Reproductive Health: Class 12 Biology · Chapter 3

Doctors would not call a heart healthy just because it beats; they also ask how well it copes with daily life. Reproduction deserves the same wider view. Picture a girl who skips school every month because nobody explained periods to her. Or a family that cannot reach a hospital when labour begins, or a teenager who trusts a rumour about how infections spread. Their reproductive organs may be perfectly normal, yet something important is missing.

The World Health Organization (WHO) therefore defines reproductive health (जनन स्वास्थ्य) broadly: well-being in every matter linked to reproduction, physical, emotional, behavioural and social, and not merely freedom from disease. In practice two things must go together: bodies whose reproductive organs work as they should, and relationships built on safety, respect and accurate knowledge.

• Physical: reproductive organs that develop and work normally, safe pregnancy and childbirth, freedom from infection.
• Emotional: being at ease with the changes of adolescence, without fear, guilt or shame.
• Behavioural: making informed, responsible choices, including the choice to say no.
• Social: mutual respect, equal value for girls and boys, and protection from abuse and exploitation.

This chapter follows how India works towards that goal. It begins with the national strategies (Section 3.1) and with population growth and the methods of birth control (Section 3.2). It then turns to legal termination of pregnancy (Section 3.3), infections spread by sexual contact (Section 3.4) and help for couples who cannot conceive (Section 3.5).

3.1 Reproductive Health – Problems and Strategies

Today India's work in this area runs as the Reproductive and Child Health (RCH) programme, part of the National Health Mission. Its roots go back to 1951–52, when India, in its First Five-Year Plan, became one of the first countries anywhere to launch a national family planning programme. Over the decades the focus broadened from birth control alone to the health of mothers and children, and the RCH name was adopted in 1997.

The programme rests on three kinds of effort that support one another (Fig. 3.1): spreading correct information, providing services that people can actually reach, and research that keeps improving both.

Awareness. Many reproductive-health problems start with silence or with myths. Young people usually take their questions about a changing body to friends, parents, relatives or teachers first, so those people need correct answers too. Schools can add age-appropriate sexuality education, so that facts arrive before rumours do. On a larger scale, government and voluntary agencies run campaigns on radio, television, print and social media. What people need to know depends on their stage of life:

• Adolescents: how the reproductive organs develop and work, the changes of puberty, menstrual hygiene, consent, and how infections such as HIV spread and can be avoided.
• Couples and those about to marry: why breastfeeding matters, how to stay healthy through pregnancy and after childbirth, which methods can space or limit births, and why a daughter deserves exactly the same care as a son.
• The whole community: how to recognise, prevent and report sexual abuse and other sex-related crimes, and what rapid population growth costs a society.

Services. Information is of little use if the nearest clinic is a day's journey away. The second strategy is therefore to build health centres and hospitals with trained staff, equipment and reliable stocks of medicines and contraceptives, ready to handle childbirth, family planning, safe abortion, infections, menstrual disorders and infertility. Immunising every child belongs here too, and so do laws that protect girls even before birth. As better techniques appear, services have to keep adopting them.

Amniocentesis and the ban on sex selection

Amniocentesis (उल्ववेधन) is a prenatal test usually done after the 15th week of pregnancy. Watching on an ultrasound screen, a doctor guides a fine needle through the mother's abdomen and draws off a small sample (around 15–20 mL) of the amniotic fluid around the foetus (Fig. 3.2). This fluid carries cells shed by the foetus and many dissolved substances. Studying the chromosomes, DNA and chemistry of the sample can reveal genetic disorders such as Down syndrome (an extra chromosome 21), haemophilia and sickle-cell anaemia. It also shows doctors how well the foetus is likely to develop.

The same cells also show whether the foetus is male or female, and this is where the test was misused. In families that preferred sons, female foetuses were identified and aborted, and the number of girls born fell sharply in many districts. The Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act, 1994 (strengthened in 2003) makes it a crime to use any test to determine or reveal the sex of a foetus. Amniocentesis remains legal for detecting disorders.

