Chapter Notes

Reproductive Health - An Introduction

Reproductive health is not just about having healthy reproductive organs that function normally. According to the World Health Organisation (WHO), it is a state of total well-being in all aspects of reproduction, which includes physical, emotional, behavioural, and social health. A society can be considered reproductively healthy when its people have physically and functionally normal reproductive organs and can have normal emotional and behavioural interactions in all sex-related matters. Understanding and maintaining reproductive health is crucial for a healthy society.

Reproductive Health - Problems and Strategies

India was one of the first countries in the world to launch national-level action plans to achieve total reproductive health as a social goal.

• Family Planning: These programmes were initiated in 1951 and have been periodically assessed and improved over the decades.
• Reproductive and Child Health Care (RCH) programmes: These are the current, improved programmes that cover a wider range of reproduction-related areas. The main goals are to create awareness and provide facilities and support to build a reproductively healthy society.

Strategies for a Reproductively Healthy Society

Several steps have been taken by governmental and non-governmental agencies to achieve these goals:

1. Creating Awareness: Using audio-visual and print media to spread information about reproduction-related aspects. Parents, relatives, teachers, and friends also play a key role in sharing this information.
2. Sex Education in Schools: Encouraging sex education helps provide correct information to young people, discouraging them from believing in myths and misconceptions about sex. This includes information about:
   • Reproductive organs
   • Adolescence and related changes
   • Safe and hygienic sexual practices
   • Sexually transmitted diseases (STIs), including AIDS
3. Educating Key Groups: Providing information to fertile couples and those of marriageable age about:
   • Available birth control options
   • Care for pregnant mothers and post-natal care for mother and child
   • Importance of breastfeeding
   • Equal opportunities for male and female children
4. Addressing Social Issues: Creating awareness about problems caused by uncontrolled population growth and social evils like sex abuse and sex-related crimes.

Implementation and Support

To successfully implement these plans, several things are essential:

• Strong infrastructural facilities
• Professional expertise
• Material support

These are needed to provide medical assistance for reproduction-related problems like pregnancy, delivery, STIs, abortions, contraception, menstrual problems, and infertility.

Research and Development

Governmental and non-governmental agencies support research to find new and improved methods related to reproductive health. A notable success is 'Saheli', a new oral contraceptive for females, developed by scientists at the Central Drug Research Institute (CDRI) in Lucknow, India.

Indicators of improved reproductive health in a society include:

• Decreased maternal and infant mortality rates
• Increased number of medically assisted deliveries
• Better detection and cure of STIs
• Increased number of couples with small families

Population Stabilisation and Birth Control

While all-round development in the last century improved the quality of life, it also led to a population explosion. Better health facilities and living conditions caused a rapid increase in population.

• World Population: Grew from around 2 billion in 1900 to about 6 billion by 2000, and 7.2 billion in 2011.
• India's Population: Grew from approximately 350 million at independence to over 1.2 billion by May 2011.

Reasons for Population Growth:

• A rapid decline in the death rate.
• A decline in maternal mortality rate (MMR) and infant mortality rate (IMR).
• An increase in the number of people in the reproducible age group.

This alarming growth can lead to a scarcity of basic needs like food, shelter, and clothing. Therefore, the government has taken serious measures to control population growth.

Measures to Control Population Growth

• Motivating smaller families using contraceptive methods. The slogan "Hum Do Hamare Do" (we two, our two) is a well-known example.
• Statutory raising of marriageable age: 18 years for females and 21 years for males.
• Giving incentives to couples with small families.

Contraceptive Methods

An ideal contraceptive should be user-friendly, easily available, effective, and reversible with few or no side effects. It should not interfere with the user's sexual drive or desire. Contraceptive methods are broadly grouped into several categories.

Natural/Traditional Methods

These methods work on the principle of avoiding the meeting of ovum and sperms.

• Periodic Abstinence: Couples avoid coitus from day 10 to 17 of the menstrual cycle, which is the fertile period when ovulation is expected and chances of fertilisation are very high.
• Withdrawal or Coitus Interruptus: The male partner withdraws his penis from the vagina just before ejaculation to avoid insemination.
• Lactational Amenorrhea: This method is based on the fact that ovulation does not occur during the period of intense lactation (breastfeeding) after childbirth. It is effective for a maximum of six months. [!note] Natural methods have almost no side effects as no medicines or devices are used. However, their chances of failure are high.

Barrier Methods

These methods physically prevent sperms from meeting the ovum.

• Condoms: Barriers made of thin rubber/latex sheath used to cover the penis in males or the vagina and cervix in females. They prevent semen from entering the female reproductive tract. 'Nirodh' is a popular brand for males.
  • Additional Benefit: Condoms protect users from contracting STIs and AIDS. They are disposable and can be self-inserted, providing privacy.
• Diaphragms, Cervical Caps, and Vaults: These are rubber barriers inserted into the female reproductive tract to cover the cervix during coitus. They are reusable.
• Spermicidal creams, jellies, and foams: These are often used with barrier methods to increase their effectiveness.

Intra Uterine Devices (IUDs)

These devices are inserted into the uterus by doctors or expert nurses. They are a very popular method in India.

• Non-medicated IUDs: Example: Lippes loop.
• Copper releasing IUDs: Examples: CuT, Cu7, Multiload 375. The copper ions released suppress sperm motility and their ability to fertilise.
• Hormone releasing IUDs: Examples: Progestasert, LNG-20. These make the uterus unsuitable for implantation and the cervix hostile to sperms. IUDs are ideal for females who want to delay pregnancy or space children.

Oral Contraceptives

These are tablets, popularly known as pills, containing small doses of either progestogens or progestogen-estrogen combinations.

