Figure 4.1 Couple Protection Rate & Birth Rate

CHAPTER – IV
PREVENTION AND MANAGEMENT OF UNWANTED PREGNANCY

Efforts to improve availability and access to contraceptive care in India
during the seventies and early eighties resulted in a steep rise in couple
protection rates. However, there was no commensurate fall in the birth rate.
Service reports on
CPR and SRS
estimates of CBR
Figure 4.1 Couple Protection Rate & Birth
indicate that there
has been a steady
Rate
decline in the CBR
50
during the nineties
45
40
in spite of the fact
35
that the rise in CPR
30
25
during the nineties
RATE
20
has been very slow
15
(Figure-4.1).
This
10
5
may indicate that
0
either there has
been a reduction in
1970-71
1972-73
1975-75
1976-77
1978-79
1980-81
1982-83
1984-85
1986-87
1988-89
1990-91
1992-93
1994-95
1996-97 1997-98 1998-99
over reporting of
contraceptive
EFFECTIVE CPR
BIRTH RATE
acceptance or
there has been
Source:- R.G.I , Deptt. of F. W
improvement in the
quality of services
and appropriate contraceptives are being provided at appropriate time.

There are massive inter -state differences in CPR and CBR. In states
like Bihar CPR is low and birth rate is high; in spite of high CPR in Punjab,
CBR is still relatively high. Kerala, Tamil Nadu and Andhra Pradesh have
achieved substantially lower CBR while CPR was still lower than that reported
currently in Punjab. (Fig4.2, annexure 4.1). Age and parity at the time of
accepting contraception as well as continuation rates of spacing methods are
critical factors that influence the relationship between CPR and CBR. The
high tubectomy
Figure 4.2 Inter-state Differences in CPR and Birth
acceptance in
Rate
70
younger women
60
with two or three
50
children in Tamil
40
Nadu and Kerala
and the higher
30
Percent
use of spacing
20
methods even
10
among older
0
women with three
Punjab
Uttar
Bihar
or more children
Andhra
Gujarat
Kerala
Orissa
Assam
Haryana
Madhya
Karnataka
Rajasthan
Tamil Nadu
in Punjab may
Maharashtra
West Bengal
account for the
C P R (31-3-2001)
Birth Rate 1999
Source : SRS, Deptt of F.W

36

---

observed differences in the CPR and CBR between these states.

Over years there has been a fall in birth rate in all the states, among all
segments of population; but the rate of reduction in the birth rate is higher in
some states. In 2000:

E 12 states /UTs with 14.4% of the population have CBR <20.
E 10 states /UTs with 32.5% of the population have CBR between 20-25.
E 5 states with 13% of the population have CBR between 25-30
E 4 states with 40% of the population have CBR > 30/1000

There is an urgent need to meet all the needs for contraception in the
populous states with high birth rate.

Data from service
reports during the Ninth
Fig4.3 Acceptors of Family Planning Methods-All
India
Plan period indicate that
as compared to the level
20
of acceptance in 1994-95,
there has been a decline
15
in acceptors of all types of
contraception in the initial
10
Million
years of the Ninth Plan ;
subsequently the decline
5
has been reversed except
0
IUD. (Figure-4.3 ).

1992-93
1993-94
1994-95
1995-96
Prov.
1996-97
1997-98
1998-99
1999-2K
The National
Family Health Survey
Sterilisation
IUD
1992-93 and 1998-99
CC users
OP Users
provided nationwide data
on contraceptive prevalence. Data from the Survey (Figure 4.4) indicate that
Figure 4.4 CONTRACEPTIVE USE BY METHOD
(MARRIED WOMEN AGES 15-49)
TRADITIONALMETHODS/
5.4
OTHERS
4.3
NFHS-II (1998-99)
1.9
STERLIZATION
3.4
NFHS-I (1992-93)
1.6
IUD
1.9
2.1
PILL
1.2
3.1
CONDOM
2.4
34.2
FEMALE STERLIZATION
27.3
0
5
10
15
20
25
30
35
40
PERCENT
contrary to the performance figures available from the service reports of the

37

---

Department of Family Welfare, there has been substantial increase in the
sterilisation and OC acceptance in the country. Only IUD and vasectomy use
has shown a decline. The improvement in CPR explains the steady decline in
the CBR during the nineties reported by the SRS. The reasons for the
observed difference in CPR data from service reports of the Department of
Family Welfare and NFHS may include:

E Reduction in the earlier over reporting in an attempt to reach the set target.
E Incomplete reporting due to changes in service reporting formats during
the current period.

