Prenatal hemoglobinopathy screening in India: Enhancing coverage, counselling, & continuity

Sir,

We read with interest the article by Agarwal et al¹ on the large-scale implementation of a targeted prenatal haemoglobinopathy screening programme across public health facilities in India. The study provides valuable operational insights and is an encouraging step toward reducing the burden of severe haemoglobinopathies, particularly in underserved populations. The authors report an impressive enrolment of over 34,000 pregnant women and identify a 6.8 per cent carrier rate across five States. While the programme’s outcomes are laudable, several areas merit further consideration to strengthen its scalability and clinical impact.

First, although the programme successfully integrated haemoglobinopathy screening into routine antenatal services, the four per cent attrition in maternal testing due to logistical factors such as sample deterioration and labelling errors remain significant. This calls for a quality assurance protocol that mandates pre-analytical audits, cold chain tracking, and barcode verification systems to minimise preventable data loss and optimise programmatic efficiency¹.

Second, the article reports a 13.6 per cent non-completion rate for paternal testing. While various contextual reasons were provided ranging from refusal to missed windows it would be prudent to explore socio-cultural determinants in greater depth. Previous studies have shown that involving male partners from the initial counselling stage and offering decentralised testing services improve compliance and shared decision-making during reproductive counselling².

Third, of the 339 couples identified as at-risk, 22 per cent could not complete foetal testing. Notably, 24 per cent of these missed the termination window despite prior risk identification¹. This represents a significant programmatic bottleneck, potentially undermining the very objective of early prenatal intervention. Introducing rapid turnaround point-of-care molecular diagnostics or mobile sample pickup units could ensure timely risk stratification and decision support. While the authors rightly point out that 68 per cent of couples with affected foetuses opted for medical termination, it is equally critical to examine the psychosocial and ethical dimensions influencing the 32 per cent who continued such pregnancies. Kulkarni et al³ have previously highlighted that uptake of paternal testing during antenatal visits remains inconsistent, often hindered by logistical and sociocultural challenges. How does the programme plan to support these families postnatally in terms of early disease management, counselling, and linkage to specialised care?

Overall, the Sankalp initiative provides a strong foundation for scalable and ethical prenatal screening in India. However, sustained investment in quality improvement, male engagement, and real-time diagnostics will be pivotal in translating this success into population-level health gains.