 So as I said, I'd really like to welcome the presenters from India. There are four presenters today, Professor Baby Venkatesh, who is a professor in a statistics and has undertaken her undergraduate and postgraduate studies in a statistic and gynecological nursing. Her main area is the interest for adolescent health, nursing education and moulding students to be the best they can be. She's published several articles and research paper and is pursuing a two-year fellowship program in the Foundation of Advancement of International Medical Education and Research, and she's currently pursuing her PhD. The next speaker is Professor Christy McCayla and she's a professor in community health and has undertaken her postgraduate studies in community health nursing. She's currently pursuing also her PhD and she's a resource person for training the trainers involved in the Global Fund for Aids, Vocavocas and Malaria program. Mr Santhi M.D. is also an associate professor in a statistics and has completed her studies in a metric and gynecological nursing. She's also published several papers and is pursuing her PhD. And Ms Anci Nathu, Anci hails from Kerala and has completed her postgraduate studies in OBG nursing and her main area is the interest in pain management in labour. And she's about to get married in a month's time and is awaiting to start her professional marital life. So welcome to the Four Ladies from India and I'll now hand over to them to start their presentation. Okay, Davey would you like to go ahead? Yes, yes, Jillian. Thanks for your introduction. Some PSG and Coimbatore, we wish you all a very happy midwife's day. We are here to present on safe motherhood initiatives from India. Just before going on to the entire topic, this is where we are, India. India has 28 states and 7 union territories. These states are further subdivided into districts. Current population of India is expected to be 1.27 billion, males comprising 655.8 million and females 614.4 million. The state where we are here is Tamil Nadu. Tamil Nadu is one of the most important states. This is even largest in terms of area, 7th most populous state in the country. Population of Tamil Nadu is around 70 million according to the 2011 census. It's one of the most adorned states in India and this stands second in total employment and holds 6% of India's population. The city where we live is Coimbatore. This is also called as Kovai, the second largest metropolitan city. It is the textile capital of Tamil Nadu. Fourth largest metropolis in South India. There are numerous temples around the city and there's a home to 7 universities, 3 medical colleges, 35 political colleges, 70 arts and science colleges and 64 engineering colleges. It is the educational hub of South India too. This is our institution, the PSG institution. The own alliance of Tibet and multi-speciality hospitals which caters adjacent population. This is our campus PSG. PSG institution has a medical college, nursing college, pharmacy, therapy, engineering, all the courses in it. Adjacent picture what you are viewing is our college, PSG college of nursing and this caters the student population of 325, inclusive of undergraduates and post-graduate. Majority of the faculty are undergraduates and those being their doctorate programs. So this is one of our classroom, model classrooms for final year classroom. Today's topic for our discussioner, I'll be discussing on the maternal mortality rate and trends in India, current education system of preparing midwives and maternal rights programs offered at the central government and at the state level. India's second most populous country in the world next to China. Currently there are about 61 births per minute. More than 50% of the India's population is below the age of 25 and over 65% below the age of 35. 72% of India's population lives in rural areas. Rest of the 28% are urban areas. And when you take the population of India, every year India adds more people than any other nation in the world. In fact, individual population of some states is equal to total population of many countries. According to the state census 2011, most populated states is Uttar Pradesh with a population of 19.96 crores. The least populated state in the country is Sikkim with a population of 6,7,688. Some of the reasons for India's rapidly growing population are poverty, illiteracy, high fertility rate, rapid decline in the death rates or the mortality rate and there is a lot of immigration from Bangladesh and Nepal too. Along by the swelling population, India started taking measures to stem the growth quite earlier. India by launching the National Family Welfare Program in 1952, India became the first country in the world to have a population policy. The family planning program has yielded some noticeable results bringing out significantly highly the country's fertility rate. So this is a global scenario of the maternal mortality rate. The global MMR in 2010 was 210 maternal deaths per 1 lakh live births that is down from 400 maternal deaths per 1 lakh live births in 1990. The MMR in the developing regions has been 15 times higher than in the developed countries. Sub-Saharan Africa had the highest MMR at 500 maternal deaths per 1 lakh live births while Eastern Asia, that is countries including China, Korea, Japan, Mongolia had the lowest among the minimum development goals in developing regions, that is at 37 maternal deaths per 1 lakh live births. This may be owing to China's one child policy adopted by China in 1978 that has brought about the tremendous results for China. The policy plans to have prevented between 250 to 300 million births from 78 to 2000 and 400 million births from 