ANM / Multi-Purpose Health Assistant (Female) · Chapter 9

Family Planning and Welfare

What to remember

Family planning helps couples decide the number and spacing of children. Methods are grouped as spacing (temporary) and limiting (permanent).
The ANM counsels the couple, gives the right method after checking eligibility, explains side effects, and arranges follow-up.
Know the dose, duration, and time limit of every method: Cu-T, pills, injectable, emergency pill, tubectomy and vasectomy.

Basic terms and indicators

Eligible couple: a married couple in which the wife is in the reproductive age group (15 to 49 years).
Couple protection rate (CPR): percentage of eligible couples effectively protected by contraception.
Total fertility rate (TFR): the average number of children a woman would have in her lifetime at current age-specific rates. Replacement level fertility is a TFR of about 2.1.
Crude birth rate: live births per 1,000 population in a year.
Pearl index: failure rate of a method = (number of accidental pregnancies × 1,200) ÷ total months of exposure. It gives pregnancies per 100 woman-years.
Worked example: 6 pregnancies in 2,400 woman-months of use give 6 × 1,200 ÷ 2,400 = 3 per 100 woman-years.
Ideal contraceptive: safe, effective, acceptable, cheap, reversible, easy to use and no effect on sexual desire.
Family welfare: India's programme began in 1952 as a family planning programme. It was later renamed "family welfare". The National Population Policy of 2000 aims at stabilising the population by meeting unmet needs for contraception, health care infrastructure and reproductive health services.
The ANM also promotes the ideal first-birth age (after 21 years) and a gap of at least 3 years between children.

Classification of methods

Group	Methods
Natural (traditional)	Calendar (rhythm) method, basal body temperature, cervical mucus method, withdrawal, lactational amenorrhoea method
Barrier	Male condom, female condom, diaphragm, spermicides
Hormonal	Combined oral pills, progestin-only pills, injectable, centchroman (non-steroidal), emergency pills
Intrauterine devices	Copper T 380A, Copper T 375, post-partum IUCD
Permanent	Female sterilisation (tubectomy), male sterilisation (vasectomy)

Barrier methods

Male condom: a thin latex sheath worn on the erect penis. It prevents pregnancy and sexually transmitted infections, including HIV. Use a new one for each act. Store away from heat. Free supply is provided under the programme, for example the Nirodh brand.
Female condom is a polyurethane sheath placed in the vagina.
Diaphragm is a rubber dome placed over the cervix, used with spermicide.
Spermicides are foam tablets, jelly or cream that kill sperm. Used alone, they have a high failure rate.

Hormonal methods

Combined oral contraceptive pills (COC): contain oestrogen and progestin. Mala-N is the pill supplied free: one pill daily for 21 days, then 7 days of iron tablets, so it is taken without a break. Start on day 1 to 5 of the period.
Missed pill: take it as soon as remembered, and take the next at the usual time. If two or more are missed, use a condom for 7 days.
Mode of action: stops ovulation, thickens cervical mucus and makes the womb lining unsuitable.
Avoid in: breastfeeding mothers in the first six months, smokers over 35 years, women with blood clots, severe high blood pressure, liver disease, or breast cancer.
Progestin-only pills are safe during breastfeeding.
Centchroman (Chhaya) is a non-steroidal weekly pill: twice weekly for 3 months, then once weekly.
Injectable contraceptive (Antara, DMPA): 150 mg medroxyprogesterone acetate intramuscular every 3 months. It can be given in the postpartum period. Common side effects are irregular periods and a delay in return of fertility. A delay of up to 4 weeks for the next dose is allowed.
Emergency contraception: levonorgestrel 1.5 mg as a single tablet, as early as possible within 72 hours of unprotected intercourse. It can still be given up to 120 hours with a lower effect. It is not meant for regular use.

Intrauterine contraceptive devices (IUCD)

Copper T 380A is effective for 10 years. Cu T 375 is effective for 5 years. These are the devices supplied in the national programme.
Mode of action: copper ions are toxic to sperm and prevent fertilisation. It also stops implantation.
Time of insertion: interval insertion after the end of a period (within the first 12 days of the cycle is ideal), post-partum IUCD within 48 hours of delivery, and post-abortion IUCD immediately after a safe first-trimester abortion.
Contraindications: pregnancy, pelvic infection, unexplained vaginal bleeding, cervical or uterine cancer.
Side effects: heavy periods, spotting, cramps, expulsion. Warning signs (PAINS): period late or missed, abdominal pain, infection or discharge, not feeling well or fever, string missing.
The woman should check the strings after each period. Follow-up visit is after the first period or 4 to 6 weeks.
Copper T can be used as emergency contraception when inserted within 5 days.