How can we be sure that missing girls are the work of people and not of chance? Nature produces slightly more boys than girls: about 105 boys for every 100 girls, or roughly 950 girls per 1000 boys. The 2011 census counted only about 918 girls per 1000 boys among children aged 0–6. Try the simulation below to see whether chance alone could open a gap that large.

With millions of births, chance cannot drag the ratio down to 918. The deficit is the result of sex-selective abortion and of daughters receiving poorer care, which is exactly why the law and awareness campaigns target both.

Measuring progress

How do we know whether a society's reproductive health is improving? Health surveys track numbers: how many mothers and babies die, what share of births take place in hospitals with trained staff, how many couples use a method of their choice and keep their families small, how quickly infections are found and cured, and how much people know. The first two are the most widely quoted.

3.2 Population Stabilisation and Birth Control

In 1900 the world held about 1.6 billion people. By 2000 there were about 6.1 billion, and the United Nations marked the arrival of the eight-billionth person in November 2022. India followed the same steep curve. The first census after independence (1951) counted 361 million people and the 2011 census 1.21 billion; by 2023, according to UN estimates, India had overtaken China as the world's most populous country.

What changed? During the twentieth century vaccines, antibiotics, safer water and more reliable food supplies cut the death rate sharply, and far fewer mothers and infants died (falling MMR and IMR). Birth rates fell much more slowly. More children survived to adulthood, so each new generation of people of reproductive age was larger than the one before (Fig. 3.4).

Demographers measure growth as births minus deaths per 1000 people each year. In the early 1950s India had about 42 births and 23 deaths per 1000, a growth rate close to 2 % a year. By 2011 births had fallen to about 22 and deaths to about 7 per 1000. Growth slowed, yet the census still recorded a 17.7 % rise over 2001–11, roughly 1.6 % a year. That sounds modest, but growth compounds: at 1.6 % a year a population doubles in about 44 years.

Even that slower rate added about 182 million people in one decade, more than the entire population of all but a handful of countries. Each of them needs food, water, housing, schooling, health care and work. Farms, schools and hospitals have expanded enormously since 1951, but providing for nearly two crore extra people every year strains every one of these systems.

There is good news. India's total fertility rate (TFR) fell from about 6 children per woman in the early 1950s to 2.0 in the National Family Health Survey of 2019–21. That is just below the replacement level of about 2.1, at which each generation simply replaces itself. The population will keep growing for a few more decades, because today's very large generation of young adults is now having children, but it is moving towards stabilisation.

Several measures work together. The law fixes the minimum age of marriage at 18 for women and 21 for men (Prohibition of Child Marriage Act, 2006), which delays first births and protects young mothers. Couples with small families have at times been offered incentives, and long-running public campaigns have made the small family a social norm; in cities a growing number of couples stop at one child. Above all, every couple should be able to have the number of children they want, when they want them, and that means making birth control easy to learn about and easy to get.

What makes a good contraceptive?

A contraceptive (गर्भनिरोधक) is any method, device or medicine used to prevent pregnancy. Imagine designing the perfect one. It would need to:

• work reliably;
• be safe, with few or no side-effects;
• be easy to use and easy to obtain;
• be reversible, so that fertility returns as soon as it is stopped;
• leave sexual desire and intercourse unaffected.

No method scores perfectly on every count, which is why so many exist. They fall into seven families: natural (traditional) methods, barriers, intra-uterine devices, oral pills, injectables, implants and surgical methods. Each family breaks the chain that leads from gametes to pregnancy at a different link (Fig. 3.6).

Natural methods

Natural methods rely only on timing and behaviour; no medicine or device is involved.

Periodic abstinence. An ovum can be fertilised for only about a day after it is released, while sperm can survive a few days inside the female tract. In a regular 28-day cycle ovulation falls near day 14, so the chance of conception is highest from about day 10 to day 17, the fertile period. Couples using this method avoid intercourse on those days (Fig. 3.7).

Withdrawal (coitus interruptus). The man pulls out before he ejaculates, so that semen is released outside the vagina.

