Reproductive Health

Reproductive health, in the sense the World Health Organization uses, means total wellbeing in all aspects of reproduction — physical, emotional, behavioural and social. Read that list slowly, because every word in it is doing work. Physical wellbeing means normally functioning reproductive organs and freedom from infection. Emotional wellbeing means being free of the fear, shame and anxiety that build up around this subject when nobody is willing to talk about it honestly. Behavioural wellbeing means that people behave responsibly, without coercion, and know what safe and hygienic practice means. Social wellbeing means that families and communities allow people to make reproductive decisions without abuse or pressure. A society is reproductively healthy only when all four are true together, so the absence of disease alone is nowhere near enough.

India was among the first countries in the world to treat this as a national goal rather than a private family matter. National programmes were launched in 1951 under the name family planning, and they were assessed and widened decade after decade. The far broader set of programmes running today is known as Reproductive and Child Health Care, usually shortened to RCH. Two objectives sit at the centre of it. The first is creating awareness among people about all reproduction-related matters. The second is providing facilities and support so that a reproductively healthy society is something people can actually reach, and not just a stated aim.

Awareness comes first because most of the harm in this area is done by ignorance. This chapter argues for sex education in schools as the practical way to deliver it: correct information about reproductive organs, about adolescence and the changes that come with it, about safe and hygienic practices, about sexually transmitted infections and AIDS. Where schools and families stay silent, young people take their information from rumour and from friends who know no more than they do, and myths and misconceptions fill the gap. Education and counselling also have to cover the problems created by uncontrolled population growth, and the social evils of sex abuse and sex-related crimes, so that young people can recognise them and resist them.

The second half of the programme is medical and legal support: care of pregnant mothers and of the developing foetus, post-natal care of mother and child, birth control and contraceptive services, treatment for infertility, and a firm statutory stand against the misuse of amniocentesis. In amniocentesis, some of the amniotic fluid around the developing foetus is drawn off so that the foetal cells and the dissolved substances in it can be analysed. It is used to test for certain genetic disorders such as Down syndrome, haemophilia and sickle-cell anaemia, and to judge the survivability of the foetus. The same analysis of foetal cells also reveals the sex of the foetus, and so the test has been badly misused for female foeticide. Its use for sex determination is therefore banned by law.

How is such a programme judged? By outcomes that can be counted: massive child immunisation coverage, better antenatal and post-natal care, a larger share of deliveries taking place with medical assistance, falling maternal and infant mortality rates, better detection and cure of sexually transmitted infections, and a rising number of couples choosing small families. Those indicators together are the report card of a reproductive health programme.

Population growth is treated in this chapter as a reproductive health problem, because a population growing faster than the food, housing, schooling and medical care available to it is a population in which reproductive health cannot be delivered. The scale is worth fixing in your mind. India's population was roughly 350 million at the time of independence in 1947. It reached close to the billion mark by the year 2000 and crossed 1.2 billion by the 2011 census. That is more than a tripling within a single lifetime.

Now the point that is most often got wrong. The main reason for this growth is not that Indian families suddenly began having more children. It is a rapid decline in the death rate, in the maternal mortality rate and in the infant mortality rate, together with an increase in the number of people in the reproducible age group. Better medicine, better sanitation, immunisation and food security meant that far more of the children born survived to adulthood, and far fewer mothers died in childbirth. Those are good things in themselves. But when deaths fall sharply while births fall only slowly, the gap between the two widens, and that gap is population growth. A larger cohort surviving into the reproductive age group then feeds the next round of growth even if each couple has fewer children than their parents did.

The arithmetic of a growth rate is unforgiving. The 2011 census put the annual growth rate at slightly under 2 per cent, which is about 20 people added per 1000 people per year. The national programmes had brought the rate down, but only marginally. Growth of this kind is compound rather than additive, because each year's addition is made to an already larger base, so a figure that looks small on paper still makes the population climb rapidly. That is why it is called alarming when it applies to more than a billion people: it can lead to an absolute scarcity of even the basic requirements — food, shelter and clothing — in spite of the real progress made in producing them.

The measures this chapter lists for population control fall into three groups. The first is motivation and education. Couples are encouraged through mass campaigns to keep families small, and this depends on people knowing that contraceptive choices exist and that a small family is socially acceptable. The education is aimed particularly at fertile couples and at people of marriageable age, since they are the ones who actually take the decision. The second measure is statutory: the minimum legal age of marriage is 18 years for women and 21 years for men. Raising the age of marriage compresses the number of childbearing years and delays the start of the next generation, which slows growth even when the number of children per couple does not change. The third is incentive: couples with small families are offered incentives of various kinds.

