Reproductive Health – Problems And Strategies

Reproductive health is not merely about having healthy reproductive organs with normal functions. According to WHO, it encompasses a state of total well-being in all aspects of reproduction: physical, emotional, behavioural, and social.

A reproductively healthy society is one where people have physically and functionally normal reproductive organs and healthy emotional and social interactions in all sex-related matters.

Maintaining reproductive health is crucial for the well-being of individuals, families, and the society as a whole. It involves addressing issues related to population growth, sexual health, safe sex practices, managing reproductive problems, and promoting responsible sexual behaviour.

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National Programmes (Rch)

India was a pioneer in initiating national-level action plans and programs to achieve total reproductive health. The 'family planning' programs, started in 1951, have evolved over time.

Currently, comprehensive programs known as 'Reproductive and Child Health Care (RCH) programmes' are in operation. These programs aim to create awareness about reproduction-related issues and provide facilities and support to build a reproductively healthy society.

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Awareness And Education

A key strategy is creating public awareness about various aspects of reproduction. This is done through:

• Media: Audio-visual and print media campaigns by governmental and non-governmental agencies.
• Informal Channels: Parents, relatives, teachers, and friends play an important role in disseminating information.
• Sex Education: Encouraging the introduction of sex education in schools to provide accurate information to young people, helping them avoid myths and misconceptions about sex and reproductive health.

Proper information about reproductive organs, changes during adolescence, safe and hygienic sexual practices, Sexually Transmitted Diseases (STDs), and AIDS is crucial, especially for adolescents, to lead healthy reproductive lives.

Educating fertile couples and those in the marriageable age group about family planning options, care during and after pregnancy, the importance of breastfeeding, and gender equality helps in building healthy families of desired size.

Awareness regarding problems of uncontrolled population growth and social issues like sex-abuse and sex-related crimes is also important for building a socially responsible society.

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Medical Care And Support

Achieving reproductive health requires strong infrastructure, professional expertise, and resources to provide medical assistance and care for reproduction-related problems. These problems include:

• Pregnancy and delivery complications.
• Sexually Transmitted Diseases (STDs).
• Abortion (Medical Termination of Pregnancy - MTP).
• Contraception.
• Menstrual problems.
• Infertility.

Continuous implementation of improved techniques and strategies in healthcare facilities is necessary. Examples of specific programs include:

• Statutory ban on amniocentesis for sex-determination: To legally curb the practice of female foeticide. Amniocentesis involves analysing amniotic fluid to detect genetic disorders but can be misused for sex selection.
• Massive child immunisation programs.

Research in reproductive health is supported by governmental and non-governmental bodies to develop new methods and improve existing ones (e.g., 'Saheli', a non-steroidal oral contraceptive developed in India).

Indicators of improved reproductive health in society include increased medically assisted deliveries, better post-natal care, reduced maternal and infant mortality rates, a higher number of couples with small families, better detection and cure of STDs, and improved medical facilities for reproductive issues.

Population Stabilisation And Birth Control

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Population Explosion

Significant improvements in quality of life, healthcare facilities, and living conditions over the past century have led to an explosive growth in the human population.

• World population increased from about 2 billion in 1900 to 6 billion by 2000 and 7.2 billion in 2011.
• India's population grew from around 350 million at independence to close to a billion by 2000 and crossed 1.2 billion in May 2011.

Probable reasons for this rapid growth include a decline in death rate, maternal mortality rate (MMR), and infant mortality rate (IMR), as well as an increase in the number of people in the reproductive age group.

Despite RCH programs bringing down the growth rate marginally (less than $2\%$ or $20/1000$/year according to the 2011 census), the rate remains high enough to cause rapid population increase, leading to potential scarcity of basic resources like food, shelter, and clothing.

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Measures To Check Population Growth

Governments have implemented measures to control population growth. The most important step is promoting smaller families through the use of various contraceptive methods.

Public campaigns like 'Hum Do Hamare Do' (We Two, Our Two) encourage smaller family sizes. Some young urban couples adopt an 'one child norm'.