The inbuilt independent surveys and coverage evaluations within the
Family Welfare Programme have provided the reassuring findings that during
the decade of the nineties, there has not been any deterioration in the
contraceptive prevalence. The coverage figures under service reporting for
spacing methods, antenatal care and immunisation are still substantially
higher than the coverage reported by evaluations. This over reporting need
to be looked into and corrected so that service reporting provide reliable
indication of progress achieved in the programme. The narrowing of the gap
in coverage figures between the service and evaluation reports can be used
as a new indicator for the quality in programme monitoring.

Unmet needs
F i g 4 . 5 . U n m e t N e e d f o r C o n t r a c e p t i o n
for
2 5
contraception
2 0
NFHS 1
and 2 (Fig4.5 &
1 5
4.6) clearly
1 0
indicate that
5
there is still
% Currently Married Women
substantial
0
unmet need for
T o t a l
S p a c i n g
L i m i t i n g
M e t h o d s
M e t h o d s
both terminal
methods and
N F H S - 1
N F H S - 2
spacing methods
F i g 4 . 6 . U n m e t N e e d f o r F a m i l y P l a n n i n g
3 5
3 0
2 5
2 0
1 5
1 0
% Currently Married Women
5
0
-5
Kerala
Bihar
INDIA
Gujarat
Assam
Punjab
Orissa
Haryana
Rajasthan
Karnataka
Maharashtra
Tamil Nadu
Uttar Pradesh
West Bengal
Andhra Pradesh
Madhya Pradesh
N F H S - 1 ( 1 9 9 2 - 9 3 )
N F H S - I I ( 1 9 9 8 - 9 9 )
D e c l i n e

38

---

in all states. There are interstate differences in magnitude of unmet need for
contraception. It is imperative that all the unmet needs for contraception are
fully met within the Tenth Plan period and substantial reduction in unwanted
pregnancy is achieved. Making balanced presentation of advantages and
disadvantages of methods, improving counselling, quality of services and
follow up care will enable couple to make appropriate choice to meet their
needs for contraception, increase couple protection rates and continuation
rates and enable the country to achieve the NPP
goal of replacement level of fertility by 2010.
Table 4.1 Inter district

variations (Birth order 3
Monitoring birth order
or more as % of total

births)
Monitoring reported birth order is a easy
<20% 27
method of monitoring the progress towards
20-40% 165
achievement of replacement level of fertility.
>40% 313
Currently in India birth order of 3 or more
Source RHS 1998-99
Fig 4.7 .Contributtion of births of order of 3 and above to all births
70
58.1
60
54.6
52.9
52.8
50.3
50
43.8
42.9
41.6
41.1
39.6
39.2
40
36.5
33.6
33.3
31.5
Percent
30
23.2
21.1
20
10
0
Bihar
J&K
Assam
Orissa
Gujrat
Kerala
Haryana
Punjab
Rajasthan
Karnataka
Himachal P
Tamil Nadu
Uttar Pradesh
Maharashtra
West Bengal
Madhya Pradesh
Andhra Pradesh
contribute to nearly half
Fig 4. 8 Percent of Couples Currently Sterilized
of all the births(Table
60
4.1). There are
57
52.2
52.2
51
massive interstate and
50
44.7
46.5
48.3
46
45.3
inter district differences
42.7
39.6
41
40.8
40
in the contribution of
36
37.9
34.8
35.6
33.8
34
different birth orders
30.6
31.7
31.6
30.6
31.8
30.9
30
26.2
(Fig 4.7). Available
Percent
20.2
data on IMR, TFR,
20
17.7
16.7
14.6
15.6
13.1
(NFHS, SRS) and
10
higher order births from
NFHS,RHS is given in
0
annexure 4.2. Based
INDIA
Kerala
Bihar
Gujarat
Orissa
Assam
on this information
Haryana
Punjab
Uttar P.
Andhra P.
Karnataka
Tamil N.
Madhya P.
Rajasthan
district specific
Maharashtra
West Bengal
NFHS I
NFHS II

39

---

differential strategy can be evolved to improve contraceptive prevalence rates,
increase interbirth interval and reduce higher order of births.