Finally, contraception itself. The chapter presents contraceptive use as the practical tool that lets a couple act on the decision to have a small family, and points out that the awareness campaigns are useless unless the methods are actually available, affordable and free of stigma. Population control, in other words, is not achieved by any one measure. It needs education, law, incentive and service delivery working at the same time.

Before the categories, the chapter sets a standard. An ideal contraceptive should be user friendly, easily available, effective and reversible, with no side effects or the least possible side effects. It should also not interfere in any way with the sexual drive, desire or the sexual act itself. No single method meets every one of those conditions, which is exactly why several categories exist. When you compare methods in an exam answer, compare them against this list.

The methods are classified as natural or traditional, barrier, intra-uterine devices, oral contraceptives, injectables, implants and surgical methods. The first three are covered here.

Natural or traditional methods work on one principle: avoid the chance of the ovum and the sperms meeting. Periodic abstinence means avoiding intercourse during the part of the menstrual cycle around ovulation, when fertilisation is possible. Coitus interruptus, or withdrawal, means withdrawal before semen is released into the female tract. Lactational amenorrhoea rests on a physiological fact: during a period of intense breastfeeding after childbirth, ovulation and therefore the menstrual cycle do not resume, so conception is unlikely. This effect is reliable only up to a maximum of about six months following parturition. The advantage of the whole group is that there are no side effects at all, since nothing is introduced into the body. The disadvantage is that the chances of failure are high, because all three depend on timing and self-control rather than on any physical or chemical block.

Barrier methods prevent the ovum and the sperms from physically meeting by placing a barrier between them. Condoms are thin sheaths of rubber or latex, available for both men and women, and Nirodh is a popular Indian brand of condom for the male. Diaphragms, cervical caps and vaults are rubber devices placed in the female reproductive tract to cover the cervix, and unlike condoms they are reusable. Spermicidal creams, jellies and foams are often used along with these barriers to raise their effectiveness. Condoms carry one advantage no other reversible method has: because they block contact as well as gamete transfer, they also protect the user against sexually transmitted infections and AIDS. They are also easy to use in privacy and disposable.

Intra-uterine devices, or IUDs, are inserted into the uterus through the vagina by a doctor or a trained nurse. They come in three types. Non-medicated IUDs, such as the Lippes loop, are plain plastic devices. Copper-releasing IUDs include the CuT, Cu7 and Multiload 375. Hormone-releasing IUDs include Progestasert and LNG-20. The mechanisms differ by type and are worth keeping straight. All IUDs increase the phagocytosis of sperms within the uterus. The copper ions released by copper IUDs additionally suppress sperm motility and the fertilising capacity of sperms. Hormone-releasing IUDs additionally make the uterus unsuitable for implantation and make the cervix hostile to sperms. IUDs are described as an excellent choice for women who want to delay pregnancy or space out their children, and they are among the most widely accepted methods of contraception in India.

Oral contraceptives are taken by women as pills and contain either progestogens alone or progestogens combined with oestrogen. They are used as a course tied to the menstrual cycle rather than as a single dose. Their mechanism has three parts and all three matter: they inhibit ovulation, they inhibit implantation, and they alter the quality of the cervical mucus so that entry of sperms is prevented or retarded. Notice that a single method here is acting at three different points — the ovary, the uterine lining and the cervix. Saheli is a distinctive Indian oral contraceptive for women. Unlike the others it contains a non-steroidal preparation, it is a once-a-week pill, and it is described as having very few side effects along with high contraceptive value.

Injectables and implants use the same chemistry in a different delivery form. Progestogens alone, or progestogens with oestrogen, can be given to women as injections or placed as implants under the skin. Their mode of action is essentially the same as that of the pills, but the effective period is much longer, which is why they are grouped separately. The trade-off across this whole hormonal family is that convenience rises as the method lasts longer, but the woman also has less immediate control over stopping it.

The chapter also records that emergency contraception exists as a category: progestogens, or progestogen and oestrogen combinations, or an IUD, used within a short window of about three days after intercourse, are effective at avoiding an unwanted pregnancy following rape or unprotected intercourse. It is an emergency category by definition and not a routine method.