Natural methods

Lactational amenorrhoea method (LAM): effective if the baby is under 6 months, exclusively breastfed day and night, and the mother's periods have not returned.
Calendar method: ovulation occurs about 14 days before the next period. The fertile days are avoided. The method is not reliable with irregular cycles.
Standard days method uses beads (CycleBeads) for cycles of 26 to 32 days; unsafe days are days 8 to 19.
Withdrawal has a high failure rate.

Permanent methods

Feature	Tubectomy	Vasectomy
Who	Woman	Man
Site	Fallopian tubes cut and tied	Vas deferens cut and tied
Common technique	Minilaparotomy (interval), post-partum within 7 days	No-scalpel vasectomy (NSV)
Timing	Interval: after a period; post-partum: within 7 days after delivery	Any time; use condoms until semen is sperm-free
Effectiveness	Over 99%	Over 99%

After a vasectomy, the semen needs about 3 months (or 20 ejaculations) to become free of sperm, so a condom is used until the semen test is clear.
Vasectomy is simpler, safer, cheaper and has fewer complications than tubectomy. It does not reduce sexual desire.
Counsel that sterilisation is intended to be permanent and consent must be voluntary and written.
The couple must be eligible: usually the woman is aged 22 to 49 years and has at least one child above 1 year (norms may change; follow current guidelines).

Postpartum and post-abortion contraception

After birth, fertility can return before periods; a method should be started early.
Postpartum choices are: LAM, condoms, progestin-only methods, injectable, PPIUCD and tubectomy.
Spacing counselling: advise a gap of at least 24 months after a live birth.

Laws related to family welfare

Medical Termination of Pregnancy (MTP) Act, 1971: legalises abortion by a registered medical practitioner at an approved facility. It was amended in 2021 with longer limits for certain categories such as rape survivors and minors.
Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act, 1994: bans sex determination of the foetus.
Prohibition of Child Marriage Act, 2006: minimum marriage age is 18 for girls and 21 for boys.
Programmes: Mission Parivar Vikas focuses on districts with high fertility; the Scheme for sterilisation gives compensation for loss of wages; Family Planning Indemnity Scheme gives insurance in case of failure or complication.

Counselling in family planning (GATHER)

G: Greet the client. A: Ask about needs. T: Tell about methods. H: Help the client choose. E: Explain how to use. R: Return visit planned.

Exam traps

Cu T 380A lasts 10 years, Cu T 375 lasts 5 years.
Emergency pill is within 72 hours (best), not 7 days.
Injectable DMPA is every 3 months, not every month.
Centchroman is non-steroidal; it is not a combination pill.
Condoms protect against STI. Pills do not.
Pearl index uses 1,200 for months (100 × 12).
LAM works only for 6 months of exclusive breastfeeding.
Vasectomy is not immediate; semen needs about 3 months to be sperm free.
PCPNDT bans sex determination, MTP legalises abortion.
Combined pills are avoided in smokers over 35, but progestin-only pills can be used.

One-liners

1. Replacement level fertility is about 2.1.
2. Cu T 380A is effective for 10 years.
3. DMPA dose is 150 mg every 3 months.
4. Emergency pill: levonorgestrel 1.5 mg within 72 hours.
5. PPIUCD: within 48 hours of delivery.
6. Pearl index = failures × 1,200 ÷ months of exposure.
7. Vasectomy technique in use: no-scalpel vasectomy.
8. MTP Act came in 1971.
9. PCPNDT Act came in 1994.
10. LAM: baby under 6 months and exclusive breastfeeding.
11. Marriage age in law: 18 for girls and 21 for boys.
12. Ovulation is about 14 days before the next period.

