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National Seminar on Maternal and child Health Care in India; Issues, Concerns

and Policy Initiative

Organized by JSS Institute of Economic Research & Population Research

Centre Dharwad, Karnataka

22nd& 23rd May, 2014

“A study to assess awareness among masses on Women oriented health schemes

with focus on institutional delivery in Aravalli district of Gujarat”

Researcher

Dr. Dinesh Kapadia

Nodal Officer SRCW (NMEW)

Director GRC

Women & Child Development Department, Govt. of Gujarat

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Key Words: Institutional Delivery, M.M.R., I.M.R., M.D.G., ICDS, JSY, Chiranjeevi Yojana,

IGMSY, KPSY, Emergency Obstetric Care, P.S.K., N.M.E.W.

“It is said that women hold up half the sky. We could persuasively argue that they hold up more than that. Yet virtually in every country in every period of history; in every culture and tradition; in every region, religion, caste, class, race, creed, ethnicity; in the diversity of our shared past and varied present, women have always been disadvantaged compared to men in almost all spheres of life. They have been discriminated against systematically in their access to food, work, education, health care and opportunities to participate in development, to lead, think, dream and to realize their dreams. They are, and have remained through millennia, truly the world’s largest ‘minority’.”– Harsh Mander, “Ash in the Belly India’s Unfinished Battle against Hunger” – Penguin Books, (Page no.-43.)

Having gone through pages of the above mentioned Harsh Mander’s book, the researcher started pondering over gender discrimination in general and inaccessibility of health care for a sizeable number of women in particular; resulting into an alarming M.M.R. and I.M.R.in the developing countries.

It is a common perception that one of the reasons attributable to maternal mortality is lack of medical facilities for pregnant women belonging to economically and socially backward strata of the society.

• Infant Mortality Rate (IMR) India Male 49% Female 52%, Gujarat Male 47% & Female 48% (Sample Registration System - SRS 2009)

• General Sex ratio India – 943, Gujarat – 919 (Census 2011)

• Child Sex ratio India – 914, Gujarat - 890 (Census 2011)

Gender biases, Social practices and misconception; prevalent in almost all castes have also adverse effects on mind and body of a woman during pregnancy. An improper care, lack of awareness on precautions and medical aid during pregnancy lead to complications like anemia, malnutrition and subsequently birth of an unhealthy child. However, it will be an exaggeration to say that the scenario is entirely gloomy and no efforts are made to bring about transformation. Social workers, academicians, NGOs and Central and state governments have been making efforts to eradicate gender discrimination and also reduce malnutrition, maternal mortality and infant mortality.

In this context; the researcher also started thinking over efforts made by international forums / Organizations and the National/State Governments in creation of gender just society.

Introduction and Back Ground

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At the Millennium Summit in September 2000 the largest gathering of world leaders in history adopted the UN Millennium Declaration, committing their nations to a new global partnership to reduce extreme poverty and setting out a series of time-bound targets, with a deadline of 2015 that have become known as the Millennium Development Goals.

The Millennium Development Goals (MDGs) are the world's time-bound and quantified targets for addressing extreme poverty in its many dimensions-income poverty, hunger, disease, lack of adequate shelter, and exclusion-while promoting gender equality, education, and environmental sustainability. They are also basic human rights-the rights of each person on the planet to health, education, shelter, and security.

Goal 1: Eradicate Extreme Hunger and Poverty

Goal 2: Achieve Universal Primary Education

� Goal 3: Promote Gender Equality and Empower Women

� Goal 4: Reduce Child Mortality

� Goal 5: Improve Maternal Health

Goal 6: Combat HIV/AIDS, Malaria and other diseases

Goal 7: Ensure Environmental Sustainability

Goal 8: Develop a Global Partnership for Development

MDGs

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• ICDS: Supplementary Nutrition Program: A package of various Nutrition services is being provided through ICDS. ICDS is a beneficiary focused Nutrition programme. With a view to combating malnutrition among children under 6 years, pregnant women, nursing mothers and adolescent girls State Government is implementing this Programme through Anganwadies both in urban and rural areas. Supplementary Nutrition equivalent to 500 calories and 12-15 gram proteins is provided to normal children under 6 years and 800 calories and 20-25 gram protein to severely underweight children under 6 years. Pregnant women, nursing mothers and adolescent girls are given SNP -THR food with 600 calories and 18-20 gram protein. This is 90:10 centrally sponsored scheme.