Lactational amenorrhoea (absence of periods while breastfeeding). A new mother who feeds her baby on breast milk alone, day and night, usually does not ovulate, because the hormones of intense breastfeeding hold the cycle back. Doctors rely on this only while three conditions hold: the baby is under six months old, it gets no other food, and the mother's periods have not returned.

Natural methods are free and carry essentially no risk to health. What they lack is reliability: cycles vary, ovulation is hard to pinpoint, and withdrawal demands perfect timing every time, so pregnancies happen often.

Barrier methods

Barrier methods block sperm physically. The best known is the condom, and it has an advantage no other contraceptive offers: used correctly every time, it also greatly lowers the risk of sexually transmitted infections, including HIV. That double protection is why its use keeps growing. A male condom is a thin latex sheath rolled onto the erect penis; a female condom is a soft pouch that lines the vagina and covers the cervix. Either way, the semen is trapped inside.

Condoms are cheap, need no prescription and are thrown away after one use, and because people put them on themselves, their use stays private. In India the government has long distributed free male condoms under the name Nirodh.

Spermicides, creams, jellies or foams that kill sperm, are seldom relied on alone. They are paired with rubber devices that a woman places over her cervix before intercourse: the dome-shaped diaphragm, or the smaller cervical cap and vault. Together they keep sperm out of the uterus, and the rubber device can be washed and used again.

Intra-uterine devices (IUDs)

An intra-uterine device (IUD) is a small plastic device that a doctor or trained nurse places inside the uterus, passing it through the vagina and cervix. It suits women who want to delay a first pregnancy or space their children: one fitting works for years, and fertility returns soon after removal. There are three kinds:

• Non-medicated IUDs, such as the Lippes loop, made of plastic alone and now largely replaced.
• Copper-releasing IUDs, such as CuT, Cu7 and Multiload 375. India's programme mainly uses Cu-T 380A, which can stay in for 10 years, and Cu-T 375, for 5 years.
• Hormone-releasing IUDs, such as Progestasert and LNG-20, which slowly release a progestogen.

How does a small device stop a pregnancy (Fig. 3.8)? Its presence sets off a mild reaction in the uterus, and the extra phagocytes that gather there engulf sperm. Copper adds a chemical effect: the copper ions it releases leave sperm sluggish and less able to fertilise an ovum. A hormone IUD acts through its progestogen, which turns the cervical mucus into a thick barrier and keeps the uterine lining from becoming ready for an embryo.

IUDs are offered free at government health centres, and a copper IUD can even be fitted soon after childbirth.

Pills, injectables and implants

The pill is a daily tablet carrying a small dose of hormone: a progestogen on its own, or a progestogen–estrogen combination. A typical pack of combined pills runs on a 28-day rhythm. The user takes one tablet daily for 21 days, starting within the first five days of a period, then has seven tablet-free days in which bleeding occurs, and then starts a new pack (Fig. 3.9). Some packs fill the break with seven iron tablets so that the daily habit is not lost; progestogen-only pills are taken without a break.

The hormones prevent pregnancy in three ways: they stop ovulation, they make implantation unlikely, and they change the cervical mucus so that sperm struggle to pass. Taken without missed tablets, the pill is one of the most effective reversible methods, and its side-effects are usually mild. Saheli, the non-steroidal weekly pill described in the box in Section 3.1, is a different kind of oral contraceptive.

Injectables and implants deliver the same hormones, a progestogen alone or with an estrogen, without a daily tablet, and they prevent pregnancy in the same ways as the pill. One injection protects for weeks to months; India's free injectable, Antara, is given every three months. A thin rod placed under the skin of the upper arm can work for three years or more, so there is nothing to remember each day.

Emergency contraception is for the rare occasion when unprotected intercourse has already happened, for example when a condom breaks or after a sexual assault. Progestogen, or progestogen–estrogen, tablets taken as soon as possible within 72 hours, or an IUD inserted within that time, can prevent a pregnancy. It is a back-up, not a regular method.

Surgical methods

Sterilisation (नसबंदी) is meant for people who are sure they want no more children. It is very effective, but undoing it is difficult and often fails, so it is treated as permanent. The idea is simple: block the tubes that carry gametes and leave everything else alone (Fig. 3.10).