Practice questions

Copper T 380A is effective for:
1. 5 years
2. 1 year
3. 3 years
4. 10 years
Answer
D. 10 years
Cu T 380A lasts 10 years; Cu T 375 lasts 5 years.
Copper T 375 is effective for:
1. 10 years
2. 5 years
3. 2 years
4. 15 years
Answer
B. 5 years
Cu T 375 is a 5-year device.
The injectable contraceptive DMPA (Antara) is given every:
1. 3 months
2. 1 year
3. 1 month
4. 6 months
Answer
A. 3 months
150 mg DMPA IM every 3 months.
The dose of medroxyprogesterone acetate in the injectable contraceptive is:
1. 300 mg
2. 15 mg
3. 50 mg
4. 150 mg
Answer
D. 150 mg
DMPA 150 mg IM.
The emergency contraceptive pill (levonorgestrel 1.5 mg) is best taken within:
1. 72 hours of unprotected intercourse
2. 7 days
3. 2 weeks
4. 12 hours only
Answer
A. 72 hours of unprotected intercourse
Early use is most effective; best within 72 hours.
Post-partum IUCD is inserted within:
1. 6 weeks
2. 3 months
3. 7 days
4. 48 hours of delivery
Answer
D. 48 hours of delivery
PPIUCD is placed within 48 hours.
Replacement level fertility is a total fertility rate of about:
1. 4.0
2. 3.5
3. 2.1
4. 1.0
Answer
C. 2.1
A TFR of 2.1 keeps the population steady in the long run.
The Pearl index measures:
1. infant mortality
2. failure rate of a contraceptive method
3. fertility rate
4. birth rate
Answer
B. failure rate of a contraceptive method
It gives pregnancies per 100 woman-years.
Ovulation usually occurs about:
1. on day 28 regardless of the cycle
2. 14 days before the next menstrual period
3. on day 1 of the period
4. 14 days after the next period
Answer
B. 14 days before the next menstrual period
Luteal phase is nearly constant at 14 days.
The non-steroidal weekly contraceptive pill (Chhaya) contains:
1. centchroman
2. norethisterone
3. levonorgestrel
4. medroxyprogesterone
Answer
A. centchroman
Centchroman is a non-hormonal (non-steroidal) pill.
The Medical Termination of Pregnancy Act was passed in:
1. 1952
2. 2006
3. 1971
4. 1994
Answer
C. 1971
MTP Act, 1971 (amended in 2021).
The PCPNDT Act, 1994 prohibits:
1. sterilisation of men
2. abortion in all cases
3. use of condoms
4. sex determination of the foetus
Answer
D. sex determination of the foetus
It bans prenatal sex determination and selection.
The legal minimum age of marriage for girls under the Prohibition of Child Marriage Act, 2006 is:
1. 15 years
2. 16 years
3. 21 years
4. 18 years
Answer
D. 18 years
18 for girls and 21 for boys.
Which method also protects against sexually transmitted infections?
1. Cu T 380A
2. Male condom
3. Injectable DMPA
4. Combined pill
Answer
B. Male condom
Only barrier methods like condoms protect against STIs.
The type of vasectomy commonly used is:
1. tubal ligation
2. hysterectomy
3. no-scalpel vasectomy
4. laparoscopic salpingectomy only
Answer
C. no-scalpel vasectomy
NSV uses a small puncture instead of a cut.
After a vasectomy, a couple should use a condom until:
1. semen is tested and found free of sperm, about 3 months
2. 1 week
3. the next day
4. the wife's next period
Answer
A. semen is tested and found free of sperm, about 3 months
Sperm remain in the tubes for around 3 months or 20 ejaculations.
The Lactational Amenorrhoea Method is effective only if:
1. the baby is above 1 year
2. the baby is under 6 months, exclusively breastfed, and periods have not returned
3. the mother takes iron tablets
4. the baby takes top feed
Answer
B. the baby is under 6 months, exclusively breastfed, and periods have not returned
All three conditions must be met.
Mala-N pill pack contains:
1. 28 hormone pills
2. 21 hormone pills and 7 iron tablets
3. 7 hormone pills and 21 iron tablets
4. 14 hormone pills only
Answer
B. 21 hormone pills and 7 iron tablets
The 28-day pack ends with 7 iron tablets.
In the Pearl index formula, the multiplier 1,200 comes from:
1. 100 × 10
2. 365 × 3
3. 1,000 × 1.2
4. 100 woman-years × 12 months
Answer
D. 100 woman-years × 12 months
1,200 converts to pregnancies per 100 woman-years.
A method was used for 2,400 woman-months and 6 pregnancies occurred. The Pearl index is:
1. 6
2. 0.5
3. 12
4. 3
Answer
D. 3
6 × 1,200 ÷ 2,400 = 3 per 100 woman-years.
A method was used for 6,000 woman-months and 5 pregnancies occurred. The Pearl index is:
1. 1
2. 5
3. 0.5
4. 2
Answer
A. 1
5 × 1,200 ÷ 6,000 = 1.
A woman 6 weeks after delivery is exclusively breastfeeding and wants a method without oestrogen. A suitable choice is:
1. combined oral pill
2. progestin-only method or Cu T
3. none of the methods are safe
4. oestrogen injection
Answer
B. progestin-only method or Cu T
Oestrogen can reduce milk; progestin-only methods and Cu T are suitable.
A woman missed one combined pill. The correct advice is to:
1. stop the pack
2. double the dose for three days
3. take it as soon as she remembers and continue the next at the usual time
4. wait for her next period
Answer
C. take it as soon as she remembers and continue the next at the usual time
One missed pill: take it now and continue.
A woman had unprotected sex 3 days ago and is not on a method. The best advice is:
1. use only a calendar method now
2. wait for the next period
3. start a combined pill pack tomorrow
4. emergency contraception as early as possible
Answer
D. emergency contraception as early as possible
Emergency contraception works if taken within 72 hours (Cu T within 5 days).