Terminal Methods of Contraception

Sterilization has been the most widely used method of contraception in
all states in India. (Figure4.8.). Currently age at marriage is very low and
majority of the women complete their families during early twenties. In the
current Indian milieu of stable marriages sterilization is the most appropriate
method of contraception. There are substantial differences between states
and between districts in different states in couples that have adopted terminal
methods of contraception(Table 4.2,annexure
4.3 & 4.4) During nineties there has been
Table 4.2 Inter district
some increase in percentage currently
variations in % Eligible
sterilized persons in all states except Punjab. couple sterilised
However, percentage of women undergoing
>50 75
sterilisation is very low in Assam, Bihar and
40-49
101
UP; women in these states majority of
30-39
106
women come for sterilisation after they have
<30 223
three or more children. Improving access to
Source RHS 1998-99
safe, good quality tubectomy/vasectomy
services through RCH Camps in CHCs/PHCs may be most viable and
sustainable strategy for meeting the unmet need for sterilisation in these
states.

Emerging needs for spacing methods:


Data from NFHS clearly shows that inspite of low use of spacing
methods the mean inter-birth interval is about 30 months. (Fig4.9) This is
Fig 4.9- Higher Order Births & Birth Interval
Fig 4.10- Intention For Future Use of Family
Planning
60
80
50
70
40
60
30
50
40
20
30
% of total Births 10
20
0
% Currently Married Women 10
Order 3+
Order 4+
Birth Interval
0
(Months)
0
1
2
3
4+
Total
Parity
NFHS-1
NFHS-2
NFHS-1
NFHS-2
because of universal prolonged breast-feeding. Exclusive breast feeding
during the first six months offers substantial protection against pregnancy; but

40

---

once supplements are introduced to breast fed infants, the contraceptive
effect of lactation wanes; introduction of appropriate contraception at this time
will ensure adequate spacing between births and prevent deterioration in
maternal and infant nutrition due to too early advent of next pregnancy.Data
from NFHS II has also shown that there is an emerging need for contraception
before first birth(Fig 4.10 ); this has to be fully met during the Tenth Plan.

Gender –bias and Acceptance of Contraception

Data from NFHS demonstrated the role of son preference both in
relation to the acceptance of permanent and temporary methods of
contraception (Fig4.11&12 ) It is important that appropriate steps are taken
by all concerned sectors to minimize and later eliminate gender-bias which
reduces contraceptive acceptance among those who have girl children.

Fig 4.11&12.Acceptance of Family Planning by No. of Living Children and Their Sex
(NFHS-1998-99)






































































Fig 4.13 - Preferred Method of Choice
Data on CPR from NFHS
1 & 2 and RHS is given in
70
Annexure 4.5 and
60
projected CPR for 2007 is
50
given in Annexure 4.6
40

Men's participation in
30
planned parenthood
20

10
Men play an
% Currently Married Women
important role in
0
determining education
and employment status,
IUCD
Oral Pill
Condom
Natural
Method
age at marriage, family
Tubectomy
Vasectomy
formation pattern, access
NFHS-1
NFHS-2

41

---

to and utilisation of health and family welfare services for women and children.
Data from NFHS clearly indicates that the population perceives this very
clearly and have expressed it in terms of preferred method of choice in the
future (Figure4.13 ). It is imperative that access to good quality sterilization
services are provided to all especially in states where the contribution of third
and higher order births is more than 50% of all the births. In the sixties and
early seventies Vasectomy was the most widely used terminal methods;
Since then, there has been a steep and continuous decline and today
vasectomy forms less than 2% of all contraceptions.
TABLE-4.3
Status of No Scalpel Vasectomy Project, Deptt of FW ( December 2000)

States
Courses
No. of
No. of
No. of
No. of Certified
Districts
Acceptors Doctors
Trainers
covered
Trained
Andhra
78
30
80558
155
11
Pradesh
Assam
1
3
60
5
1
Maharashtra
9
8
546
38
4
Tamil Nadu
10
19
327
40
2
Uttar Pradesh
11
11
391
13
2
Haryana
14
18
567
51
1
Orissa
17
34
1171
72
1
Punjab
16
16
590
61
1
West Bengal
8
6
1084
25
4
Rajasthan
2
3
31
4
1
Sikkim
8
6
677
28
3
Himachal
1
1
83
0
0
Pradesh
Kerala
6
7
382
27
1
Bighar
4
2
162
13
0
Gujarat
6
5
118
24
1
Karnataka
12
11
231
45
3
Delhi
4
4
181
15
2
Manipur
5
4
315
20
3
Madhya
10
23
3466
119
2
Pradesh
J & K
1
8
19
6
0
FPAI, Mumbai
1
1
88
0
1

Vasectomy is safer and easier to perform in primary health care
settings than tubectomy. Efforts to repopularise vasectomy including IEC
campaigns and training of surgeons in No Scalpel Vasectomy (NSV) has
resulted in substantial increase in vasectomies in some districts in Andhra
Pradesh and in Sikkim(Table 4.3); however similar change has not happened
in other states.