• Vasectomy (in men): through a tiny opening in the skin of the scrotum, each vas deferens is cut and its ends tied or sealed, often after a short piece is taken out.
• Tubectomy (in women): each fallopian tube is tied and cut, or a short section is taken out, working through a small cut in the abdomen or through the vagina.

The gonads are not touched. The testes go on making sperm and testosterone, and the ovaries go on releasing ova and hormones; the gametes that cannot pass are simply absorbed by the body. Sexual function and secondary sexual characters therefore do not change. After a vasectomy, sperm already beyond the cut can remain for about three months, so another method is needed until a semen test shows none.

3.3 Medical Termination of Pregnancy (MTP)

Not every pregnancy continues to term. Some end on their own, which is called a spontaneous abortion or miscarriage. When a pregnancy is ended on purpose by a medical procedure, the process is known as medical termination of pregnancy (MTP), or induced abortion.

Societies disagree deeply about abortion. People weigh it against their emotional, ethical, religious and social beliefs, and countries have drawn the legal line in very different places. India chose in 1971 to permit it within limits, and the limits exist partly to stop abortion being used to eliminate female foetuses. Worldwide, the WHO estimates that about 73 million induced abortions take place each year, close to three in every ten pregnancies.

Sometimes ending a pregnancy is a medical necessity: continuing it would endanger the woman's life or health, or the foetus has a serious abnormality. In other cases the pregnancy was unwanted from the start, after a contraceptive failed, after unprotected intercourse, or after rape.

Timing matters for safety. Pregnancy is divided into three trimesters of about three months each. In the first trimester, up to about 12 weeks, MTP done by a trained provider is a safe procedure. In the second trimester the risks rise considerably (Fig. 3.12).

• Up to 20 weeks: the opinion of a single registered medical practitioner is enough.
• From 20 to 24 weeks: two practitioners must agree, and only specified groups of women qualify. They include survivors of rape or incest, minors, women whose marital status changes during the pregnancy, and women with disabilities.
• Beyond 24 weeks: only for substantial abnormalities of the foetus, as decided by a state medical board.
• At any stage: when the termination is immediately necessary to save the woman's life.
• A pregnancy caused by rape is presumed to gravely injure the woman's mental health. Failure of a contraceptive used by any woman or her partner is also an accepted ground, up to 20 weeks.
• The woman's identity must be kept confidential, and a minor needs the written consent of a guardian.

Your textbook's margin box gives different limits (12 and 24 weeks, under an amendment it dates to 2017). The limits above are those of the Act as amended in 202111The Medical Termination of Pregnancy (Amendment) Act, 2021 came into force on 24 September 2021.; check which version your examination expects.

What makes an abortion dangerous is rarely the procedure itself, but who performs it and where. Abortions by untrained people in unhygienic places still cause infection, heavy bleeding, infertility and deaths. The remedies are safe, legal MTP within easy reach, counselling on safer sex so that fewer unwanted pregnancies occur, and honest information about the risks of illegal abortion. Aborting a foetus because it is female is a crime: the sex test breaks the PCPNDT Act, and the sex of a foetus is not a lawful ground for MTP.

3.4 Sexually Transmitted Infections (STIs)

Infections passed from one person to another mainly through sexual contact are called sexually transmitted infections (STIs) (यौन संचारित संक्रमण). Older names for them are venereal diseases (VD) and reproductive tract infections (RTI). They are caused by bacteria, viruses and protozoa (Table 3.4).

HIV, which leads to AIDS, is the most serious of these; Chapter 7 deals with it in detail. Hepatitis B and HIV do not spread through sex alone. They can pass from an infected mother to her baby during pregnancy, birth or breastfeeding, through transfusion of infected blood, and through needles, syringes or surgical and tattooing instruments that have been shared or not sterilised.

Bacterial and protozoan STIs can be cured completely if they are found early and the full course of treatment is taken. Viral STIs are different: HIV, hepatitis B and genital herpes cannot be cured, although medicines keep them in check. Vaccines now prevent hepatitis B and the human papillomavirus (HPV) that causes genital warts and most cervical cancers.