79 to 2010. The MMR of the remaining million development goals developing regions in defending all the maternal deaths per 1 lakh live births in Southern Asia, Oshania, Latin America, Northern Africa and Central Asia. The direct causes that contribute to majority of the maternal deaths include haemorrhage, sexes, unsafe abortions, eclampsia and obstetric labor. And since the rural population is more, the access to healthcare facilities are little less in the rural populations for which the government of India and the state government is working. This is the MMR of the statistics of maternal mortality rate in India. India currently the maternal mortality rate is 212 per 1 lakh live births. We have started working towards the minimum developmental goals. Already three states, Tamil Nadu, Perilla and Maharashtra have reached the minimum developmental goals and other states are on the way to reach the minimum developmental goals. As we know this minimum developmental goals are as numerical and time-bound targets to measure the achievement in human and social development laid down by UN, goal 5 concentrates on improving the maternal health and indicator is the MMR. India by its all the programs are on the way of reducing the MMR and reaching its way to minimum developmental goals. So it is not sufficient that adequate planning is done from the part of the government but also we need a health force that is sufficient enough to implement these programs. As a part of that, the government has taken a lot of steps to improve this workforce. So to improve the nursing workforce, what are the initiatives taken? I hand over the session to An Singh to continue on the workforce centering. Thank you ma'am. Thank you all a very happy International Advice Day. Midwife means with the woman. Midwife is considered to be one of the world's oldest provision and India has got a rich tradition on midwife. In the traditional practice, women from within the community have turned into midwives and they were attending the deliveries. Today, these traditional midwives are replaced by trained certified midwives. Indian midwife free practice is based on midwife free model of care. In this, after this model pregnancy and childbirth are considered as normal physiological process and only assistance will be provided to the mother who is in labor. The components of the model of care includes monitoring the physical, psychological and social well-being of the mother throughout the childbearing cycle, providing the mother with individualized education, counseling and prenatal care and hands-on assistance during labor and delivery, minimizing the technological interventions, identifying and referring the women who are in need of surgical attention. So, initiatives for training midwives in India, initiatives for training midwives in India is taken by Indian Nursing Council established under Indian Nursing Council Act of 1947. There are various programs offered by Indian Nursing Council which includes auxiliary nurse and midwife free with the basic qualification they need is a 12 year of schooling and it is a one year program and they will be designated as registered auxiliary nurse and midwife. The next program offered is general nursing and midwife free. The basic requirement is 12 years of schooling, it is a three and a half year course and they will be designated as registered nurse and midwife and they can work in the primary health centers and hospitals. The third program offered is basic BSE nursing program. It is a 12 year of, it also needs a basic schooling of 12 years. This is a four year degree course and they will be designated as registered nurse and registered midwife. And the fourth program offered is master's degree in obstetrics. The basic qualification needed for this is a four year basic BSE nursing program and this master's degree program is for two years and they will be designated as registered nurse and registered midwife. They can practice in the hospital setting as well as they can be in the teaching side. So even after having these many programs, there is still a lag of 3.50 lakh nurses against the total need of 10.43 lakh nurses in India. So Indian Nursing Council along with the trained nurses association of India have introduced the program of independent nurse practitioner which is already being implemented in the states of Kerala, Tamil Nadu, Gujarat and West Bengal. Under this program, trained nurses are expected to take up normal deliveries in the sub centers and primary health centers in the absence of doctors. As for this independent nurse midwife practitioner, this program is focusing on utilizing the knowledge, skills and authoritative power of midwives and they will be accountable for the care what they are doing. Along with all these things, along with the female, taking care of the female they also take care of the male patients also who are suffering with sexually transmitted disease or reproductive tract infections. And under this program, a continuity of care is expected out of the midwives. What is the scope of midwives practice is they can, even after doing their specialization, they can further specialize in areas where they are interested like they can work as lactation consultants, they can focus only on postnatal care or they can focus on complementary therapies which can be provided during labor like acupressure, refluxology, on naturopathy and other things. So India is expecting that out of all these programs there will be a decrease in the maternal mortality rate and infant mortality rate and the Millennium Development Goals will be achieved. So the other programs which is conducted by the central government and