 Shanti, she is a professor at the College of Nursing, the Shridh Bokulam College of Nursing in Salem in Tamil Nadu in India. We have Mrs. Manjula as well who is a tutor in obstetrics and gynaecological nursing at the same college and Soni, who is an assistant professor in obstetrics and gynaecology nursing. So I'll just hand over to Shanti. So can you turn your speaker volume up maybe? Hi Shanti, do you have your headset on? I can hear you very faintly with lots of feedback. Do you want to try and do the audio wizard underneath meeting and do the audio setup wizard for us? Shanti, have you done the audio wizard setup? Hello Shanti, we can't hear you at the moment. Not at the moment Shanti. Okay, if you can with us everyone while we get this technical issue sorted out, sometimes this does happen in here. Shanti, did you remember to press the icon of the microphone in the tab across the top? You need to make the icon go green so that you can speak. We can see you've got your microphone unmuted, which is great. But just make sure you press the icon so it goes from white to green and try talking again. We could hear you in a very muffled way earlier. It's already green. Have you been through the audio wizard so that if you press the meeting button, you can see audio setup wizard and you can take yourself through a check of your equipment. It just takes a couple of seconds and that might help you problem solve any issues. Can the other presenter with you have a microphone as well? Manjula, do you have a microphone? That's better. We can hear you. You may have to put your mouth close to the microphone and speak strongly. Good morning, ma'am. I'm Shanti. That's perfect, Shanti. That's excellent. Good morning, ma'am. Can I start this, ma'am? Yes, that would be great if you can start your presentation. Manjula, if you can just put yours on mute while Shanti is here, that will help with our echo. Yes, Ma'am. If you are seeing adolescence and pre-treatment, according to many development goals, also the global metamotor rate has declined by nearly half since 1990. It declined for a short of the MBG target, 109 per 1 lakh by 2015. It is still 15 times higher in developing countries than in the developed regions. It is given by according to United Nations. After estimators, 287,000 metadays that occurred in 2010 in globally. In this, the India accounted for 56,000, that is nearly 19 percentage of the global total. If you are seeing R&M CHS adolescent strategy, it promotes links between various interventions that enhance the lifestyle to improve child development in India. This plus, within the strategy, focus on adolescent and existing life stages within the world strategy. They included the age, this adolescent. So, it gives the linkages, references, counter-references between the health activities, that is primary, secondary and tertiary levels. If you are seeing the goals, it has three goals mainly given. That is reduction of infant mortality rate to 25 among the 1,000 live births in the year 2017. And reduction in mother mortality rate to 100 among 100 live births by 2017, to 2.1 by the year 2017. If you are seeing the 5 into 5 matrix, that is 5 important thing, that is reproductive health, maternal health, newborn health, child health and adolescent health. So, this is the concentration of R&M CHS plus AI intervention. And if you are seeing the issues and actions, it has some issues, that is continuous monitoring, supportive, supervision and feedback mechanism. So, through this way, they are giving the improved quality of care and also accountability for each health persons. And they are giving the best performance and also best incentives under the R&M CHS mandatory, that is according to the 12th to 5th year plan. And availability and utilization of high quality health services, mainly in the urban areas, it also to improve the quality of care. And increase the attention to the nutritional status among women and children, mainly the CBAs and other women and also CBAs in malnourished children. They are giving a more attention according to the government of India initiating iron and calcium supplementation for them. And next issue is strengthen the continuum of care, mainly from the community mobilization to the rural and urban area. And increase the involvement of the private sector and also the CSO, that is central statistical organization. And continue to focus on larger health system and also strengthening the issues. First, innovation consistently evaluate, document and share these practices. So, these are the some issues and actions according to the R&M CHS guidelines. If you are seeing the key interventions for them according to the total health challenging year, to increase the proportion of prenatal care, they all should have 100% age. Then all goes in government and accredited private institution at annual rate of 5.6% age. And present women who are receiving anti-natal care at the rate of 6% age. And mothers and newborns receiving post-natal care that is 7.5% age. And delivery is conducted by skilled birth attendants that is 2% age. And exclusive breastfeeding rate 9.6% age. Covering of three groups of both criteria, attendance and birth rate is 3.5% age. And oral pre-hydration therapy is in under 5 children for the diarrhea 7.2% age. And met need for newer family planning lecture mainly the integral couples 4.5% age. And science education 0 to 6 years. And yes ma'am. Hello. Hello. Hello. Hello. Hello. Hello. I can hear you. Carry on. You're hearing. Okay ma'am. Because