Prof. Dr. Neerja Bhatla, Head of Obstetrics and Gynaecology at AIIMS, New Delhi, acknowledges India's progress in reducing maternal mortality during childbirth but emphasizes the need for improvement. With 35 years of dedication to eliminating cervical cancer, Prof. Bhatla is a distinguished figure, serving as the first Indian woman Chairperson of FIGO's Gyne-Oncology Committee. She led the revision of FIGO staging for cervical cancer and actively contributes to advisory groups on women's cancer and maternal health. Prof. Bhatla focuses on making HPV vaccines and tests more accessible in India, initiating fellowship programs, M.Ch. at AIIMS, and virtual courses for gynaecologists to promote gynaecological cancer education. In a recent interview with Drug Today Medical Times, she addressed various challenges in mother-and-child healthcare in India.. In a candid conversation with Rohit Shishodia of Drug Today Medical Times, Prof. Bhatla discussed a number of issues confronting mother-and-child healthcare in India. Excerpts.

DTMT: How do you see maternal and child health in India, and where do we stand compared to international standards?

Dr. Bhatla: There has been a lot of progress in maternal healthcare now and a lot of emphasis on institutional deliveries, which has seen the transition from traditional or unskilled birth attendants delivering the mother at home, and today, nearly 80% of the deliveries in India are taking place in institutions.

Incentive and facility-based approaches taken by governments have reduced the maternal mortality ratio (MMR) dramatically in the country. In fact, many states in the country have achieved the Sustainable Development Goal (SDG) of 70 per one lakh live births, and we are hoping it will decline further.

In terms of basic realities, the situation is much better, but there is still scope for improving the quality of care in institutional deliveries even further. We can ensure that the institutions are staffed adequately and that continuous in-service training is provided.

However, as all states are not equal in this matter, the focus is now on those states that have not made sufficient progress.

Compared to international standards, we still have a long way to go, but we hope that by 2030 we will achieve the SDGs.

In maternal care, one thing that is still worrying us is that we have not been able to conquer anaemia. Therefore, a lot of efforts are made to identify better methods to manage anaemia, as anaemic patients are more likely to have adverse outcomes owing to a lack of resources in their body to withstand the blood loss and other pregnancy-related problems, including outcomes for their neonates.

DTMT: Any data about the anaemia patients coming to AIIMS?

Dr. Bhatla: In AIIMS, we mostly see people who are largely under our prenatal care; most of them will be treated well before, and subsequently, the number of severe anemics at the time of delivery will not be very many.

However, among the rural population, where many of them do not take regular iron supplements, the number of severely anaemic cases can range between 0 and 70%..

Here, I must clarify that anaemia not only exists in pregnant women but is widely prevalent among adolescent girls too.

Actually, the thrust for care should start right with adolescent health, when we need to start preparing them for motherhood and make sure that their haemoglobin levels are good and their thyroid status is fine.

We also have to ensure other aspects, including immunisation against rubella and chickenpox, as they can cause serious problems during pregnancy. Ideally, every woman should get herself checked on her health status even before conceiving through preconception counselling.

As many as 10–15% of heart diseases are diagnosed during pregnancy, which is not a good thing, and as a result, we sometimes need to perform serious interventions like valve repair procedures during pregnancy, which is very risky. It should be kept in mind that abortion is also not safe for heart disease, so it becomes a dilemma for us whether to continue or not.

DTMT: What are the reasons for the growing infertility in India?

Dr Bhatla: We have always been constrained by statistics, and hopefully, with progressing digitalization, we will have more data access. Yes, we perceive that there is more infertility, but we do not know whether this is because more patients are seeking treatment or whether these numbers are due to genuine infertility. But something is very obvious: among a lot of people in urban areas, the age of childbearing is pushed back because women are more focused on their careers during their younger years and want to settle down before they have their babies. So a lot of women have this problem because fertility begins to decline.

Moreover, problems like PCOS and endometriosis, which are partly lifestyle-related, are becoming more prevalent and are interfering with conception. We see more endometriosis and fibroids, and other reasons are coming into play as the conceiving age is advancing, resulting in a woman being unable to conceive.

Additionally, stress, substance abuse, and environmental factors like pollution may be having effects on male spermatogenesis too. Declining sperm counts as well as ovulation-related issues are becoming quite common.

Then the other thing is that we also have solutions in the form of assisted reproductive technologies now, which make people come forward.

DTMT: What is your opinion about the rising trend of cervical cancer?

