 Right, let me introduce our speaker and then I'll hand the presentation over to her. So Dr Ritu Agrawal is a public health management professional, working in the domain of sexual reproductive maternal and newborn health. She has done MPH from the London School of Hygiene and Tropical Medicine in the UK and is a trained obstetrician and gynecologist. She's worked with the Centre for Maternal and Newborn Health at the University of Liverpool. She's worked with the World Health Organisation and in UNICEF and country offices in India. She's a senior professional with 16 years of cumulative experience in public health, clinical obstetrics and gynecology and she provides quality improvement strategies and frameworks for the successful management and expansion of public health interventions. She identifies new strategies and innovations for public health improvement and to her accolade she has co-authored more than 15 national guidelines. The latest one is a national operation plan for midwifery released during the Partners Global Forum in December of last year. She has many publications in peer-reviewed journals and has been a part of national and international research initiatives. And currently she works as the deputy director for sexual reproduction, reproductive health and rights with the MAMTA Health Institute for mother and child in New Delhi in India. So it's my pleasure to welcome Ritu Agrawal. Thank you very much Chris. Yes. Good morning everyone. Yeah, good morning everyone. At the outset, it's a good morning. There's always gathering on the centre of the MAMTA Health Institute and presenting on behalf of MAMTA Health Institute for mother and child. You're working predominantly in the area of sexual and reproductive health and known for working with community and health systems. I'm thankful to my co-authors who have been of immense support to me. And now I am an obstetrician and a public health professional by training who is working in the area of sexual and reproductive health from the last two decades now. In fact, this is a thanksgiving moment for me to all those midwives who taught me patient care, patient safety and labour room protocols. To increase women's access to quality midwifery services has become a focus of my efforts, realising that it is the right of every woman to receive the best possible healthcare during pregnancy and childbirth. With this perspective, I'm here presenting on how to optimise health workers' role for improved quality of reproductive and newborn healthcare services by promoting midwife-led care. My presentation, rather this brief journey with you a few minutes, will take you through the Indian scenario and burden of preventable deaths. This is the outline of my presentation where I wish you to walk with me on why midwives are ideal while optimising health workers' role in RMNCH space and how the newly launched programme on midwives will pay dividends in long run for India. To begin this, let me present some demographic data reflecting on disparities between Southeast Asian countries and India. I'm here reflecting on Southeast Asia status to emphasise the magnitude of India and its diversity. The Southeast Asia region is made up of 11 countries with over 1.8 billion people with India's population contributing to 1.2 billion. The diversity of people and the health situation everywhere requires, on the demand side, a good understanding of the emerging socio-economic, epidemiologic and demographic patterns to reduce sensitivity to disadvantaged populations and vulnerable segments of the society. On the supply side, it is equally crucial to have a good understanding of the health systems, the circumstances and political economy under which they operate. In this context, I would say that midwives are really a cost-effective fit. Within the continuum of reproductive health care, antenatal care increases the likelihood of an institutional delivery and acts as a potential determinant in reduction of maternal morbidity and mortality, low birth weights, perinatal and infant mortality. The figure in front of you reflects the National Family Health Survey for data where 74% of mothers had one ANC visit and only 51% had four ANC visits. The good point here is that 91% of would-be mothers who had four ANC visits delivered in a health facility. But the not-so-good thing is that this clearly implies loss of contact with many pregnant women after their first visit. The blue row below shows the regional status of health workforce density per 10,000 population and where you can see India is no different. Almost all countries are struggling with the issue of human resource. This is to link why task-shifting is of paramount importance and how investing in midwives will be helpful. I don't have to speak about significance of skilled birth attainers in this august gathering. The blue highlighter bar around India is showing the date of institutional delivery. Our national average of institutional delivery is 79%. However, in a public health facility it is still 52%. In addition, most of these deliveries are happening at tertiary level of health care system. The reasons for lower tendons are distance from home to facilities more, there is no transportation and high out-of-pocket expenses. This further clearly points to a missing link in the health care system where promotion of access to health care alone is not sufficient. It points towards the non-homogeneous nature of pregnant women whose ask is to understand the social system around them. Again, the lower blue bro is showing India is no different. Under such low availability of human resource, access-shifting is a necessity and not an option. In an era of digitalization I unapologetically I unapologetically say that there is no health without a workforce. The Lancet 2014 guides that med-life free is associated with efficient use of resources and improved birth outcomes when provided by the professionally trained med-fives. Post-natal care within two days of delivery of the mother and her newborn is not only important but also reflects the efficiency of the health system, the reach of human resource and community processes. 