somebody given this message is like they are not hearing. I just want to check is who is the sound coming through? Is it through Mandula or is Shanti? I'm Shanti ma'am. Because both of the speakers are on. That's why we're getting some feedback I think. Through Manjula and I'm speaking. So are you using Manjula's microphone? Yes ma'am. Okay. All right. Okay. Shall I carry on? Yeah. Yeah. I'll. Yeah. Carry on. Okay ma'am. Next. It reduce the prevalence of under 5 children who are under 8 that is 5.5% age. And reduce the handmade needs for family planning lectures among eligible couples 8.8% age. Reduce anemia in adolescent girls both girls and boys that is 6% age. And decrease the proportion of total fertility for adolescents 3.8% age. Mainly in all of these they added adolescents. That because adolescents have limited awareness of sexual and reproductive health. So it has 15% of men and women reported receiving any family life of sexes. Because they didn't receive any reported of sex education. The PRT has include nutrition, sexual and reproductive health, mental health, addressing gender-based violence, non-communicable disease and substance use. So if you are seeing the PRT intervention, there are 5 interventions they given for mainly adolescents. First one is adolescent nutrition and holy gender supplementation. So for adequate nutrition is important for growth and sexual maturation. So if they are getting inadequate nutrition, adolescents can cause chronic disease and other adverse lifestyle behavior. So nutrition education to be included in full curriculum. The principle of condom of care, the National IN plus initiative, provides a minimum service package for management of anemia. The process for iron and body care is the supplementation among pregnant and lactating women, children in the age group of 6 to 60 months. That is 6 months to 5 years and also include the new age group like adolescents. Iron efficient adolescent girls have the higher risk of preterm labor and also lower rate. So iron and body care is tabbed for adolescents is colored blue. To distinguish it from the rate, iron and body care is tabbed for pregnant and lactating women. So they initiated the weekly iron and body care supplementation scheme. It is a community based intervention that addresses the nutritional anemia among adolescents, both boys and girls in the rural and urban areas. The key features of scheme are supervised administration of weekly iron and body care supplements. That is 100 milligram elemental iron and 500 microgram of body care seeds. Clearing of target groups for moderate and severe anemia. By January de-bombing that is half and the so they are giving 400 milligram for adolescent girls and boys. That the information comes in for improving dietary intake like preventive action for intestinal bone insertation. The second priority intervention, adolescents friendly health services, access to reproductive and sexual health information services including access to contraceptives and also safe abortion services. These services they will get through the reducing of incidence of sexual transmitted infections and planned or unwanted pregnancy and also unsafe abortion. Unless the information counseling center will be made functionally by the medical officer and also actually nurse midwife at the primary health center on a weekly basis and in a community health center it will be provided on a daily basis. Services in adolescents health training will be available to all adolescents in providing integrated counseling testing services, HIV testing and sexually transmitted infection management. And third priority information, information counseling or adolescents sexual reproductive health and other health issues. The life skills based adolescents education program implemented through schools. It provides an important opportunity to inform and also educate adolescents on relevant health issues. School setting will serve as a platform to educate and also found for adolescents on behavior mismatch modification. It is recommended that schools should incorporate at least 60 minutes that is 1 hour of physical activity per day for every working day. And also they are insisted peer education approach at the community and also village level will be adapted to make appropriate reference to adolescents health training. All newly married couples and experiences will be informed about the risk of early construction and also importance of spacing between the children. Then fourth priority intervention, scheme for promotion of material items. Ensuring that they have adequate knowledge and information about the use of sanitary napkins, high quality and safe products are made available to the girls and environment to save resources and mechanism are made accessible. Through this scheme, mainly adolescents girls, we have to insist sexual and reproductive health issues, nutrition, non-communicable diseases and also mentally well-being. And fifth priority intervention, preventing health checkups and screening for diseases, deficiency and disability. Through this we can have the biannual health screening is undertaken for all the students that is 6 to 18 years of age group, enrolled in government and also government saliors schools. The component of school health programs includes screening, desiccate services, referral, immunization, micro nutrient supplements that is iron and poly-casin and also vitamin A supplements and also de-moving. The new approach in the implementation of the school health program