• Janani SurakshaYojana (JSY): Janani Suraksha Yojana (JSY) is a safe motherhood intervention under the National Rural Health Mission (NRHM). It is being implemented with the objective of reducing maternal and neonatal mortality by promoting institutional delivery among poor pregnant women. The scheme is under implementation in all states and Union Territories (UTs).

• ChiranjeeviYojana: In Gujarat it was realized that simply improving the access to the trained health attendant during delivery cannot ensure reduction in the maternal mortality. Services need to be backed up by provision of the Emergency Obstetric Care Facilities to save the lives of women who develop complications during pregnancy and delivery.

In order to bridge the gap in availability services of obstetricians and gynecologist for providing Emergency Obstetric Care and institutional delivery in rural areas of Gujarat, the State Government formulated the ‘Chiranjeevi Yojna’. The scheme sought to use the potential resource available in the form of large number of private gynecologist providers, to provide free and quality services to poor pregnant women in return for predetermined capitation based payment from the Government. Beneficiaries could avail of the scheme through vouchers (distributed under the scheme) or through BPL cards. The project was initially planned as a pilot in 5 priority districts: Banaskantha, Dahod, Kutch, Panchmahal and Sabarkantha and has been scaled up to all districts in the state based on the encouraging result.

� The project envisioned that district level health officials would anchor and implement the project. For this purpose training was provided to officials in aspects of negotiation, consultation and networking skills.

� Detailed selection criteria were developed for choosing private obstetricians and gynecologist such as educational qualification, availability of own hospital with labor room, operation theatre and blood store, and ability to arrange for anesthetists and perform emergency surgeries.

Projects /Schemes

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� Based on the selection criteria an inventory of private obstetricians and gynecologist in the district was prepared by respective District health officials in the 5 districts where the programme was to be piloted.

� Details of remuneration to the Private practitioners were established through consultation with existing providers and professional bodies such as the federation of obstetrics and gynecology Society of India (FOGSI) and the Society for Welfare and Action.

� Vouchers were distributed through District Health Officials to pregnant women belonging to BPL families.

� Public investment required for the project was made through state Government funds and grants provided by the Central Government under the NRHM.

� Chiranjeevi Yojana is being implemented, now, in all districts of Gujarat.

• Indira Gandhi MatritvaSahyogYojana (IGMSY): A new scheme for pregnant and lactating women called Indira Gandhi Matritva SahyogYojana (IGMSY) has been initiated by the Government of India, initially on pilot basis, in 52 selected districts across the country. The scheme is a centrally sponsored scheme, wherein grant-in aid is released by the GoI to the States/UTs, and it is implemented through the ICDS machinery. In Gujarat, Bharuch and Patan districts have been selected for the implementation of the IGMSY scheme.

• Objectives : To improve the health and nutrition status of pregnant and lactating women and infants by:

• Promoting appropriate practices, care and service utilization during pregnancy,

safe delivery and lactation. • Encouraging the women to follow (optimal) Infant and Young Child Feeding -

IYCF practices including early and exclusive breastfeeding for the first six

months • Contributing to better enabling environment by providing cash incentives for

improved health and nutrition of pregnant and lactating women • Target Group: Pregnant women of 19 years of age and above for first two live

births • Each pregnant and lactating mother would receive a total cash incentive of Rs.

6000/- between second Trimesters till the child attains the age of 6 months subject

to fulfilling of the set conditions

• Kasturba PoshanSahayYojana (KPSY): With broad objectives of Safe Motherhood

and Institutional Deliveries of BPL card holder pregnant women at grass root level Kasturba PoshanSahay Yojana has been initiated by the Government of India. The

beneficiaries of this scheme get the total amount of Rs. 2100/- periodically in three stages.

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An attempt is made in the present study to assess the ground level scenario in respect of accessibility of health services, for pregnant and lactating women; especially facility for institutional delivery and awareness on its beneficial effects among the rural folk; in the selected Aravalli district of Gujarat.

