • The couple should have at least one child whose age is above one year • Clients or their spouses/partners must not have undergone sterilization in the past. • Clients must be in a sound state of mind Pearl Index

The number of unintentional pregnancies related to 100 women years will determine the Pearl index. Total Accidental Pregnancies Pearl Index = ------X 1200 Total Months of Exposure The following statements are true about IUD except- (AIPGME 2004) a) Multiload Cu-375 is a third generation IUCD b) The pregnancy rate of Lippe’s loop and Cu-T 200 are similar c) IUD can be used for emergency contraception within 5 days d) Levonorgestrel releasing IUD has an effective life of 10 years Which of the following contraception method is contraindicated in women with epilepsy? a) Oral Contraceptive pill b) IUCD c) Condom d) Tubal Ligation Female sterilization is contraindicated in: (UPSC CMS 2014) a) Heart disease b) Diabetes mellitus c) Hypertension d) None of the above Laparoscopic sterilization is not recommended during the period of: (UPSC CMS 2014) a) Immediate post partum b) Interval c) Post menstrual d) Post first trimester M.T.P Which one of the following is the most suitable situation for prescribing progestin only pill? (UPSC CMS 2014) a) Young patients b) Emergency contraception c) Lactating mother d) Woman with unexplained vaginal bleeding Which of the following is not true regarding ‘no scalpel’ vasectomy? (UPSC CMS 2014) a) Special instruments are used to deliver the vas instead of cutting the skin b) Scrotal skin is cut with LASER to expose the vas c) The failure rate is same as that of conventional vasectomy d) It is a very popular method in China Contraceptive options for a 28-year-old woman who is breastfeeding a six-week-old baby, wanting to avoid pregnancy for a longer interval are the following except: (UPSC CMS 2015) a) LNG-IUD b) IUD- 380A c) Implanon d) Combined oral contraceptives A woman using combined oral contraceptive has the following non-contraceptive benefits except: (UPSC CMS 2015) a) Protection against PID b) Prevention of colorectal malignancy c) Protection against ovarian cancer d) Protection against cervical cancer Ideal time to perform post partum sterilization as per Government of India guidelines is: (UPSC CMS 2015) a) From 12 hours to 7 days of delivery b) From 24 hours to 7 days of delivery c) From 48 hours to 7 days of delivery d) Within 7 days of delivery Absolute contraindication for the use of OCPs is: (UPSC CMS 2014) a) Thromboembolism b) Hypertension c) Diabetes d) Epilepsy Misoprostol can be used during pregnancy by the following routes, except (UPSC CMS 2013) a) Intravenous b) Oral c) Vaginal d) Sub-lingual A man underwent vasectomy, but 6 months later his wife was 16 weeks pregnant. What is the most likely cause? (UPSC CMS 2013) a) Failure of operative procedure b) Pregnancy antedating vasectomy c) Recanalization of vas d) Failure to use additional contraception in postoperative period All of the following are eligibility criteria for female sterilization, except a) Clients age should not be less than 22 years or more than 49 years b) Client should be married c) Client or her spouse must not have undergone sterilization in the past d) At least two living children should be present Contraindications for medical abortions are all except: (UPSC CMS 2013) a) Age more than 35 years b) Hemoglobin less than 8 gm% c) Undiagnosed adnexal mass d) Uncontrolled seizure disorder The drugs, which may interfere with the efficacy of oral contraceptives and increase the failure rates are the following except (UPSC CMS 2012) a) Barbiturates b) Rifampicin c) Ampicillin d) Phenytoin Which of the following criterion is false regarding the effectiveness of Lactational Amenorrhea Method? a) Should be exclusively breastfeeding b) Menstruation should not have resumed c) Effective only up to four months after delivery d) None of the above Which one is not an absolute contraindication for IUD insertion? a) Pregnancy b) Puerperal sepsis c) Anemia d) Bleeding P/V of unknown etiology Single pill of MALA-D contains- a) L-norgesterol (LNGL) 0.15mg and EE 0.03mg b) L-norgesterol (LNGL) 0.03mg and EE 0.15mg c) D-norgesterol (LNGL) 0.15mg and EE 0.03mg d) D-norgesterol (LNGL) 0. 03mg and EE 0.15 mg Which of the following is not the likely mechanism of action of OCPs? a) Inhibition of ovulation by bringing about changes in FSH & LH secretion b) By altering the endometrium c) By bringing about changes in cervical mucus d) Incapacitates sperm Which of the following is not an indication for MTP? a) Failure of contraception b) Malformed fetus c) Pregnancy arising out of rape d) None of the above Third generation IUCD acts by – a) Foreign body reaction b) Hampering sperm survival c) Thickening cervical mucus d) Both a and c In case of Mala-N, backup method is indicated if ______or more pills are missed successively. a) One b) Two c) Three d) Four The effect of Ormeloxifene contraceptive pill starts after a) 1 month b) 2 months c) 3 months d) 4 months Which of the following pairs of contraceptive and time for onset of effectiveness is incorrect- a) Combined Oral contraceptives – 7 Days b) Centchroman- 1 month c) Progesterone only pills- 2 days d) IUCD- 24 hours 结束