is to establish dedicated mobile health team needed at the block level. So can I hand over to Manjula ma'am. Hello. Hello Hansel ma'am. Hello Shanti. Are you okay? Yes ma'am. I completed my portion. Can I add out to Manjula? Yes please do. So let's pass on to Manjula for the next part of the presentation. Yes ma'am. Thank you so much. Thank you Manjula ma'am. Just speak nice and clearly into the mic. Manjula are you able to use the one that was being used before? The Shanti because that worked great. Hello we can hear you then. Please go ahead Manjula. Yes ma'am. Hello. Ma'am can you hear? Yes we can hear you. Please go ahead that's great. The next component in RMSCH is pregnancy and childbirth. Pregnancy and childbirth are physiological events in the life of a woman. So though most pregnancy result in normal birth it is estimated that about 15% by develop a complication which cannot be predicted. So majority of these complications can be prevented by anti-hatred shakeups, birth preparedness, skilled care at birth, early detection of birth, appropriate and timely management of obstetric complications and postnatal care. So here the RMSCH is given some of the priority interventions for preventing the complication. The first is delivery of anti-hatred package and tracking of high risk pregnancy. Second is skilled obstetric care. Third immediate essential e-bond care and documentation. Fourth emergency obstetric and e-bond care. Sixth postpartum care for mother and e-bond. Sixth postpartum IUC and sterilization. The seventh is implementation of pre-conception and prenatal diagnosis act. The first delivery of anti-hatred care package. So it mainly concentrate on the pre-conception care. That is because pre-conception health status is an important, it has an impact on pregnancy outcome. So all mothers who are undergoing the pregnancy should have a pre-conception care. So promoting the use of colic acid in plant pregnancy during the pre-conception phase. That is three months before and three months after the conception they have to take. That is the colic acid supplementation should be given the dose of 400 micrograms after 12 weeks of pregnancy. And they should go a pre pregnancy visit before they are entered into the pregnancy. Then the next intervention is prophylactic dose of iron and folic acid supplementation in order to meet the demand of iron and folic acid during pregnancy. One tablet of iron and folic acid should be given. That is which contains 100 milligram of elemental iron plus 0.5 milligram of folic acid. It should be continued for 100 days starting at 14 to 16 weeks. And it should be continued for three months postpartum. And third intervention is injection tetanus toxa or administration. So for preventing the maternal and neonatal intent tetanus, two doses of injection TT that is 0.5 ml given in IM in the upper arm. The first dose should be given as well as the woman's resistance for anti-antique checkup. The second dose will be given for four weeks after the first dose. So if the woman is previously vaccinated within three years, only one dose is given after a year possible. Then the tracking of virus pregnancy. Mainly the three dosage conditions are mainly managed. That is anemia. If the woman is HP less than 7 grams and if she has breathlessness and if she has tachycardia that is heart rate more than 100 beats per minute she should be started with the therapy dose of iron and folic acid and she should be referred immediately to the medical officer at first after the treatment. And if HP is less than 11 gram, she should be started with the therapeutic dose of iron and folic acid and if she improves she can continue the same treatment. So here the axillary nurse, midwives of the primary health center in charges plays a nodal officer and they will be doing the timely and appropriate management of serary anaemic urban. Next is preeclampsia. So for preeclampsia routine urine testing is done in order to screen the protein at HP antidepressant. So if the mother has reduced urine output with high blood pressure that is more than 140 by 90 with or without proteins in the urine she should be referred to the medical officer at first referral unit. The third is the LTA and RTA that is sexually transmitted inflection and reproductive nerve inflection. It is considered an important public health problem in India. So this LTA and RTA has an above adverse effect in pregnancy which includes abortions, stillbirth, pre-term delivery, low birth rate, postpartum services and country care infections. And also the parent to child transmission of HIV plays a major root of new and emerging HIV infections in the children. So in order to prevent this, that is prevention of parent to child transmission services was implemented. So this services includes universal confidentiality screening and early initiation of antiretroviral therapy to reduce the HIV transmission from mother to child. So the dose of HIV, liver up in, the single dose is given 200 milligram one tablet which is given at the onset of labor pain or during the delivery which is followed by syrup, liver up in to the baby soon after birth. So now the new guidelines has recommended a single drug prophylaxis to multi drug prophylaxis. And next the priority two, that is skilled obstetrics care. The skilled obstetrics care can be managed by operationalizing by delivery points, birth preparedness, Jananese rupture eogera and Jananese issues rupture, rupture career drug. The first is operationalizing delivery points can be