42

---

It is essential that the efforts to popularize vasectomy are continued by
addressing the concerns and conveniences of men, and improving the
techniques and quality of vasectomy services. This would result not only in
improving men’s participation in the FW programme but also result in
substantial increase in access to sterilisation services and reduction in the
morbidity and mortality associated with sterilization.

Their active co-operation is essential for the success of STD/RTI
prevention and control. In condom users, consistent and correct use is
essential pre-requisites for STD as well as pregnancy prevention. Vasectomy
was the most widely used terminal method of contraception in the sixties and
seventies but since then there has been a steep decline (Fig4.14 ) . It is
essential that efforts are intensified to re-popularize vasectomy.
Fig 4.14. ACCEPTORS OF VASECTOMY & TUBECTOMY
70
60
50
40
Lakhs 30
20
10
0
1968-69
1970-71
1972-73
1974-75
1976-77
1978-79
1980-81
1982-83
1984-85
1986-87
1988-89
1990-91
1992-93
1994-95
1996-97
1998-99
V A S E C T O M Y
T U B E C T O M Y
Source:- Department of Family Welfare
Tenth Plan strategy to meet all the felt needs for contraception would
include:
In all districts
E Improve access to services to ensure effective implementation
E Counselling and balanced presentation of advantages and disadvantages
of all available methods of contraception to enable the family to make the
right choice
E Good quality services in the vicinity of their residence
E Good follow up care

In states/districts where birth order three or more is over 40% of the
births
E Ensure ready access to tubectomy/vasectomy by sending, if necessary
doctors from CHCs/District hospitals to PHC/CHC on fixed days

43

---

In states/districts where birth order two or less is over 60% of the
births
E meet the unmet needs for spacing methods on a priority basis and also
continue to provide terminal methods.

Management of unwanted pregnancy
Table 4.4 .Causes of maternal
It is estimated that in 1998 about 9%
death (%)
of maternal deaths are due to unsafe

abortion(Table 4.4) It is estimated that in
Haemorrhage 30
1998 about 9% of maternal deaths are due
Anaemia 19
to unsafe abortion. Available service data
Sepsis 16
on MTPs indicate that following an initial rise,
Obstructed labor 10
the number of MTPs have remained around
Abortion 8
0.5 – 0.7 million in the last decade. The
Toxemia 8
estimated number of illegal induced
Others 8
abortions in the country is in the range of 4-6
Source :Survey of COD 1998
million. There has not been any substantial
decline in
estimated
Fig4.15 Medical Termination Of Pregnancies
number of
illegal
7
abortions,
6
reported
5
morbidity due
4
to illegal
Lakh
3
abortions or
2
share of
1
illegal
abortions as
0
the cause of
maternal
1972-76
1976-77
1980-81
1985-86
1990-91
1993-94
1995-96
1997-98
1999-2K
mortality.
Source:- Depatt of F. W.
Management
of unwanted
pregnancy through early and safe MTP services as envisaged under the
Medical Termination of Pregnancy Act is an important component of the on
going RCH Programme(.Fig 4.15)

During the Ninth Plan efforts were made

E to improve access to family planning services and to reduce the number
of unwanted pregnancies
E to cater to the demand/request for MTP
E to improve access to safe abortion services by training physicians in
MTP and recognising and strengthening institutions capable of providing
safe abortion services


44

---

Inspite of these efforts there has not been any increase in terms of
coverage, number of MTPs reported and reduction in number of women
suffering adverse health consequences of illegal induced abortions.

Tenth plan Strategies for reducing morbidity due to induced abortion

E Reduce the number of pregnancies by fully meeting the felt but unmet
needs for contraception.
E Improve access to safe MTP services through:

§ Registering and ensuring availability MTP services in all institutions
where there is a qualified Gynaecologist and adequate
infrastructure
§ Simplify the regulation and reporting of MTP so that all MTPs done
by qualified doctors are registered.
§ Train physicians working in institutions with adequate infrastructure
in government, private and voluntary sector in MTP so that they
also can provide safe MTP services.
§ In places where there is a trained physician but no Vacuum
Aspiration Machine, provide MVA syringes.
§ In districts where a gynaecologist visits CHC/PHC on a fixed day,
they may perform MTPs using MVA
§ Explore feasibility and safety of introducing non-surgical methods of
MTP in Medical College Hospitals and then in a phased manner
extend service to district hospitals.
Ensure that women do accept appropriate contraception at the time of MTP
so that there is no recurrence of unwanted pregnancies requiring a repeat
MTP.

45

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