state government will be discussed by Professor Christie. Thank you. Hi and warm greetings from TSC College of Nursing. I am Christie. I am Christie here. I wish you a happy International Advice Day. India is a developing country and we are in industrial demographic stage. That means we have high birth rate and low death rate. We have achieved the death rate here. Our nation is taking diverse steps to reduce our growth rate. So from the starting from history in 1946 exactly both communities have recommended the primary health care focus and in 1952 we have started with family welfare program. It is the first nation we are concentrated on towards control and comes to after that 19, like 1978, it is a millennium we have changed in the primary health care concept after the Alma Atta Conference held in USSR in 1978. Based on this we have started with nation health policy in 1983 and we have given 12 targets including maternal mortality rate and infant mortality rate, like MMR we are focused to reduce to 2 and IMR we are focused to reduce to 60. But we have started in the year of 1992 child survival and faith motherhood. Here mainly we are concentrated on how to bring the child survival rate and bring the faith motherhood. And after that it is 1997 it is reproductive child health program it is started. Here we have it is incorporated with child survival and faith motherhood is incorporated with RCKH. So the components of RCKH is family planning, child survival and faith motherhood, prevention and management of reproductive tract infections, sexual transmitted disease and HIV and AIDS. Also adolescent health care and family life education and last one is client opposed to health care. These are the focus we have started in 1997 and when we are reaching 2001 census actually we have kept the target for 60 IMR and 2 per 1000 MMR but we have reached it is almost 4 per 1000 MMR and 72 per 1000 IMR. So on one goal we have achieved this death rate that we have reduced to 6 per 1000 actually we have reached our goal. After 2001 again we have revised the nation health policy in 19 2002 and 2005 we have started with NRX program. So in the RCKH program mainly we are concentrated like decentralized health care and what is the main shift of this paradigm is vertical program into integrated service delivery. Like earlier in our nation it is a very many states are here so they have focus from central they have focus all the states and they have concentrated all the programs. But now it is integrated from the peripheral level they have to start working and they have to tell their needs and demands from the peripheral level. That is the main paradigm shift it is happen here and it is earlier it is camp oriented like we will conduct camps and we will reduce collect all the mothers of family planning everything will collect the people. But here it is client oriented they have to come forward they have to take initiative. Then target oriented we have set the target and here it is goal oriented and we have focus quantity earlier and now it is quality. So quality wise we are improving the whole health service and the peripheral rural level. We are incorporating all the health system services and we are developing the resources in the rural areas. And mainly in RCKH program we are concentrating three that is early obstetrical care, essential obstetrical care and emergency obstetrical. Here we are focus with mobile services then they are need they have mobile services to come to the hospitals or rural health centers. And here this program it is providing safe delivery kit also so wherever the delivery is taking place we have to have a clean and more or less safe environment to conduct the delivery activities that is the main focus in this RCKH program. So after that in 2005 we have started with national rural health mission. It is mainly focus on first 18 states in north and states. Here we are in southern part so actually southern part the literacy level and MMR is very less compared to north and states. So these are this program is mainly concentrated in north and states to reduce MMR and total fertility rate and improve the control and prevention of disease like emerging and re-emerging diseases and non-communicable diseases too. And to provide accessible, affordable, accountable and effective and reliable primary healthcare and bridging the gap in rural healthcare because all majority of our 72% of people they are living rural service. And as earlier this mention it is accredited social health activist she is working in rural areas to reduce the birth and we have GDP how much we allotted it is earlier it is only 0.9% of national GDP it is allotted. Now it is increased to 2% is more or less we are concentrating on preventing and poverty services for faith motherhood. And also we are increasing public-private partnership because public-private we are combined together only because this huge population we can meet and we can meet the targets and promoting IEC information, education and communication because women will be educated from the earlier states from up tactical and during adolescent period also they will be educated and during adolescent they will be providing iron-rich supplements plus iron and folic acid tablets because here in India the HB hemorrhage is the first cost in the IMR, promoting IMR. So we are concentrating on hemoglobin level among adolescent age group and maternal, during maternal period. And next program we have is in the NRK mainly is Jananis Raksha Yojana. It is during pregnancy period they will be given concentration and they will be providing rupees 700 it is almost also 13 US dollars. It is only to bring the nutrition to