done by improving infrastructure, human resources by drugs, supplies and referral transport. So here the delivery point is designated as L1, L2, and L3 based on the delivery which is conducted in the state health facility. So L1 means that is minimum three normal deliveries per month, L2 is minimum 10 deliveries per month and which is including the management of complication and L3 that is minimum 20 to 50 deliveries per month including cesarean section. And also the health facility should have a referral transfer system so that they can reach the patient within 30 minutes of receiving a call and health facility within next 30 minutes. And next is the human resources. So we have to fill the filling up of regular course under the state government. So the main preference should be given to the local candidates so that they can ensure availability and presence of service provided for the community. And the sub-centers need to be equipped with a basic treatment for the most common health conditions. So each sub-centers should be mandated by at least two accredited nurse midwife, one male multi-purpose health worker, one pharmacist, and one OIS doctor or community health officer. So here all the human persons should underway free service training and they should have other trainings like IM and CI that is integrated management of women and child leaders and N-assistee that is Navajath's issue structure choreogram and IYCF that is infant and N-child feeding and by emergency obstetric and neonatal care. And next is Janani Surakshal Yojana. So which gives a cash incentives for the pregnant woman to seek an institutional birth. It was launched in the year 2005. That is mainly motivated women to deliver at the health facilities and its main objective is to reach the unreached pregnant women. So they will be giving a cash incentives both rural and urban areas. And next is Janani Sishu Surakshal Karyakram which is absolutely free and no expense delivery. This was launched on 1st June 2011 and it has a provision for both pregnant women and sick women till 30 days after birth. That is they are giving free and zero expense treatment, free drugs and consumables, free diagnostic and diet, free provision of blood, free transport from home to health institution, free transport between facilities in case of referral, drop back from institution to home and exception from all kinds of mischarges. So mainly this addresses the level to delivery on transport algorithm. And also all the vehicles have provision with advanced life support and it has a trained staff so that we can manage the emergencies during the transition. So now the Janani Sishu Surakshal Karyakram is implemented in all states and union territories across the country. The third priority is the immediate essential newborn care and resuscitation. So all the health care providers should be trained in basic newborn care and resuscitation through Navachad Sishu Surakshal Karyakram. It is nothing but it is a new program where the health personnel are trained for 2 days and they will be having a certificate in the basic newborn and resuscitation care. And all the health facilities should have a newborn care including drying, warming, skin to skin contact and initiation of breastfeeding within 1 hour of life. And they should have a linkages with the sick newborn care units at all health facilities both in first after all and district hospitals so that if the newborn requires any special advanced newborn care they can be immediately reported. And the fourth priority is the emergency obstetric and newborn care. This can be managed by 24 into 7 services maternal and child health being and strengthening public health system. 24 into 7 services is that is 24 days and 7 days 24 hours and 7 days of working all community health centers have been working and in order to provide the basic and comprehensive obstetric and newborn care services. Next is maternal and child health being this has been established due to the high case load facilities and in order to expand the health infrastructure for maternal and newborn care. Following the launch of January Surakshal Yoja and January Sishu Surakshal Karyakram so all the pregnant women are now has been coming to the institution for the deliveries so in order to prevent the over load now the msh mch wings has been implemented so which contains antenatal waiting rooms labor wing, essential newborn care room and sick newborn care unit, operation theaters blood storage unit and a postnatal ward as well as the academic wing. And by strengthening the public system that is all the health care providers should have a under control on a specific program that is they should have a 18 week long training program of MPBS quality doctors in life saving and aesthetic skills long training program in obstetric management a 10 day long training program for medical officers in basic emergency obstetric care and the 3 week long skill birth and death training for A&M and for staff analysis so thus they can provide a gain of confidence and they can be able to practice newly accurate skills and the fifth priority is the postpartum care for mother and baby so after the delivery in the institution it is mandatory to stay 48 hours in hospital and the postnatal home will be made by the frontline workers so here in the morning case of home delivery the first visit will be takes place within 24 hours of birth in all other cases atleast 3 postnatal versions should be done to the mother and 6 postnatal visits to the newborn are to