73% of urban women received a post-natal check within two days compared with 62% of urban women. To add, there is a positive relationship between the mother's level of education and post-natal checks. India's economic growth has been steadily with GDP growth above 8% per annum. However, health challenges have still prevailed for a large proportion of the population. 70% of the Indian population lives in rural areas and among them, the most vulnerable population are the pregnant women and children who get disproportionately affected. Though I can proudly say that India noticed significant improvement in maternal and unital outcomes observed rapid expansion in healthcare delivery infrastructure and still experiencing improvement in overall human development index after the launch of the National Health Mission. The maternal mortality ratio has also declined by 77% from 556 to 130 per 100,000 live births in few decades and unital mortality rate has also come down. However, this impressive increase has not led to commensurate decline in maternal mortality and neonatal mortality. As per the rural health statistics 2016, there is a 77% shortage of obstetricians at middle level of healthcare facilities. As a result, the tertiary level is getting overcrowded and those who need special attention of doctors or specialists suffer. The rising rates of cesarean sections are alarming. Cesarean sections have almost doubled from 9% to 17% in last decade. The desegregated data shows high cesarean sections among first births. They are more in private sector health facilities in urban areas and among more educated women. However, the most worrisome part is increasing complications during second or subsequent deliveries. There are rising rates of placentaic rita and out-of-pocket expenses averaging to 46 US dollars. I don't have to inform the able audience that social determinants are operational at various levels and undoubtedly play a detrimental role. India's population is the second largest in the world and a 70% rule and the status of women is low. Overall coverage of evidence-based interventions has increased over the past decades but still hasn't reached the desired level. Ensuring availability for skill attendance and birth in remote facilities remains a challenge when there is overall shortage of skilled human resource. As per WHO, the task shifting or task sharing is a process of delegation enabling mid-level health care professionals to provide clinical workforce. It deals with the efficient use of human resources and help increase coverage, access and efficiency of healthcare service delivery while remaining cost effective. Within this context, to optimize health workers role and expand the resource pool, task shifting is important and will help with improved ratio of providers to women, amount of doctors time getting freed up for more specialized services and overall improvement in quality of care. Global evidence is shows that midwives trained to international standards can take care of 87% of essential newborn and maternal services. Since this I have covered already in my previous slides so I will just skip this slide. Taking example of contraception in task shifting. Contraception is an inexpensive and cost effective intervention but health workforce shortage and restrictive policies on the roles of mid and lower level carters limit access to effective contraceptive methods in many settings. The high end met need shows disconnection between a woman's fertility preferences and what she does about them. She wants to avoid conceiving but fails to do what is needed to prevent pregnancy. As informed earlier that almost 40% of our women reported during last survey the lack of awareness about the contraceptive methods despite the fact that there is a growing demand for both limiting and spacing birds. The lack of women's autonomy in reproductive decision making compounded by poor male involvement in sexual and reproductive health matters. Though India has already enabled mid and lower level carters of health workers to deliver a range of contraceptive methods however authorization to provide basket of contraceptive choices are limited. The actual history here dates back to 1872 when few nurses were trained in New Delhi and then battery of work followed in relation to midwives but then later in 1946 the Boer committee stressed on the need of professional midwives. Today here I am reflecting upon learnings from 2002 onwards when Indian nursing council introduced post basic diploma in nurse practitioner midwife when the program did not take up the intended shape due to lack of role clarity among staff nurses and auxiliary nurse midwives. Lack of integration into the existing health system. Probably the health system was not ready to accept midwives as a separate carter at that point of time. Lack of clearly defined career progression pathway making it difficult for the newly introduced midwives to move forward and lack of legal and regulatory framework. All these together pose a significant challenge. Apologies this slide