Surgical methods, also called sterilisation, are advised for a male or a female partner as a terminal method to prevent any more pregnancies. The principle is different from every method above: sterilisation does not act on hormones or on the meeting of gametes inside the tract, it blocks the transport of the gametes altogether. In the male the procedure is vasectomy, in which a small part of the vas deferens is removed or tied through a small incision on the scrotum. In the female it is tubectomy, in which a small part of the fallopian tube is removed or tied through a small incision in the abdomen or through the vagina. Both are highly effective, but their reversibility is very poor, which is why they are treated as terminal rather than as a way to space children. It is worth adding that sterilisation does not remove the gonads: the testes and ovaries stay in place and go on producing hormones, so secondary sexual characters and sexual drive are unaffected. Removing the gonads would end hormone production as well, which is why it is not and cannot be a contraceptive option.

Finally, a caution the chapter itself makes. Contraceptives are not something the body needs. They are used to avoid pregnancy, and their use can have ill effects — nausea, abdominal pain, breakthrough bleeding, irregular menstrual bleeding, and even breast cancer has been listed among them. These are described as not very significant, but the chapter is clear that they should not be ignored altogether. It is equally clear that the selection of a suitable method, and its use, should always be undertaken in consultation with qualified medical professionals; nothing in a textbook chapter substitutes for that.

Medical termination of pregnancy, usually shortened to MTP, is the intentional or voluntary termination of a pregnancy before full term. It is a subject on which opinion is divided worldwide, and that division is exactly why the law matters. The Government of India legalised MTP in 1971, and the Act was written with strict conditions attached precisely to prevent its misuse. The law has since been amended to widen the grounds and to extend the permitted upper limit of gestation for specified categories of women, with decisions beyond the ordinary limit requiring approval from a medical board.

Why is such a provision needed at all? The chapter gives clear public-health reasons. A large proportion of pregnancies worldwide are unwanted, and some pregnancies, if continued, would be harmful or even fatal to the mother, to the foetus, or to both. MTP is also relevant where a pregnancy has resulted from rape, or from the failure of a contraceptive that was in use. Against that stands the risk. MTP is considered relatively safe during the first trimester, that is, up to about twelve weeks of pregnancy. Second trimester terminations carry considerably more risk. That distinction between the first and second trimester is the fact to carry away from this section.

Now the misuse. Legalising the procedure has an unintended consequence in a society that values sons over daughters. Foetal sex determination, most often by amniocentesis, followed by termination of female foetuses, has been practised on a scale large enough to distort the sex ratio in parts of the country. That is female foeticide, and it is criminal. India's legal answer has two parts working together: the conditions written into the MTP law, and a separate statutory ban on the use of prenatal diagnostic techniques for determining the sex of a foetus. Amniocentesis and similar prenatal tests remain fully legal for their intended purpose of detecting genetic disorders in the foetus; what is banned is disclosing the sex of the foetus and terminating a pregnancy on that ground.

The other misuse is unsafe abortion. Even though MTP is legal, a very large number of terminations are still performed illegally, by people who are not qualified and in places that are not equipped. These are unsafe and can be fatal for the woman. This is where the education and counselling side of the reproductive health programme joins up with the legal side. If people do not know that MTP is legal, do not know that it is safest early, and are afraid of the social consequences of asking, they end up in the hands of unqualified practitioners. Awareness campaigns therefore try to make three things widely known: that the service is legal and available through registered medical practitioners, that timing matters, and that no clinic anywhere may lawfully tell a family the sex of a foetus.

Ethically, the chapter presents the debate honestly rather than resolving it. The argument in favour is that a woman's health, her survival and her right to decide have to count, especially where the pregnancy is the result of rape or contraceptive failure. The argument against rests on the moral status of the developing foetus. What the law in India does is not choose one side absolutely, but permit termination within defined conditions, by qualified practitioners, within defined limits of gestation, and never on the ground of the foetus being female.

Infections or diseases transmitted through sexual intercourse are collectively called sexually transmitted infections, abbreviated STI. Two older names for the same group also appear: venereal diseases, or VD, and reproductive tract infections, or RTI. The common ones named in this chapter are gonorrhoea, syphilis, genital herpes, chlamydiasis, genital warts, trichomoniasis, hepatitis-B and HIV, which leads to AIDS. Of these, HIV infection is the most dangerous. Learn the group as a list, because the names are the starting point for everything else in this section.

Sexual contact is the main route, but not the only one. Some of these infections, particularly hepatitis-B and HIV, can also be transmitted by sharing injection needles or surgical instruments with an infected person, through transfusion of infected blood, and from an infected mother to the foetus. This matters for public health policy: it is why blood banks screen donations and why the safe handling of needles and instruments is part of infection control everywhere, not only in reproductive health services.