be made within 6 weeks of delivery and birth here Asha which is accredited social health actress plays an important role she will be for providing a home based newborn care she will be visiting to all newborns according to a specific schedule up to 42 days of life here she will be giving an incentive of Rs. Rs. 50 per home visit of around 1 hour duration so totally of Rs. Rs. 250 for 5 visit she will be recording the weight of the newborn and she will be ensuring the BCG first it was whether the first it was of OP and DPT vaccination was given and she will be checking whether both the mother and newborn are safe till 42 days of delivery and she will be registering the birth and next priority is postpartum IUCD insertion sterilization so postpartum family planning now becomes another priority for action so currently it focuses on placement of trained providers for postpartum IUCD at district and sub district hospital and here the medical officers should also be trained with the mini lab in order to provide for provision of postpartum sterilization so dedicated RM and CH council has been appointed at public health sector so she will play a key role in increasing awareness and generating the demand for various RM and CH services and she also provide a counseling services she will be motivating the woman to adapt the modern and terminal family planning methods wherever it is appropriate and she will be ensuring the healthy timing and spacing between the pregnancy in addition she also will give a counseling on breastfeeding and other infant child feeding and child care practices and the last priority is implementation of pre-conception and prenatal diagnostic techniques act so under because at present there is a declining of six ratio at birth due to six selective abortions and due to continued neglect and poor care seeking for the cold shape so in order to prevent that the DCP entity act was introduced under LRHM so these sales will be implemented at state and basic level and they will be having a statutory bodies so they will be supervising and strengthening and including they will be doing the online maintenance analysis of scrutiny and recording and they will be doing the digitalization of registration records with periodic evaluation and they will also build a community opinion against such selective abortions and fetus site so however this DCP entity act on the other hand will not should not become a barrier to woman which is a right to the access to safe abortions for women particularly the vulnerable woman such as adolescent, rape survivors and more women from rural and marginal population so hence this act should be our utmost care must be taken to ensure the six ratio can be equal hello yes thank you thank you ma'am Jula thank you ma'am I completed ma'am should I hand over to ma'am Sonima yes please do is she there with you yes she is there excellent okay welcome Soni please continue your presentation hello ma'am hello is that Soni yes ma'am that's my soni hello welcome if you'd like to continue your presentation that'll be great okay ma'am is that audible now ma'am yes go ahead yes we can hear you yes okay thank you we're discussing other two topics in our MNCHA like adolescent and rape pregnancy health and pregnancy and childbirth so I'll be moving on to the third category in that like postpartum care for mother and baby so in that first I'll be telling you about the postpartum care so to ensure postpartum care for mothers and newborns 48 hours of sleep at the health facility is mandated in case of injury child health wings have been established in many case load facilities to provide quality postnatal care to mothers and newborns when the post dental home visit are made by the frontline workers as mentioned like ASHA workers with respect to the place of delivery in case of home delivery the first visit takes place within 24 hours of work in all other cases at least 3 postnatal visits to the mother and 6 postnatal visits to the newborn are to be made within 6 weeks of delivery of that next about the newborn and child care so in MNCHA there are certain priority interventions in newborn and child care so the priority goes like this so first is home-based and newborn care and second priority is facility-based care of sick newborn and third is integrated management of home and child care illnesses there are four first is child care operation and essential micro-optimization and first is immunization fix early detection and management of defects and birth deficiencies diseases and disability of children so here I will be explaining the fourth and the sixth priority together moving on to the first priority home-based newborn care and child care so the infant mortality rate neonatal death accounts for 59% of infant mortality at a national level most of this occurs in the first week of life so global events shows that home visit by community health workers to provide neonatal care and settings where access to facility-based care is limited or not available in associated with release of neonatal mortality the home-based newborn care came launched in 2011 provides for immediate postnatal care again this grand plan workers are trained and they are incentivized to provide special care to preterm and newborns they are also trained in identification of illness, appropriate care and referral through home visit so moving on to the next priority facility-based care of newborns in order to strengthen the care of sick premature and low heart rate newborn special care unit that is