is crowded but this is just to flag the depth of analysis which was undertaken by Indian government and experts before the launch of our midwifery program in December. The slide is reflecting the specific areas and gaps with the earlier curriculum in nurse practitioner in midwifery course against the ICM standards. What former secretary general of the united nation said to ensure every woman and her newborn have access to quality midwifery services demands bold steps. Although overcoming failures is necessary but learnings from failure is most essential. In December 2018 during a global event the ministry of health and family welfare made the landmark announcement to initiate midwife led healthcare services and introduced new carter the midwife. These were in fact very warm moments which were ingrained for lifetime for many many like me. The objectives of the new midwifery program are in context with a public health scenario as shown in slide 8 which focuses on improvement of access to quality maternal and newborn health services. The new objectives of the midwifery program is promotion of natural birthing promotion of positive child birthing experience, promotion of respectful maternity care, identification management and referral of women and newborns experiencing complications and finally to decongest higher level of healthcare facilities. At a personal level I wish the midwives to ensure a behavior that fulfills women's personal expectations of giving birth to a healthy baby in a clinically and psychologically safe environment in hands of a competent midwife. My personal and professional experience taught me that this is possible only when a midwife tries to be kind and compassionate not only towards the woman but a family and a newborn and I am very hopeful that this will be palpable soon across the country. Out of all objectives I put the respectful care because it utilizes the midwife led philosophy of care and my belief is that one happy woman going back to community motivates 10 others to come into the institutional fold. So the key features of our midwife free program are promotion of task shifting, recognition and status by providing career progression, Indian nursing council and respective state councils are working towards certification regulation and legal protection of midwives and for their autonomous practice, establishment of task forces to overview program at every level. Non-rotatory duty of free midwives for reasons known to everyone here. The criteria as you can see is very well defined at these facilities the midwives will be the first point of contact. The midwife led healthcare facilities will be at all high case load facilities even in hard to reach areas and where the rate of own deliveries are high. Availability of a specialist with established referral linkages forward with tertiary level of healthcare facility and backward with community is a must. Once functional these facilities will also help in reduction of second delay due to transportation reduction of out of pocket expenses and improve access and coverage with which I see increased number of antinatal and postnatal visits for both mother and her newborn. The scope of care covers the continuum of care from frame planning, antinatal care, intranatal and postnatal care of mother and newborn. For education and training the curriculum is based on adapted global ICM competencies. The focus will be here on continuous competency assessments of educator and care providers both. Now a special directive has come into force in India this states that midwifery educators will have a dual role as clinician and teacher. I again see this having a dual impact on our public health. One educator skills will remain intact and during classroom or demonstration classes they will be able to share their own experiences and build on case scenarios to help students learn. Two the other best part what I feel is standardization of technical protocols. There won't be gap in practice and teaching. What you are teaching is what you are practicing. This slide is reflecting the selection criteria to apply for new professional training in midwifery. A registered nurse registered midwife with GNM or BSE nursing and with two years of work experience can apply for this course. The midwifery training curriculum will be based on revised ICM essential for competencies. The training to be on par with global standards it is imperative to focus on educators and their trainings. The selection criteria for midwifery educators is well defined as you can see in this slide. A cascade model will be used and the roles and responsibilities are again as per WHO and ICM recommendations. As far challenges are concerned WHO Boolean analysis states any country to accelerate progress a range of factors inside and outside the health sector need to be acknowledged. This further implies that no single factor or strategy or configuration can work to get the desired results in acceleration of health. At one hand, barriers or challenges like income inequalities, geographical disparities and socio-cultural practices limit acceleration processes. However, on the other hand enablers like women's participation in workforce, higher education cross sectoral converges and collaboration with different stakeholders, involvement of local leaders accelerate processes. In this context, selection of right-willing in-service candidates, right educators and right working environment, which include use of adult training methodologies focus on cognitive functions and working in a team-based manner is challenging but not impossible. Considering