Dr. Bhatla: I will not say that cervical cancer is increasing; actually, it is showing a decreasing trend in the country, though the decrease is not fast enough. Increasing the age of marriage, fewer pregnancies, and better attention to reproductive tract infections could be some of the factors behind it. Understanding menstrual hygiene and many other factors are also playing a role in reducing it to some extent.

However, we are quite far from the WHO elimination goal of four cervical cancers per hundred thousand women.

Another point that we should keep in mind is that cervical cancers have shown a resurgence in many countries after initially declining. Hence, just because we have seen a decline so far should not make us complacent.

Today, preventing cervical cancer has become easier with the availability of indigenous HPV vaccines; hopefully, they will be included in the government vaccine programme soon. For prevention, vaccination is the best route, as it can reach a large number of people, and in India, people have faith in vaccines. In fact, our experience in Sikkim and Bhutan shows that vaccination uptake has seen 96–97% coverage, which is even more than EPI vaccines.

Another good thing is that the single-dose HPV vaccine schedule has already been approved by the WHO. The Indian HPV vaccine has been approved for a double dose at the moment, but with more data, it is possible that we may have a single-dose Indian HPV vaccine approved soon.

It is best to vaccinate girls under the age of 15 because, apart from getting a good immunological response, they have yet to initiate any sexual activity. For older women, we need not put it under a national programme but can allow them to get vaccinated individually. In fact, the vaccine has been licenced for boys too.

While vaccination is one side of the story, screening is also important. Vaccines protect people from disease in the future, but we must not forget that HPV infection manifests into cancer even after 15–20 years. So, women over the age of 30 should go for screening either by pap or vinegar tests (VIA) or the latest HPV test. According to WHO recommendations, HPV tests should be done twice, once at the age of 35 and the other at 45. In fact, women over 45 who have never been tested should get the test done.

DTMT: The cases of osteoporosis are also increasing among women. What lifestyle changes are required to reduce the risk of osteoporosis?

Dr Bhatla: Lifestyle measures remain the same in most cases, and they have multiple benefits. Particularly when we are talking about osteoporosis, the first thing that remains is good calcium, vitamin, and protein intake, required for strong bones, which can be achieved through dietary means at a younger age and as supplements for older people.

Physical exercises, especially weight-bearing ones, play an important role in having strong bones. Additionally, exposure to adequate sunlight is a good way to get vitamin D, but if it is not possible to have adequate vitamin D naturally, then we must get the blood test done and then take a vitamin D supplement.

However, people must refrain from taking vitamin D without determining their blood vitamin D levels, as an excess amount of vitamin D can lead to hypervitaminosis, which can cause kidney damage and other problems.

Lifestyle measures mentioned above, including physical exercise, can help to keep weight gain under check, as I have mentioned in the case of PCOS. It will be helpful to prevent certain cancers linked to obesity.

Broadly speaking, good exercise, correct posture, good nutrition, having a nutritious diet along with adequate sleep, staying away from stress, and finding ways to relax can keep us healthy.

DTMT: Can you please tell our readers something about preeclampsia?

Dr Bhatla: Yes, among all the pregnancy-related killers, preeclampsia is quite important. In India, it is not number one, as most Indian women still suffer from postpartum haemorrhage and obstructed labour.

In the West, where they have controlled all other problems, preeclampsia has become the number one pregnancy-related killer because of increasing hypertension. During preeclampsia, blood pressure suddenly surges, usually after 20 weeks of pregnancy, and if unchecked, a woman suffers convulsions affecting the baby, which is the major cause of maternal mortality.

Apart from maternal mortality, preeclampsia is also associated with what we call near-miss maternal mortality, meaning that we could save the women in the nick of time. However, in such cases, the risk of developing comorbidities and potentially long-term sequelae remains.

DTMT: What are your tips for pregnant women?

Dr Bhatla: What does the pregnant woman want? She wants to have a healthy child. It is very important to understand that this begins with the first week of pregnancy, so ideally, a woman who is planning a pregnancy should go for pre-pregnancy counselling and take tests for haemoglobin, blood sugar, TSH, and her blood group.

And then they must plan in advance, right from the beginning of the pregnancy, where they are going to deliver, and not leave the decision for the last moment when they go into labour. They should also be aware if their pregnancy falls under the low- or high-risk category.

The expecting mother must also prepare a Plan B so that she can contact her healthcare provider or someone in her network who can help her during an emergency.

During pregnancy, at least four basic visits are a must: one in the beginning, a second in the middle, and then two more. Now that we have good level two ultrasounds, we can even look for congenital malformations.

My message is that everyone should maintain a healthy weight and lifestyle. Health-seeking behaviour is very important, and much of gynaecology is about preventive care; even antenatal care, pregnancy, and menopausal care are preventive care.