SNC being established at district hospitals and tertiary care hospitals so SNC use with provision of advanced care of sick newborns must serve as the referral center for entire district referrals from peripheral unit and admission of outbound sick newborns to SNC should be monitored closely another non-unit known as newborn stabilization unit that is NBSU which is a prohibited unit providing basic level of sick newborn care is being established at community health center as part of the journey Shishu Sureshkarikram all newborns providing referral transport is also to be provided for transport from home or community to healthcare facility so follow-up of sick newborn after discharge from the newborn facility to be an integral component of unit of care next priority is integrated management of common childhood in us so in order to address the common causes of neonatal and child death in India an integrated strategy that includes both preventive and curative intervention has been adopted that is known as integrated management of more neonatal and childhood in us, IMNCI and it is provided at different levels that is ASHA package if it is at the community level it will be ASHA package and if it is a first level care IMNCI and referral level care that is F IMNCI so various aspects if you are looking at the various aspects of this IMNCI it includes child nutrition, immunization the importance of disease prevention and health promotion so again there are mainly three components for that it includes improvement in case management fields of health improvement in overall health required for effective management of neonatal and childhood illness and improvement in family and community care practices the leading causes of death beyond the neonatal period are diarrhea and pneumonia prevention must be given to the management of these two illnesses two illnesses so availability of ORS and sync should be considered at all sub centers and with all frontline workers use of sync should be actively promoted along with use of ORS in the case of diarrhea in children then again use of recommended antibiotics according to the national guideline in children aged 2 months to 5 years with the non severe pneumonia must be ensured through frontline workers that is the ASHA workers or ANM workers and at all level of health facilities the prevention and treatment of malaria as per the guideline in national malaria health control program should be emphasized as part of child health intervention the child health program managers should closely direct the managers of the medical facilities control program and the medical facilities district to track progress hospital based care and management of children severe diarrhea and pneumonia is another important aspect of preventing death due to these two causes this includes training of health care health service providers that is the doctor's analysis especially those that require you at least 1st or 2nd unit which is the organization of emergency care to receive healthcare ensuring availability of essential equipment and drug and application of management protocol next is the next that is immunization immunization has one of the largest in India has one of the largest immunization program in the world for vaccination each year universal immunization program includes vaccines to program 7 vaccines collected in the hospital to prepare for your procedure, procedure, etc. in the hospital hepatitis B the Japanese answer flag that is J.E. vaccine has been introduced in a campaign mode and also is confronted into the routine immunization program second dose of immunization has been introduced and hepatitis B vaccine is now available in the entire country the pentavalence vaccine a combination of combination of hepatitis B, hepatitis B and main ophthalmic of the intracranthal B was introduced in the state that is Kailan, Tamil Nadu and it is being expanded to 6 states and this event should be used for the entire country the call to change must be further set to the requirement supply so India has been declared for the since 2011 however a high level of disease has to be introduced maintaining high vaccination coverage level among children with at least 3 doses of oral polio vaccine administration supplementary doses of OPB to all children for 5 years to the next administration days so coming on to the next part of 2 there is child health screening and early intervention services but with last year Bala Swasti Parikram expanding focus on child survival through more comprehensive approach of improving child development and quality of life is the guiding principle of new initiative called child screening and early intervention strategies the objective of child health screening is to detect medical condition at an early stage thus enabling early intervention and management ultimately leading to production in mobility and life-long stability so this initiative aims to raise 27 poor children and only in the age group of 0 to 18 and fully implemented across the country so here I want to explain about the 4 categories that is child nutrition and essential micro-nucleotide supplementation which will be coming under the preventive strategy so given the magnitude of child and education in India one of the key preventive intervention is the promotion of infant and young child screening strategies optimal breastfeeding and complementary screening strategies to be there to allow children to be in their full growth potential their client resting of weight is born of lower weight