Other measures include:

• Increasing the statutory marriageable age for females to 18 years and for males to 21 years.
• Providing incentives to couples who adopt small family norms.

To prevent unwanted pregnancies, a wide range of contraceptive methods are available. An ideal contraceptive should be user-friendly, easily accessible, effective, reversible, and have minimal side effects, without interfering with sexual desire or act.

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Contraceptive Methods: Natural And Traditional

These methods work by avoiding the meeting of ovum and sperm, without using devices or medicines. Their chances of failure are relatively high.

• Periodic Abstinence: Couples avoid or abstain from sexual intercourse during the fertile period of the menstrual cycle (typically days 10-17), when ovulation is likely and the chance of fertilisation is highest.
• Withdrawal (Coitus Interruptus): The male partner withdraws the penis from the vagina just before ejaculation to prevent semen from entering the female reproductive tract.
• Lactational Amenorrhea: Based on the principle that ovulation and menstruation do not occur during intense lactation following childbirth. This method is effective for up to about six months postpartum, provided the mother breastfeeds fully.

These methods have almost no side effects but are less reliable than other contraceptive methods.

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Contraceptive Methods: Barrier

Barrier methods prevent the physical meeting of sperm and ovum by using barriers. These are available for both males and females, and their effectiveness is often enhanced by using spermicidal agents.

• Condoms: Thin rubber/latex sheaths used to cover the penis (male condom) or vagina and cervix (female condom) before coitus. They collect the ejaculated semen, preventing its entry into the female reproductive tract. Condom use has the added benefit of protecting against STIs and AIDS. They are disposable and offer privacy.
• Diaphragms, Cervical Caps, and Vaults: Rubber barriers inserted into the female reproductive tract to cover the cervix before coitus, blocking sperm entry. These are reusable.
• Spermicidal Creams, Jellies, and Foams: Chemical agents used along with barrier methods to kill or immobilize sperms, increasing contraceptive efficiency.

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Contraceptive Methods: Intra Uterine Devices (Iuds)

IUDs are devices inserted by doctors or trained nurses into the uterus through the vagina. They are a popular contraceptive method in India, particularly for women who want to delay pregnancy or space children.

Types of IUDs:

• Non-medicated IUDs: E.g., Lippes loop. They increase phagocytosis of sperms within the uterus.
• Copper Releasing IUDs: E.g., CuT, Cu7, Multiload 375. They release copper ions which suppress sperm motility and their fertilising capacity, in addition to increasing phagocytosis.
• Hormone Releasing IUDs: E.g., Progestasert, LNG-20. They make the uterus unsuitable for implantation and the cervix hostile to sperms, in addition to phagocytosis.

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Contraceptive Methods: Oral Contraceptives

These are pills taken orally, typically containing small doses of either progestogens or a combination of progestogens and estrogen.

• Pills are usually taken daily for 21 days, starting within the first 5 days of the menstrual cycle, followed by a 7-day gap (during which menstruation occurs), and then the cycle is repeated.
• Mechanism of action: They primarily inhibit ovulation, prevent implantation, and alter the quality of cervical mucus to impede sperm entry.
• Oral pills are very effective and generally have fewer side effects compared to older methods.
• 'Saheli' is a new, non-steroidal oral contraceptive developed in India. It is a 'once a week' pill with very few side effects and high contraceptive value.

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Contraceptive Methods: Injectables And Implants

Progestogens alone or combined with estrogen can also be administered as injections or small implants placed under the skin. The implants are inserted beneath the skin of the upper arm.

• Their mode of action is similar to oral pills (inhibiting ovulation and implantation).
• They provide contraceptive protection for a much longer period compared to pills.

Emergency Contraceptives: Taking progestogen or progestogen-estrogen combinations, or inserting IUDs, within 72 hours of unprotected sexual intercourse can be very effective in preventing possible pregnancy. This is used in cases of rape or accidental unprotected sex.

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Contraceptive Methods: Surgical (Sterilisation)

These methods, also called sterilisation, are permanent or terminal methods advised for male or female partners who wish to prevent any future pregnancies. They block the transport of gametes, thus preventing conception.

