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Prof Neerja Bhatla

We have come a long way, but still have miles to go: Prof Neerja Bhatla

Though India has come a long way in controlling maternal mortality during childbirth, there is a lot of scope for improvement, says Prof Dr Neerja Bhatla, Head of the Department for Obsttratetics and  Gynaecology at AIIMS, New Delhi.

Though India has come a long way in controlling maternal mortality during childbirth, there is a lot of scope for improvement, says Prof Dr Neerja Bhatla, Head of the Department for Obstetrics and  Gynaecology at AIIMS, New Delhi.

Prof Bhatla, who has been working tirelessly for the last 35 years to eliminate cervical cancer in the country, is a Shobha Seth Wenger Distinguished Professor of Gynae-Oncology at AIIMS.

Prof Bhatla is the first woman doctor from India to grace as Chairperson of The International Federation of Gynaecology and Obstetrics' (FIGO) Gyne-Oncology Committee. She led the revision of FIGO staging of cervical cancer.

With over more than 500 research publications authored by her, Prof Bhatla also serves as a member of advisory groups on issues related to Women’s Cancers & maternal health, including NTAGI, WHO, MOHFW, ICMR and DBT.

Prof Bhatla is also credited with developing several biomedical devices to promote the training of health workers, and screening and treatment of cervical cancer in remote areas.

Working relentlessly to bring low-cost Indian HPV vaccine to reduce the cost of HPV vaccination for Indian girls and to develop low-cost indigenous HPV tests to promote screening, Prof Bhatla has been at the forefront of promoting gynaecological cancer education by starting fellowship programmes across India, M.Ch at AIIMS and implementing virtual courses for gynaecologists.

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.

Here are the 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 the governments have reduced the Maternal Mortality Ratio (MMR) dramatically in the country. In fact, many states in the country have achieved the Sustainable Development Goa (SDG) of 70 per one lakh live birth and we are hoping it will decline further.

In terms of basic realities, the situation though much better, 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 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 as we mostly see people who are largely under our pre-natal care so, most of them will be treated well before and subsequently the number of severe anaemic 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 can range between 50-70% of the cases.

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 from 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 about 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 repairing procedures during pregnancy which is very risky and should be kept in mind that abortion is also not safe in the heart disease so it becomes a dilemma for us whether to continue or not.

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

Dr Bhatla: We have always in constrained about statistics and hopefully with progressing digitalisation 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 seeking treatment or these numbers are due to genuine infertility. But something is very obvious: one, among a lot of people in urban areas, the age of childbearing is pushed back because they 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 increasing pollution may be having effects on male spermatogenesis as well. 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 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 may also are 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 declining initially. Hence just because we had seen a decline so far should not make us complacent.

Today preventing cervical cancer has become easier with the availability of indigenous HPV vaccine hopefully it will be included in the government vaccine program 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 had seen 96-97% coverage, which is even more than EPI vaccines.

Another good news is that the single-dose HPV vaccine schedule has already been approved by 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 when under the age of 15 because apart from getting a good immunological response, they are yet to initiate any sexual activity. For older women, we need not put it under a national program but can allow them to get vaccinated individually. In fact, the vaccine has been licensed for boys too.

While vaccination is one side of the story, screening is also important. Vaccines protect people from disease in future we must not forget that HPV infection manifests into cancer only after 15-20 years. So, women over the age of 30 years should go for screening either by pap or vinegar tests (VIA) or the latest HPV test. According to WHO recommendation 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 got tested should get the test done even if they are over 45.

DTMT: Apart from cervical cancer, 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 for having strong bones. Additionally, exposure to adequate sunlight is a good way to get vitamin D, but in case it is not possible to have adequate vitamin D naturally, then we must get the blood test done and take then take vitamin D supplement.

However, people must refrain from taking Vitamin D supplements without determining blood vitamin D levels as in excess amount, vitamin D can lead to hypervitaminosis-D that can cause kidney damage and other problems.

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

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

DTMT: Can you please tell our readers something about preeclampsia which according to some studies, is believed to be a major killer during pregnancy?

Dr Bhatla: Yes, amongst 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 goes high usually after 20 weeks of pregnancy and if it remains unchecked woman suffers convulsions and the baby is also affected and which is a 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 potentially and long-term sequels remains.

DTMT: What are your tips for pregnant women?

Dr Bhatla: What does the pregnant woman want? She wants that she should 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 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 basic four visits in pregnancy are a must, one in the beginning, a second in the middle and then two more. Now we have good level two ultrasounds we can look for congenital malformation.

My message to everyone is, to maintain a healthy weight and lifestyle. Health-seeking behaviour is very important and much of gynaecology is about preventive care, even ante-natal care is preventive care. In pregnancy most of what we do is to provide preventive care, in the menopausal phase too there is a lot of preventive care.

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