and be maintained by the frontline workers that is ASHA workers and their follow-up should be ensured so that mothers are supported mothers are supported for optimum feeding and childcare practices and growth, quality will be detected early on in order to promote social condition of moderate or serious rendition so in order to introduce in order to reduce the prevalence of anemia among children all children between the age of 6 months to 5 years must retrieve iron and folic acid tablets or syrups as appropriate for 100 days in a year as a prevention measure if in the presence of ground therapy a quality decision has to be provided by weekly iron and folic acid supplementation for 3 to 4 children of 6 months to 5 years as part of national iron initiative ASHA workers will be incentivized to make more budget and to provide at least one dose per week under direct observation and educate the mothers about benefits of iron supplementary then in addition there is a provision of weekly supplementation of iron and folic acid supplement to prove the grade in government and government aid at schools then weekly supplementation for out-of-school children at other body centers then deworming can be carried out that is with alphabet or syrup or tablet and syrups can be carried out every 6 months in order to reduce the industrial parameter using the bi-administration of deworming tablet or syrup this intervention can be combined as a vitamin A supplementation for high annual rounds as part of government's for vitamin A supplementation children between 9 months 9 months to 5 years and even 6 monthly doses of vitamin A a child must receive 9 doses of vitamin A 1 sub-verbal currently the program provides care to children with severe acute malnutrition that is ASAM and this is mainly through facility care given the magnitude of this program in India it is not the most viable approach the comprehensive strategy including promotion of optimal infant and end child feeding practices throat monitoring and promotion care of children with severe acute malnutrition in community care centers at a complicated cases of specialty based will be implemented in partnership with ICDs integrated child care I am just going to have to interrupt you there I know you have one more slide to go but we are running out of time so I am just wondering if you mind if we stop there and see if the audience has any questions almost I have completed the topic yes I know we got right to the end so thank you very much thank you very much and let's see if anyone out there has any questions Shagufa you had your hand up earlier and I think it's come down now did you have a question for us no no but we are not having you don't have any we'll just see if anyone can type oh here we go here is one what are some reasons that women avoid going to hospital for birth hello ma'am because they are fear to alone yes ma'am because women are having a fear to go institution delivery so they want always home delivery it is easier for them so that's why they are avoiding to go for hospital for birth hello so the question is why are they avoiding to go is it the cost even though you were talking about being so with the implementation of the free service has that increased the attendance to the hospital and now they are getting free service so many mothers are going nowadays even though the remote area they are having home delivery thank you we have another question here what is the role of the professional midwife in India so now she is both educator, guide and researcher and now NRAC that is national rural health mission they are arranging the harsha one lady health worker she is going to house to house and finding out their problems from the mothers so like in her role also like a midwife role so according to professional role means we are one thing educator and clinically we are managing it not like we are going for team team to the remote area hello thank you, thank you Shanti, thank you for that answer okay and how is the relationship between the mothers and the midwives it is very good nowadays because it is very good nowadays ma'am because government of India they are arranging many health workers they are finding many health workers so instead of house to house identifying the problems so they are more mingling so they are having good relationship between the midwives and also mothers so they are increasing more to the institutional way of getting care rather than the home care so nowadays police is very good that's great, thank you very much thank you okay any others I always will say thank you I'm assuming that the programs you have talked about are for the poor, what do the richer women do definitely she will go to institution delivery because here the government of India concentrating only the village and urban area so in the rich like town and district and city me they are going to the institutional delivery and they are getting good care from the hospital but government of India concentrating only the remote area who are at poor so they are giving free service and they are getting more benefit from the government okay excellent thank you very much that was very interesting and it sounds like a lot of implementation and workers has happened in this area so thank you very much Shanti and Manjula and Sony for your excellent presentation and so we just offer the end there yes okay so I'm just going to stop recording now okay man thank you so much for giving opportunity thank you to one and all thank you very much pleasure thank you