develop the nutrition status of mother and they have early registrations it is must and registered care and faith industry, institution deliveries we are encouraging and early newborn care and family oriented care also we are providing here. This is this program also it is concentrating first north and part of India and it is almost 18 states it is benefited out of this. And we have family planning program here we are focusing small family norm that is in India we have total fertility rate it is almost around 2.9 or almost 3 and that means all reproductive age group human they are giving birth to minimum 3 children. So we are bringing this norm small family norm that means only any one child either male or female one child if you are giving birth it is too good and we are focusing for NRR that is net reproductive rate is 2.1 actually it is our rate is 1.5 we are focusing for one all even though all these things we have one more thing a problem is major problem is female infant is like the female 6th case when we are seeing in north and part it is 800 per 1000 in southern part it is doing well 900 around 930 they are doing well so all the whole nation we have average of 930 per 1000 and we are promoting girls child protection act also we are taking care of. These are the main merits and demerits we have we have limitation like highly populated country and lack of resource trains professional midwives when we are seeing midwives the ratio doctor population ratio we have is 0.7 per 1000 and north population ratio is 0.8 per 1000 and midwife population rate is 0.4 actually we have R and M R and register nurse and register midwife in India we have combined that is midwife and nurse certificate program is we are doing but still we have in actually nurse midwife and trained birth they are trained people to conduct delivery and mainly for focusing on midwife these are the limitations we have also we have all these limitations we have one strong meritus we have family system traditional and cultural practice when we are going to cultural practice this is a picture that it is like during the pregnancy period the family is taking care of the mother and this is occasion they will have 7th and 9th month they will do one day they will celebrate the mother and they will wear all the new silk fairies so she will be decorated and she will be wearing bangles all the relatives and neighbors will wear bangles this mainly actually focus that this glass material it will give more sound this will produce the cognitive into the cognitive field of fetus this is the actual practice we are following and this shows we are our family system and tradition also taking care of our pregnant women I wish you all the best and have a nice day I will just hand over to Santhi thank you man so warm good evening to one and all wish you all very happy international midwife day till now we have seen various national level schemes along with the other schemes also that state government was implemented they are this scheme was implemented in the year 2006 it is a monetary benefits scheme for the mother in order to compensate the wage loss during pregnancy to get new tissues diet and to avoid delivery of low birth rate babies this scheme was implemented for the mother the total money they are giving to the mother almost $222 this also they are giving in three installment basis in each installment the mother is getting around $74 the first installment they are giving at the mother who avails their required antinatal services in a concern primary health center second installment giving at the mother who delivers at government institutions third installment giving to the mother who is completion of immunization for the child up to third dose of PTT, hepatitis D and oral polio vaccine the eligibility criteria are it is restricted to first two delivery funding the pregnant mother should be at the age of 19 years and above the pregnant woman should be in the below poverty line group that means the mother's annual income should be around $222 and second program birth companionship program this program was implemented in the year 2004 it is a key component of midwifery model of care the development of this program is based on shared responsibility mutual trust understanding and empowerment this program is followed in all over the world but they are including a birth companion but in India only woman will be allowed as a birth companion the eligibility criteria are the woman should have undergone the process of labor compulsory and she should not suffer from any communicable diseases she should be willing to stay with the mother throughout the labor the benefits of this program are it gives increased satisfaction with your birthing experience and gives reduction of postpartum depression gives increased suffering success and better interaction with mother and baby and also shorten the duration of labor it gives less pain and fever medical procedures during labor and also reduction of instrumental material birth and featuring delivery and third program is integrated child development scheme this scheme was implemented in the year 1982 it gives service to both antenatal and postnatal mothers that means they are doing they are doing weight monitoring for the mother periodic medical checkup, subliminal nutrition subliminal iron and calcium medications and immunization monitoring compulsory the subliminal nutrition is the main mode of this scheme they are giving this subliminal nutrition to children below 6 years of age, antenatal mothers and lactating mothers each pregnant and nursing woman the diet covers around 600 calories and 18 to 20 grams of protein per day along with this they are