• Vasectomy: Sterilisation procedure in males. A small part of the vas deferens is cut or tied up through a small incision on the scrotum. This prevents sperm from reaching the ejaculatory duct.
• Tubectomy: Sterilisation procedure in females. A small part of the fallopian tube (oviduct) is cut or tied up through a small incision in the abdomen or through the vagina. This prevents the ovum from reaching the uterus and sperm from reaching the ovum.

These surgical methods are highly effective for preventing pregnancy, but their reversibility is very poor.

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Selection And Use Of Contraceptives

The choice and use of a suitable contraceptive method should always be made in consultation with a qualified medical professional.

It is important to understand that contraceptives are not typically required for maintaining general reproductive health. They are used specifically to prevent, delay, or space pregnancies due to personal reasons.

The widespread use of contraceptives has played a significant role in controlling the rapid population growth.

While generally safe, contraceptives can have potential side effects, although usually minor. These can include nausea, abdominal pain, irregular menstrual bleeding, or even a slight increase in the risk of certain conditions like breast cancer (though not very significant). These potential ill-effects should not be completely ignored.

Medical Termination Of Pregnancy (Mtp)

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Definition And Legal Aspects

Medical Termination of Pregnancy (MTP), also known as induced abortion, refers to the intentional or voluntary termination of a pregnancy before it reaches full term.

Globally, a large number of MTPs are performed annually (around 45-50 million), representing a significant proportion of total pregnancies.

The legality and acceptance of MTP are subjects of debate in many countries due to associated emotional, ethical, religious, and social issues.

In India, MTP was legalised in 1971 under strict conditions to prevent misuse, particularly the increasing problem of illegal female foeticide.

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Reasons And Safety Considerations

MTPs are primarily performed:

• To get rid of unwanted pregnancies resulting from casual unprotected sex, contraceptive failure, or rape.
• When the continuation of pregnancy is deemed harmful or potentially fatal to either the mother, the foetus, or both due to medical reasons.

MTPs are considered relatively safe when performed during the first trimester (up to 12 weeks of pregnancy).

Abortions performed during the second trimester (beyond 12 weeks) are significantly riskier and carry higher risks of complications.

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Issues And Prevention

A disturbing trend is the performance of a large number of MTPs illegally by unqualified individuals (quacks), which is highly unsafe and can be fatal for the woman.

Another dangerous misuse involves using diagnostic procedures like amniocentesis (originally for detecting genetic disorders) to determine the sex of the fetus, followed by illegal MTP if the fetus is female. This practice of female foeticide is illegal and poses significant risks to the health of the mother.

These harmful trends can be curbed by:

• Effective counselling regarding the risks of unprotected sex and illegal abortions.
• Providing increased healthcare facilities and access to safe abortion services by qualified professionals.

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The Mtp Act, 2017

The Medical Termination of Pregnancy (Amendment) Act, 2017 in India aims to reduce illegal abortions and associated maternal mortality and morbidity. Key provisions include:

• Pregnancy can be terminated up to 12 weeks based on the opinion of one registered medical practitioner.
• For pregnancies between 12 and 24 weeks, the opinion of two registered medical practitioners is required.
• Grounds for termination include risk to the pregnant woman's life or grave injury to her physical or mental health, or a substantial risk that the child would suffer from serious physical or mental abnormalities if born.

Sexually Transmitted Infections (Stis)

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Definition And Types

Sexually Transmitted Infections (STIs), also known as Venereal Diseases (VD) or Reproductive Tract Infections (RTI), are infections or diseases primarily transmitted through sexual intercourse.

Common STIs include:

• Gonorrhoea
• Syphilis
• Genital herpes
• Chlamydiasis
• Genital warts
• Trichomoniasis
• Hepatitis-B
• HIV infection (leading to AIDS) - arguably the most dangerous.

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Transmission Routes

While primarily transmitted sexually, some STIs, like Hepatitis-B and HIV, can also spread through non-sexual routes:

• Sharing of infected injection needles or surgical instruments.
• Transfusion of contaminated blood.
• From an infected mother to her fetus during pregnancy or childbirth.