Now the point the chapter really wants to land. Except for hepatitis-B, genital herpes and HIV infection, the remaining STIs in the list are completely curable if they are detected early and treated properly. That is a striking statement. Most of the suffering caused by this group of infections is therefore not inevitable — it is the result of late detection. Why does detection come late? Because the early symptoms are minor and easy to dismiss: itching, fluid discharge, slight pain or swelling in the genital region. Many infected women are asymptomatic altogether and so remain undetected for long periods. And on top of the biology sits the social problem, which is that shame and social stigma keep people from consulting a doctor even when they do notice something.

The price of that delay is heavy. Untreated STIs lead on to pelvic inflammatory disease, spontaneous abortion, still birth, ectopic pregnancy, infertility, and in some cases cancer of the reproductive tract. Read that list next to the previous paragraph and the public-health logic becomes obvious: an infection that was completely curable at the mild-symptom stage becomes a cause of permanent infertility if nobody speaks about it in time. That is why the chapter treats STIs as a major threat to a healthy society, and notes that although everyone is vulnerable, the reported incidence is very high among people in the 15 to 24 year age group, which is precisely the group school-level education can reach.

What does prevention look like at the level of policy rather than personal advice? The chapter lists three principles. First, avoidance of sexual contact with unknown partners or multiple partners. Second, the use of condoms, which as barrier devices block the transfer of infection as well as of gametes. Third, and most important for outcomes, early consultation with a qualified doctor when an infection is suspected, followed by complete treatment rather than treatment abandoned once symptoms fade. Everything a national programme does here — awareness campaigns, counselling, free and non-judgemental testing services, treating a partner as well as the patient — is aimed at shortening the gap between infection and detection.

A couple who are unable to conceive or produce children in spite of unprotected sexual cohabitation, even after about two years, are said to be infertile. The causes may be physical, congenital, disease-related, drug-related, immunological or even psychological. The chapter makes a social point immediately after the biological one, and it is a point worth taking seriously: in India the woman is very often held responsible when a couple cannot have a child, when in a large number of cases the cause lies with the male partner. Blaming without diagnosis is both unjust and useless, because the correct treatment depends entirely on which partner has the problem and what that problem is. Specialised health care units, called infertility clinics, exist to diagnose the cause and to offer correction where correction is possible. Only where the problem cannot be corrected are the assisted technologies considered.

Assisted reproductive technologies, abbreviated ART, are the group of procedures that help a couple have a child when normal conception is not happening. Learn them as procedures, defined by what is transferred and where it is placed.

In vitro fertilisation, or IVF, means fertilisation carried out outside the body in conditions made as close as possible to those inside the body. Ova from the woman or from a donor and sperms from the man or from a donor are brought together in the laboratory to form a zygote. This is what the newspapers call the test tube baby programme, though nothing is grown to term in a tube. IVF is followed by embryo transfer, abbreviated ET, and here the destination depends on the stage reached, which is the detail most often confused. A zygote or an early embryo of up to 8 blastomeres is transferred into the fallopian tube, and this is called zygote intra fallopian transfer, or ZIFT. An embryo with more than 8 blastomeres is transferred into the uterus, and this is called intra uterine transfer, or IUT. The logic is that an early embryo would normally still be travelling down the fallopian tube at that stage, while a later embryo would normally already have reached the uterus, so each is placed where nature would have had it.

Gamete intra fallopian transfer, or GIFT, is a different idea altogether. Here an ovum collected from a donor is transferred into the fallopian tube of another woman who cannot produce an ovum herself but whose tract can support fertilisation and further development. Note the contrast with ZIFT: GIFT transfers a gamete, ZIFT transfers a zygote or early embryo. The names tell you this if you read them carefully.

Intra cytoplasmic sperm injection, or ICSI, is a specialised laboratory procedure in which a single sperm is injected directly into the cytoplasm of an ovum to form the embryo. It is used where sperms cannot fertilise the ovum on their own.

Artificial insemination, or AI, handles a different class of problem. Semen collected either from the husband or from a healthy donor is introduced artificially into the vagina, or into the uterus, of the woman. Introduction into the uterus is called intra uterine insemination, or IUI. AI is used where the male partner is unable to inseminate the female, or where the sperm count in the ejaculate is very low.

The chapter closes this topic on a realistic note. These procedures demand very high precision, expensive equipment and trained specialists, so only a few centres in the country can offer them. Emotional, religious and social factors are further deterrents to their adoption. Given all this, legal adoption of an orphaned or destitute child is presented as one of the best ways for a couple wanting parenthood, and as an answer that also serves a child who needs a family.