giving health education about childcare to the postnatal mothers also till now, due to this scheme 718,000 children 156,000 pregnant women and 875,000 lactating mothers were benefited through this program next program, comprehensive emergency obstetrics and newborn care unit this hospital is initiated mainly in rural areas because in order to reduce the mental mortality rate in emergency conditions because 70% of population were resided in rural areas this scheme was implemented in rural areas according to gross domestic products the government allotting 4.7% of income to implement this type of centers it is very equipped with both manpower and equipment to require to give care for the mother and baby this center has crowned the class obstetrician, pediatrician, doctors, staff nurses lab technician and other supporting staff on duty the services available are it gives representation of all emergency conditions blood transition facilities supportive lab and imaging studies prevention of parent to child transmission services free 108 emergency ambulance system and emergency treatment protocols in the labor room and also in the newborn care services the next program is medical mobile unit this unit was developed in the year 2009 the aim of this unit are to improve the institutional delivery to identify the iris pregnancy and it is easy to approach for the population and also refer for emergency care the services available from this unit are doping immunization monitoring antenatal care, postnatal care family welfare services and referral and counseling services and next scheme is one day modern scheme it is a voluntary scheme the indoor doctors will display one day modern logo at their clinic so they are providing iron and folic acid medication, TT injections and oral pills at three of cost through this state level of scheme the Tamil Nadu achieved in the year 2007 to 2008 99% of mothers were at institutional delivery and only 0.1% of mothers are delivered by untrained personnel at home due to the institutional delivery the material mortality rate was reduced gradually in both state level and also in national level thank you I will hand over to purpose the day demand so with all aiming towards the million development goals there is no doubt world needs us more than ever India also celebrates on April 11th National Safe Motherhood Day so that citizens and communities and other stakeholders take a path, deliberate on the maternal health situation in the country and look at what interventions are working and what more is needed to be done this April 11th is a birth anniversary of Kasturiba Gandhi and Safe Motherhood Day is commemorated to mark the occasion I now let the forum open for this session thank you very much ladies that was a lovely presentation there are certainly a couple of questions that are coming through and I prefer the first one one of the participants was just asking in relation to the education we noticed that the midwives and nursing education were together are the midwives referred to as nurses or are they called midwives baby could you answer that question please we have a basic program of DSE nursing so this DSE nursing those who graduate on that will be able to work as educators and also as a clinical midwife and after a post graduation also they can work as educators and a clinical midwife the option is for individuals to choose either of these areas they can be allowed for both education and also in the practice setting is it clear Arjunian? yes lovely alright thank you very much for that one of the other questions that came through was just in relation to the slide that you had about caring for the mothers and wearing the bangles even if the mothers appear to be quite well supported postnatally do you have any idea in relation to the levels of postnatal depression that you experience in your country? yes this bangles ceremony is almost done in south India this is kept that a day is marked an auspicious day is marked so people all get together to make the mother happy where bangles usually it is done in the seventh month we can also state that this also improves the acoustic skills the hearing abilities of the newborn which the mother will be wearing this bangles till her delivery and also mother has given a lot of nutritious food throughout the pregnancy her relatives will be bringing her sweets fruits and things so that they care for the mother not only as a family but also as a society her relatives all too which will be keeping the mother happy too okay excellent now I think there is a question from Sona Sona can I you've got the microphone can you ask your question please yeah we have we have noted up certain questions like in India majority of the birth are mostly handled by doctors not necessarily because there are a lot of areas where midwives are conducting and not necessarily all the doctors are in the hospital or conducting institution deliveries majority of the time they are too prescribed they are too suggestive procedures and midwives are the one those are carrying out everything for they have the responsibility starting from pre-construction care till the mother gets delivered and if only complicated we refer to doctors as that and we have the next question already there is in the fact that there was an answer on it there is a independent nursing midwife nursing practitioner program yes of course there are already three states that is on the way to delivering of this independent practitioner program there is and there are a lot of initiatives to further make more nurses practice independently then there were like why men do not go for vatakthami usually it's a men do go for vatakthami but