size of India, achieving optimum number of professionally trained midwives before 2030 may pose a challenge. Here, I am referring to requirement of number of educators, number of training institutes and number of care providers to achieve saturation to be able to palpate the change. From a long time, midwife was simmering under the surface but now there is a political commitment and ambient governance to drive this agenda with full acceleration. Being an OBGYN already informs the audience that this is welcome. Our word is to strengthen accountability mechanisms at various levels. Understanding of the healthcare market and market forces and role of private sector is the next step in our onward journey. Positive attitude towards innovation and practices and keeping ourselves evolving with new evidence is the way to go. Thank you very much for listening out to me. Thank you very much. Have a good day. Any questions are welcome. Portia wants to applaud if you highlight your own name you can applaud by setting your status which is what I'm about to do like that. Thank you very much Ritu for that. Obviously there were people really interested because there were quite a few comments going through so I'd like to throw the floor open to questions. If you have any questions for Ritu you can put them in the chat box if you want to speak I can enable a microphone for you but if you do ask a question verbally I would ask you to put it in the chat box too. Any questions please? Portia I will ask there are several questions coming in now can we start with Deeper's question Deeper says there is no scope for direct entry education and why is that Ritu? Presently this is a conscious decision with Government of India that there won't be a direct entry education. Probably we are not prepared for this course we need to first strengthen our pre-service courses and then look forward to the direct entry it may happen or it may not happen but currently we are India government is close to this and with great difficulties everybody has come on board to launch the mid-wife as a carter and the mid-wife led care services so we are not currently looking forward to direct entry education but still we are not closed if we get enough evidence in support of direct entry education then it may happen. Thank you for that Portia would like to ask a question I think you should be able to unmute now Portia, try unmuting. There is a question why is there a restriction on having been a nurse prior undertaking mid-wife retraining so I would say that there are different public health carters also in India who are who look forward to apply for this mid-wife workforce restricting ourselves to GNM and BSE courses because we did thorough evaluation of their course content and we found even the auxiliary nurse mid-wife course content is lagging behind it needs to match up the course content for the mid-wife so GNM and BSE public health nurse is the eligible candidate for this hope this satisfies your question. Thanks okay thank you for that Portia would like to speak Portia when you've asked your question please will you also type in the chat so we will see it there so go ahead now Portia I'm afraid there is one more question actually we see mid-wife retraining as an autonomous profession that is why the carter has been started if there if there won't be a carter you know there won't be an autonomous profession so I inform you in my one of my present in my slide that in a nursing council and many of our state councils are working towards making it autonomous by providing the legal authority and the autonomous character to the entire mid-wives and the mid-wife free framework yeah so this would be a long thing you know obstetric lead culture will be addressed in regard so being an obstetrician many of our obstetrician forums are open currently to introduce midwife and they are welcoming midwife we were not expecting this kind of a you know we were also not expecting this but you know everybody has come forward to welcome midwives and midwife lead care health services because currently everybody realizes that in India and Indian women are suffering because of lack of human resource and in rural areas especially and in hard to reach areas there is significant number of less number of people working in the area um so next question um have a question from Sarah how will the obstetric lead culture be addressed in regard to allowing midwife lead services so this I see there are some potential challenges you know in the private sector but not in the public sector because in the public sector people would we will be able to handle and train most of our midwives and obstetricians and the specialist and it is not only the obstetricians actually it is the allied health care professionals also who working in a team with the midwife who needs to give respect and support to the this newly introduced charter initially there would be some resistance but I think that the um government intervening and government and the nursing council intervening at every step I see this as a big support system rather than a challenge so I think our midwives will be able to handle and we will be training our midwives to handle all these during our 18 months course also so for this behaviour change and everything for the forward looking for the onward journey we will prepare them okay thank you thank you that's answer the question Tara yeah okay um Portia has asked a question about um you talked a little bit about it earlier I think about the restrictive policies against contraception in India perhaps you could enlarge on that for us so