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Symptoms And Detection

Early symptoms of many STIs are often minor and may include:

• Itching in the genital region.
• Fluid discharge.
• Slight pain.
• Swelling in the genital region.

Importantly, infected females may frequently be asymptomatic, meaning they show no obvious symptoms, which can lead to infections remaining undetected and untreated for long periods.

Early detection and proper treatment are crucial for curing most STIs, except for Hepatitis-B, genital herpes, and HIV infection, which are currently incurable though manageable.

Social stigma associated with STIs and the minor or absent symptoms in early stages often deter infected individuals from seeking timely medical attention, delaying detection and treatment.

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Complications

Delayed detection and improper treatment of STIs can lead to serious complications, including:

• Pelvic Inflammatory Diseases (PID), infections of the female reproductive organs.
• Abortions or stillbirths.
• Ectopic pregnancies (pregnancy outside the uterus).
• Infertility.
• Potentially lead to cancer of the reproductive tract.

STIs pose a major threat to reproductive health and the overall health of a society. Prevention and early management are key components of reproductive health-care programs.

Individuals in the age group of 15-24 years are particularly vulnerable to these infections.

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Prevention

Preventing STIs is possible by following simple practices:

• Avoid sexual contact with unknown partners or multiple partners.
• Always use condoms during sexual intercourse.
• In case of any doubt or suspicion of infection, consult a qualified doctor immediately for testing, early detection, and complete treatment if diagnosed.

Infertility

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Definition And Causes

Infertility is defined as the inability of a couple to produce children despite having unprotected sexual cohabitation for a certain period (often considered two years).

Infertility can affect both males and females. Reasons for infertility can be numerous and varied:

• Physical abnormalities.
• Congenital conditions.
• Diseases (e.g., STIs leading to blocked ducts).
• Drug use.
• Immunological factors.
• Psychological issues.

Contrary to common societal blame on the female, the problem of infertility often lies with the male partner as well.

Specialised infertility clinics can help diagnose the underlying causes and provide corrective treatments for some disorders, enabling couples to conceive naturally.

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Assisted Reproductive Technologies (Art)

When natural conception is not possible, couples can be assisted in having children through special techniques collectively called Assisted Reproductive Technologies (ART).

Some common ART methods include:

1. In Vitro Fertilisation (IVF) and Embryo Transfer (ET): Popularly known as the 'test tube baby' program. Ova from the wife or a donor female and sperms from the husband or a donor male are collected. Fertilisation occurs outside the body in a laboratory setting under simulated conditions.
   • The resulting zygote or very early embryos (up to 8 blastomeres) can be transferred into the fallopian tube (Zygote Intra Fallopian Transfer - ZIFT).
   • Embryos with more than 8 blastomeres are transferred into the uterus (Intra Uterine Transfer - IUT).
   • Embryos formed by in-vivo fertilisation (fertilisation within the female body) can also be transferred using these techniques to assist women who cannot conceive or carry a pregnancy.
2. Gamete Intra Fallopian Transfer (GIFT): Transfer of an ovum collected from a donor into the fallopian tube of another female who cannot produce ova but can provide a suitable environment for fertilisation and development. In this case, fertilisation occurs inside the recipient's fallopian tube.
3. Intra Cytoplasmic Sperm Injection (ICSI): A highly specialised procedure where a single sperm is directly injected into the cytoplasm of an ovum in the laboratory to form an embryo. This is particularly useful in cases of low sperm count or poor sperm motility.
4. Artificial Insemination (AI): Technique used when the male partner is unable to inseminate the female or has a very low sperm count. Semen collected from the husband or a healthy donor is artificially introduced either into the vagina or into the uterus (Intra-Uterine Insemination - IUI) of the female.

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Challenges And Alternatives (Adoption)

ART techniques require high precision, specialised professionals, and expensive equipment, making them accessible to only a limited number of people in India.

Emotional, religious, and social factors can also act as barriers to the adoption of ART methods.

Given that the ultimate goal is parenthood, and considering the large number of orphaned and destitute children in India, legal adoption remains an excellent and often the best alternative method for couples seeking to have children, providing a home and care for needy children.

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