The trouble with STIs is that they are easy to miss. Many infected women, and some men, notice nothing for months. Others feel only mild itching, a little pain, an unusual discharge, or a sore or swelling in the genital area, which they may ignore, and shame or the fear of being judged adds to the delay. Meanwhile the infection can travel upwards (Fig. 3.13). The long-term damage includes pelvic inflammatory disease (PID), scarred fallopian tubes, ectopic pregnancy, miscarriage and stillbirth, infertility, and in some cases cancer of the reproductive tract.

STI rates are highest among 15–24-year-olds. Knowing this is useful rather than frightening, because almost every STI can be prevented, and the RCH programme puts prevention, early testing and complete treatment at the centre of its work. These habits protect a person:

• Avoid sexual contact with unknown partners or with many partners.
• Use a condom correctly every time.
• Never share needles, syringes or razors, and insist on sterile instruments for injections, piercing and tattoos.
• Get vaccinated against hepatitis B, and against HPV where the vaccine is offered.
• If you suspect an infection, see a qualified doctor early, and finish the full course of treatment even after the symptoms fade.

3.5 Infertility

For some couples the problem is the reverse of the one that contraception solves. Infertility (बंध्यता) is the failure to achieve a pregnancy despite regular unprotected intercourse. Doctors and the WHO usually diagnose it after 12 months of trying; your textbook's summary uses a two-year period. The WHO estimates that about one in six people of reproductive age experience infertility at some point in their lives.

Infertility clinics begin by testing both partners, and with good reason: although in India the woman is often blamed when a couple has no child, male factors are involved in roughly half of all cases. The tests look for causes of many kinds: a low sperm count or blocked tubes, damage from past infections such as untreated STIs, hormonal or immune problems, conditions present from birth, the effects of drugs, alcohol and tobacco, and psychological stress. Many of these can be corrected with medicines or surgery. For the rest there are assisted reproductive technologies (ART).

Assisted reproductive technologies

The best-known technique is IVF–ET, the test-tube baby programme. Its name describes it: fertilisation in vitro ('in glass', that is, in a laboratory dish) followed by embryo transfer. Doctors collect ova from the woman's ovaries, or from a donor, and mix them with sperm from her partner or a donor in a dish kept at body temperature in a nutrient medium (Fig. 3.14). Once a zygote forms and starts dividing, it goes back into the woman's body. Where it goes depends on its stage:

• ZIFT (zygote intra-fallopian transfer) puts a zygote, or an embryo of no more than 8 blastomeres, into a fallopian tube.
• IUT (intra-uterine transfer) puts an embryo that has gone beyond 8 blastomeres into the uterus.

Transfer works with embryos from a donor's body as well: an embryo produced by natural (in vivo) fertilisation can be moved to a woman who cannot conceive herself. Other techniques solve other problems (Fig. 3.15):

• GIFT (gamete intra-fallopian transfer): an ovum (from a donor if the woman cannot produce her own) is placed in her fallopian tube along with sperm. Fertilisation and development then take place inside her body. It suits a woman whose tubes and uterus are healthy but who cannot produce ova.
• ICSI (intra-cytoplasmic sperm injection): a single sperm is injected straight into the cytoplasm of an ovum in the laboratory, and the embryo formed is then transferred. It is used when sperm are too few or too weak to fertilise an ovum themselves.
• Artificial insemination (AI): the husband's semen, or a healthy donor's, is introduced into the vagina, or directly into the uterus (IUI, intra-uterine insemination). It helps when the man cannot deposit semen in the vagina, or when his sperm count is very low.

ART is not an easy option. A single IVF cycle commonly costs a lakh of rupees or more, often has to be repeated, and depends on specialists and laboratories found mainly in large cities. Many couples also hesitate for emotional, religious or social reasons. Since 2021 the Assisted Reproductive Technology (Regulation) Act has required ART clinics and banks to be registered, and it sets rules on donors and consent.

Parenthood does not have to be biological. Many orphaned and abandoned children in India are waiting for a family, and adopting a child through the legal process overseen by the Central Adoption Resource Authority (CARA) gives that child a home and a couple a family.