um I Portia I really did not understand your question because um this is in regard to the policy framework or to the implementation ground because we have very clear policies in terms of and the policies are not restricting somehow about the contraception that is the that is the gap we have the policies in place but the implementation level at the implementation level we are not able to implement it properly because the contraception and the sexual health matters is a very sensitive issue and the community comes very close and Indian diversity offers it a very big challenge currently to implement contraception in India somewhere you know injectable contraceptives are welcome and somewhere it is not so it is quite a diverse situation currently with us but Indian government is dealing with it and we are preparing our frontline workers on contraception policies and to make them implement so many of the non-governmental organizations and local partnerships we are encouraging and the local leaders are getting on board so that you know contraception needs for the marriage as well as for the unmarried women can be met so we are taking young people on board so probably the target force is now the adolescent age group which is aging from you know 14 to 19 or 22 so that is our focus group currently okay thank you does that answer your question Portia legal support of religious barriers to contraception legal support of religious barriers you know there are two different contradictory things so there are more religious barriers here you know that religious barriers always exist in the society and that is the biggest challenge but but the policies do not consider the religious barriers they are for the public in general and they do not consider the religious barriers so we are not divided on that front the policies I think Portia I think Portia's question is she if there are religious what is the word I am looking for if some religions are against some method of contraception and the law then enshrines those religious objections so that the state has effectively made some things difficult or illegal because they are frowned on by a religion one or more of your religion no no no it is not like that those state health is a state subject we call state as a province is called so it is a state subject but nothing related to contraception contraception is allowed and females are females can take anything from the basket of choice but the only thing is female itself because of the rural population and the uneducated strata of the background characteristic it does not make them aware what is available to them so they are not able to utilize so the unmet need is still high people are not aware people are not utilizing the services provided and those which are available are little you know they are people are not very competent to provide them so it is fundamentally an access problem rather than a rules problem yes so it is an access problem along with somewhere it is availability and out of pocket expenses to reach that thing understand okay thank you deep has asked another question now what is the legality of midway so willing to work in India presumably therefore from another country to increase access to midwifery care but they are not nurses but they are professional midwise with the midwifery registration so I will answer yes sure so this one we have taken special consideration since we are open to all those midwives who are working who are Indian and who are not Indian who are working around and in the globe and who have good background of midwifery are welcome in India so Indian nursing council would make a special provision for one year sub you know they will give a one year period for them to come to India and practice and at the end of one year that license can be renewed so this is a special provision which will come into play you know in one in few months now because Indian nursing council is currently working on them and during the last expert group meeting this was taken a decision so I am sure they will be able to implement but I will take your work forward with the Indian nursing council and ask them to expedite their work thanks and Kerry asks have you seen Kerry's question are there plans for a separate midwifery council eventually so Kerry there are no plans currently for separate midwifery council but I am glad to inform you that the Indian nursing council has put their name to change to Indian nursing and midwifery council and parliament has passed that bill and it will be soon not the Indian nursing council but Indian nursing midwifery council so there would be one body who would be looking at the nursing and midwifery there won't be a separate midwifery council per se yes this is a very big step and we need all luck thank you very much okay we have a few minutes left we have time for one indeed we have time for one or two more questions if people still have questions to ask you want to see that this is annoying me this is annoying me that's a problem to do with the argument I can hear some background noise Deb okay I think we're coming to the close now I'm about to move on to final slides oh thank you Rita for sharing your email if you do touch with, if you don't capture Rita's details and you do want to contact her then of course you can always come via us at vidm but if you connect directly with Rita that would be brilliant thank you very much Rita that was a really interesting presentation and we can obviously see that a lot of people were engaged with the progress you're making in India thank you very much Chris and thank you very much everyone