Reproductive Health — Notes

Reproductive health (WHO): total well-being in all aspects of reproduction — physical, emotional, behavioural and social. A reproductively healthy society has people with physically and functionally normal reproductive organs and normal emotional and behavioural interactions in all sex-related aspects.

India: among the first countries to start national family planning (1951); now Reproductive and Child Health Care (RCH) programmes. Actions:

• awareness through audio-visual and print media; sex education in schools to give correct information and dispel myths;
• training and counselling on family planning, care of pregnant mothers, post-natal care, breastfeeding, equal opportunities for boys and girls;
• a statutory ban on amniocentesis for sex determination, to prevent female foeticide; mass child immunisation;
• research on new, safer contraceptives and better medical facilities.

Signs of improvement: better awareness, more medically assisted deliveries and better post-natal care (so lower maternal and infant mortality rates), more couples with small families, and better detection and cure of STIs.

STIs (venereal diseases, reproductive tract infections): gonorrhoea, syphilis, genital herpes, chlamydiasis, genital warts, trichomoniasis, hepatitis-B and HIV infection (leading to AIDS).

• Hepatitis-B and HIV also spread by sharing injection needles or surgical instruments with infected persons, by transfusion of infected blood, and from an infected mother to the foetus. They do not spread by casual contact.
• Curability: except hepatitis-B, genital herpes and HIV, the others are completely curable if detected early and treated properly.
• Early symptoms are minor (itching, fluid discharge, slight pain, swellings in the genital region) and may be absent, especially in women; social stigma delays treatment.
• Complications of untreated STIs: pelvic inflammatory disease, abortions, stillbirths, ectopic pregnancies, infertility, cancer of the reproductive tract.
• Incidence is high in the 15–24 age group.

Prevention: avoid sex with unknown partners or multiple partners; always use condoms during intercourse; in case of doubt, consult a qualified doctor early for diagnosis and complete treatment.

India's population: about 350 million (1947), 1 billion (2000), about 1.2 billion (2011 census). Causes: rapid decline in death rate, maternal mortality rate (MMR) and infant mortality rate (IMR), and more people of reproductive age. At a steady 2 percent a year a population doubles in about 35 years.

Measures: motivate smaller families; legal minimum marriageable age of 18 years for females and 21 for males; incentives for small families; contraceptives.

Ideal contraceptive: user-friendly, easily available, effective, reversible, with no or least side effects, not interfering with sexual drive or the sexual act.

Natural methods:

• Periodic abstinence: avoid coitus from day 10 to day 17 of the cycle, when ovulation is expected.
• Withdrawal (coitus interruptus).
• Lactational amenorrhea: no ovulation or menstruation during intense full breastfeeding; effective only up to about six months after parturition.

Barrier methods: condoms (male and female; latex; disposable; also protect against STIs and AIDS), diaphragms, cervical caps and vaults (rubber, over the cervix, reusable), with spermicidal creams, jellies and foams.

Intrauterine devices (IUDs), inserted by doctors or expert nurses through the vagina into the uterus:

IUDs suit females who want to delay pregnancy or space children; they are among the most widely accepted methods in India.

Oral pills: progestogens or progestogen–estrogen combinations; daily for 21 days, starting preferably within the first five days of the cycle, then a 7-day gap; they inhibit ovulation and implantation and change the quality of cervical mucus to retard sperms. Saheli: once a week, non-steroidal, developed at CDRI, Lucknow.

Injections or implants under the skin: same hormones; effective for much longer. Emergency contraceptives: progestogens or progestogen–estrogen combinations, or IUDs, within 72 hours of coitus (useful after assault or a casual unprotected act).

Sterilisation (terminal method): vasectomy (a small part of the vas deferens removed or tied through a small incision on the scrotum); tubectomy (a small part of the fallopian tube removed or tied through a small incision in the abdomen or through the vagina). Highly effective, but reversibility is very poor.

Side effects (nausea, abdominal pain, breakthrough bleeding, irregular bleeding, rarely breast cancer) are not very common but should not be ignored.

MTP is intentional or voluntary termination of pregnancy before full term. India legalised MTP in 1971 with strict conditions, to check unsafe, illegal abortions and the resulting deaths and illness of mothers.

• Permitted on specific grounds (for example, risk to the mother's life or health, serious foetal abnormality, or contraceptive failure), only by registered medical practitioners and within the time limits set by law.
• Safest during the first trimester (up to 12 weeks); second-trimester terminations are much riskier.
• MTP is not a contraceptive method.
• Misuse: illegal female foeticide after illegal sex determination; unsafe MTPs by unqualified quacks can be fatal. Both are illegal.

Amniocentesis: a sample of amniotic fluid (with foetal cells) is taken to test for genetic disorders and chromosomal abnormalities. Its misuse to determine the sex of the foetus led to female foeticide, so there is a statutory ban on prenatal sex determination.

Infertility: inability to produce children despite unprotected sexual cohabitation; causes may be physical, congenital, diseases, drugs, immunological or psychological, in either partner.

Assisted reproductive technologies (ART):

Embryos formed by fertilisation inside the female can also be transferred to assist women who cannot conceive. ART needs specialised professionals and costly equipment and is available in few centres; emotional, religious and social factors also play a part. Legal adoption of orphaned and destitute children is one of the best options for couples wanting parenthood.