in our very quite less numbers majority of the permanent contraception is underbound by seniors and temporary contraception of course both equally opt for it okay thank you very much for that Soma we have a question from Penny and she said with the dramatic rise in institutional birth and doctors attending so a specific model of care how much care do you feel is women centered and how is this good yes as we discussed earlier 72% of the India's population lives in rural areas so majority of these births we are trying to make it institutional because to avoid the complications the transport facilities they get from the rural area to the building centers less and also since it's a very much rural area even the availability of nurses there is difficult so all care is women centered only but promoting institutional births to avoid complications of the delivery thank you okay so they are trying to encourage the amount of institutional birth to prevent obviously the mortality rate is that correct yes yes this is to reduce the complications of delivery and side birth okay I know one of the other questions that was put forward before is if the doctors are handling most of the births I heard one of the presenters say that the midwives' roles and responsibilities are certainly involved around the post-natal area and complementary therapy so just to clarify do the midwives actually do any of the births or assist the mothers to do any of the births midwives definitely do except like even in hospitals midwives do deliver but there is a little of presence where complications arise with the two doctors and the majority in primary health centers are limit wise deliver and main responsibilities are like starting some histories assessment, monitoring the fetus and the mother maintaining a pathogram conducting the delivery maybe there is a teaching institution medical colleges attached so there is a tendency for doctors to get practice too excellent thank you very much does anyone have any other questions so by the way I can answer you can please raise your hand in the chat box if you want to there is a question to like increasing number of cesarean sections that yes there are increasing number of cesarean sections maybe again to avoid complications of the to reduce infant mortality stale births and mortality rates that's why they go up for a cesarean section excellent one of the questions from Henrietta here is what is the cesarean section like in India this we cannot specifically point out maybe around 50% to 10 to 10 to 20% that depends on no 10 depends on the mother 10 to 20% so that's in the public arena because I'm taking it on the chat box it's going 50 to 80% in private hospitals is that there is increasing number of cesarean deliveries we do agree some private hospitals they pay some other for cesarean section but it is not the condition throughout India okay excellent there is there is association called SOMI there is association we all belong to train nurses association of India and mid-vice belong to this yearly there is conferences and there is a network that is between the mid-vice okay thank you Sana do you have a question I'll just enable your microphone Sana do you have a question if you've got your question please no problem you can type it I'm answering for you well we're just waiting for her to do that Penny just has a question here do you think mid-vice would be interested in autonomous practice currently there are some like several mid-vice coming up I think in the future definitely there will be a lot of mid-vice doing autonomy practice okay Priyanka I've just enabled your microphone do you want to she's got her hand up sorry I can see that you don't have unable to use the mic so she said isn't Henry doing to high rate of induction in hospital rather than hemoglobin levels alone I don't think so Henry is not related to induction in our hospitals Henry is the cause but that is related to anemia less hemoglobin levels it is not of not related to induction but related to hemoglobin levels levels yep excellent okay isn't there going to be further questions no Henry is not much linked to induction here in India Henry is related majority to anemia so into anemia very good thank you very much for that ladies do you think that do you think that the induction rate obviously is increasing too and I suppose there's a you know obviously there's got to be a correlation if you're having more institutionalised birth with your induction rate and can I just ask when is your induction rate what is generally the cutoff for women to be induced is it 41 weeks 42 weeks we couldn't get this again can I just ask what is the most common time for induction in India do they normally induce women at 41 weeks or 42 weeks 40 plus weeks 40 plus when the baby is mature enough above 40 okay so that 40 okay that's great it's just very interesting to hear the different rules around induction in different countries here in Australia normally about 41 plus 3 or 40 plus 10 days so and that's just dependent you know in what area but that's generally the norm here so it's just very interesting to know what was the norm in India definitely then I think you're talking on the nutritionist or grants that has definitely reduced the anemia rate in women excellent does anyone else got any more questions they'd like to put forward the hemorrhage may be linked to induction but that is not the cause of majority of the hemorrhage here lovely ladies well thank you very much for that presentation it's just been wonderful to have the four of you and I think that presentation went so well it was really very clearly it was lovely so thank you very much I'll just turn the record