A woman using Cu T notices a missing string. She should:
1. ignore it
2. remove it herself
3. visit the health centre; use a condom meanwhile
4. stop all contraception without telling anyone
Answer
C. visit the health centre; use a condom meanwhile
A missing string needs checking for expulsion or displacement.
A 38-year-old smoker wants contraception. Which method is not suitable?
1. condom
2. combined oral pill
3. Cu T
4. progestin-only pill
Answer
B. combined oral pill
Combined pills are avoided in smokers over 35.
A young couple wants to delay the first child by two years. A reasonable spacing method is:
1. condoms or oral pills
2. vasectomy
3. tubectomy
4. post-partum sterilisation
Answer
A. condoms or oral pills
Permanent methods are not for delaying.
Match: Which pairing is correct?
1. Centchroman: yearly
2. Emergency pill: daily
3. Injectable: every 3 months
4. Cu T 380A: 3 months
Answer
C. Injectable: every 3 months
Correct pairing is the 3-month injectable.
Match: Which pairing of law and subject is correct?
1. MTP Act: legal termination of pregnancy
2. Child Marriage Act: sterilisation
3. Registration Act: pills
4. PCPNDT Act: contraception supply
Answer
A. MTP Act: legal termination of pregnancy
MTP Act deals with abortion; PCPNDT with prenatal sex determination.
Which of the following statements is/are correct? 1. Condoms protect against both pregnancy and many STIs. 2. Combined pills protect against HIV.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
A. 1 only
Pills do not protect against STIs.
Which of the following statements is/are correct? 1. Cu T 380A acts for 10 years. 2. Cu T acts by releasing hormones.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
A. 1 only
Copper ions, not hormones, are the active agent.
Which of the following statements is/are correct? 1. Vasectomy reduces sexual desire. 2. Vasectomy is simpler than tubectomy.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
B. 2 only
Vasectomy does not reduce sexual desire.
Which of the following statements is/are correct? 1. The replacement TFR is about 2.1. 2. The eligible couple is one in which the wife is aged 15 to 49 years.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
C. Both 1 and 2
Both are correct.
Which of the following statements is/are correct? 1. The male sterilisation method is called tubectomy. 2. The female sterilisation method is called vasectomy.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
D. Neither 1 nor 2
Vasectomy is male and tubectomy is female.
Which of the following statements is/are correct? 1. DMPA injection can be given in the postpartum period. 2. DMPA is given every month.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
A. 1 only
It is given every 3 months.
Which of the following statements is/are correct? 1. The emergency pill is meant for regular use. 2. Cu T can be used as emergency contraception within 5 days.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
B. 2 only
Emergency methods are not for regular use.
Which of the following statements is/are correct? 1. The calendar method is reliable even with irregular cycles. 2. Basal body temperature and cervical mucus are natural methods.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
B. 2 only
Calendar method is unreliable with irregular cycles.
Which of the following statements is/are correct? 1. Mission Parivar Vikas focuses on districts with high fertility. 2. The National Population Policy was announced in 2000.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
C. Both 1 and 2
Both are correct.
Which of the following statements is/are correct? 1. Sterilisation should be advised as a permanent method with voluntary written consent. 2. Sterilisation can be forced when a family has many children.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
A. 1 only
Consent must be voluntary.
Which of the following statements is/are correct? 1. PPIUCD is inserted within 48 hours of delivery. 2. A post-abortion IUCD is inserted after a safe first-trimester abortion.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
C. Both 1 and 2
Both are correct.
The meaning of 'couple protection rate' is the:
1. number of births per 1,000 people
2. number of sterilised men
3. percentage of women who are pregnant
4. percentage of eligible couples effectively protected by contraception
Answer
D. percentage of eligible couples effectively protected by contraception
CPR measures contraceptive coverage.
The 'T' in the counselling steps GATHER stands for:
1. Teach mathematics
2. Treat the infection
3. Test the client
4. Tell about methods
Answer
D. Tell about methods
G greet, A ask, T tell, H help, E explain, R return.
The Cu T warning sign 'P' in PAINS stands for:
1. pills not taken
2. pain in the legs
3. period late or missed
4. pulse rate high
Answer
C. period late or missed
PAINS: Period late, Abdominal pain, Infection or discharge, Not feeling well, String missing.
In the lactational amenorrhoea method, the baby must be:
1. given top milk at night
2. fed breast milk only, day and night
3. above 8 months
4. fed solids twice daily
Answer
B. fed breast milk only, day and night
Exclusive breastfeeding is a condition for LAM.

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