• Usage: Taken daily for 21 days, starting within the first five days of the menstrual cycle, followed by a 7-day gap.
• Mechanism of Action: They inhibit ovulation and implantation and alter the quality of cervical mucus to prevent sperm entry.
• Saheli: A new oral contraceptive for females developed in India. It is a non-steroidal, 'once-a-week' pill with very few side effects and high contraceptive value.

Injectables and Implants

Progestogens, alone or in combination with estrogen, can be used by females as injections or implants under the skin. Their mode of action is similar to pills, but they are effective for much longer periods.

Surgical Methods (Sterilisation)

These are terminal methods advised when a couple does not want any more children. Surgical intervention blocks gamete transport, preventing conception.

• Vasectomy: The procedure for males. A small part of the vas deferens is removed or tied up through a small incision on the scrotum.
• Tubectomy: The procedure for females. A small part of the fallopian tube is removed or tied up through a small incision in the abdomen or through the vagina. These methods are highly effective, but their reversibility is very poor.

It is important to remember that contraceptives are not regular requirements for reproductive health but are used to prevent or space pregnancies. While they play a significant role in controlling population growth, possible side effects like nausea, abdominal pain, irregular bleeding, or even breast cancer should not be ignored. The selection and use of any contraceptive method should always be done in consultation with a qualified medical professional.

Medical Termination of Pregnancy (MTP)

Medical Termination of Pregnancy (MTP), or induced abortion, is the intentional or voluntary termination of pregnancy before full term.

• Globally, 45 to 50 million MTPs are performed each year.
• The Government of India legalised MTP in 1971 with strict conditions to prevent its misuse, particularly for illegal female foeticide.

Why is MTP performed?

• To get rid of unwanted pregnancies resulting from unprotected intercourse, contraceptive failure, or rapes.
• In cases where continuing the pregnancy could be harmful or fatal to the mother, the foetus, or both.

Safety and Risks

• MTPs are considered relatively safe during the first trimester (up to 12 weeks of pregnancy).
• Second-trimester abortions are much riskier.
• A dangerous trend is that many MTPs are performed illegally by unqualified individuals, which can be unsafe and even fatal.

Sexually Transmitted Infections (STIs)

Infections or diseases transmitted through sexual intercourse are collectively called Sexually Transmitted Infections (STIs), Venereal Diseases (VD), or Reproductive Tract Infections (RTI).

Common STIs include:

• Gonorrhoea
• Syphilis
• Genital herpes
• Chlamydiasis
• Genital warts
• Trichomoniasis
• Hepatitis-B
• HIV (leading to AIDS)

Transmission and Curability

• Hepatitis-B and HIV can also be transmitted by sharing injection needles, surgical instruments, blood transfusions, or from an infected mother to her foetus.
• Except for hepatitis-B, genital herpes, and HIV infection, other STIs are completely curable if detected early and treated properly.

Symptoms and Complications

• Early symptoms are often minor and include itching, fluid discharge, slight pain, and swelling in the genital region.
• Infected females may often be asymptomatic (show no symptoms) and remain undetected for a long time.
• The social stigma attached to STIs and the absence of significant early symptoms often deter people from seeking timely treatment.
• This can lead to later complications such as:
  • Pelvic Inflammatory Diseases (PID)
  • Abortions and stillbirths
  • Ectopic pregnancies (pregnancy outside the uterus)
  • Infertility or even cancer of the reproductive tract.

Prevention of STIs

STIs are a major threat to a healthy society, especially among the 15-24 year age group where incidences are high. Prevention is possible by following these simple principles:

1. Avoid sex with unknown or multiple partners.
2. Always try to use condoms during coitus.
3. In case of doubt, consult a qualified doctor for early detection and get complete treatment if diagnosed.

Infertility

Infertility is the inability to produce children despite unprotected sexual cohabitation. A large number of couples worldwide, including in India, face this issue.

• Causes: The reasons can be physical, congenital, diseases, drugs, immunological, or even psychological. In India, the female is often blamed, but frequently the problem lies with the male partner.
• Treatment: Specialised health care units like infertility clinics can help diagnose and treat some of these disorders.

Assisted Reproductive Technologies (ART)

For couples where corrective treatments are not possible, special techniques known as Assisted Reproductive Technologies (ART) can help them have children.

• In Vitro Fertilisation (IVF) and Embryo Transfer (ET): Popularly known as the test-tube baby programme.

  • Ova (from wife/donor) and sperms (from husband/donor) are collected and fertilised outside the body in a laboratory under simulated conditions.
  • ZIFT (Zygote Intra Fallopian Transfer): The resulting zygote or early embryo (up to 8 blastomeres) is transferred into the fallopian tube.
  • IUT (Intra Uterine Transfer): An embryo with more than 8 blastomeres is transferred into the uterus.

• GIFT (Gamete Intra Fallopian Transfer): An ovum from a donor is transferred into the fallopian tube of another female who cannot produce eggs but can provide a suitable environment for fertilisation and development.

• ICSI (Intra Cytoplasmic Sperm Injection): A specialised procedure where a single sperm is directly injected into an ovum in the laboratory to form an embryo.

• Artificial Insemination (AI): Used when the male partner cannot inseminate the female or has a very low sperm count.

  • Semen collected from the husband or a healthy donor is artificially introduced into the vagina or the uterus of the female.
  • IUI (Intra-Uterine Insemination): Introduction of semen directly into the uterus.

Challenges and Alternatives

ART techniques require high precision, expensive instrumentation, and specialised professionals, making them accessible to only a few. Emotional, religious, and social factors can also be deterrents.