The study also throws light on fruitfulness or otherwise, of above mentioned women oriented health schemes/ projects like ICDS, JSY, Chiranjeevi Yojana, KPSY etc.

• Qualitative and Quantitative methods • Primary Data collection

� Quantitative method 1. Structured Questionnaire

� Qualitative method 1. Interview – With the check list

• Secondary Data collection: Data related to various Govt. Schemes/Program related to Women healthcare.

• Sampling: Purposive Sampling � Personal interview of Pregnant and lactating women, Asha Workers,

AWWs, ICDS supervisors, Medical officers, Female Health workers, Village coordinators of PSK under NMEW

• The Universe of the study o Aravalli District Gujarat

o Six blocks 1. Bayad 2. Malpur 3. Modasa 4. Dhansura 5. Meghraj 6. Bhiloda

Objective of the Study

Methodology

Map of Aravalli Dist.

Aravalli is a new district; carved out of Sabarkantha backward district.

Table I

Scheduled Castes and Scheduled

Block / Taluka Persons

Bhiloda 206,168 Meghraj 141,853 Dhansura 96,389 Bayad 186,328

Malpur 86,063 Modasa 191,996

Total 908,797

Map of Gujarat State

Aravalli is a new district; carved out of Sabarkantha – a BRGF district in Gujarat

Scheduled Castes and Scheduled Tribes Population (Census 2001)

Scheduled Caste

Population

Scheduled Tribe

Population

General Cast

Population

11538 114007 80623 5381 51612 84,860 5728 1503 89158 13508 2343 170477 5509 2981 77573 17489 5990 168517 59153 (6.5%)

178436 (19.5)

671208 (73.9)

Profile of Aravalli District

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Map of Gujarat State

district in Gujarat thus it is a

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The research team paid visits to one P.H.C and one Anganwadi center in all the six blocks of the district and interacted with Medical officers, ASHA workers, C.D.P.O.s, Supervisors, Female health workers and Anganwadi workers to get their input on fruitfulness of Govt. schemes for pregnant and lactating women.

The research team also interacted with as many as 39 Pregnant / lactating women to get their feedback on usefulness of Govt. schemes for them for the present study.

Micro details of the field work are shown in the following tables.

Table – II

Aravalli Dist. Demographic Profile

Total / Rural / Urban

No of Households Persons Males Females

Bayad 36,256 186,328 96,451 89,877 Bhiloda 39,852 206,168 103,829 102,339 Dhansura 18,320 96,389 50,310 46,079 Malpur 16,050 86,063 44,586 41,477 Meghraj 25,647 141,853 72,227 69,626 Modasa 37,408 191,996 98,678 93,318 Total 173,533 908,797 466,081 442,716

Source: Census report 2001

Table: III Details of the respondents

Block

PHC/ Village

Medical Officer

Female Health Worker ASHA AWW

Pregnant women

Lactating Women Total

Bayad Ambliyara 1 1 3 1 4 2 12

Malpur Malpur (CHC) 1 1 2 2 5 0 11

Modasa Modasa 1 1 2 1 4 3 12 Dhansura Vadagam-1 1 1 3 1 9 0 15 Meghraj Ramgadhi 1 1 1 2 1 6

Bhiloda DhuletaPall

a 1 1 2 1 4 5 14 Total Respondent 6 5 13 7 28 11 70

Table – IV Segregation of the Respondents

Interaction with M O at Ambaliyar PHC – Bayad (5-5-2014)

Table – V Pregnant and lactating women

Age Number of Pregnant

18 to 20 21 to 25 26 to 30 31 to 35

Total

MangalpurAnganwadi Kendra – Malpur (7-5

Subject Medical Officer FHW ASHA AWW Pregnant and Lactating Women Total

Segregation of the Respondents

Interaction with Anganwadi workers at RamgadhiAnganwadi Kendra

2014) Interaction with pregnant and lactating women at VdagamAnganwadi Kendra – Dhansura (9-5-2014)

Pregnant and lactating women – Age wise segregation Number of Pregnant

Women Lactating Total 5 1 6 16 9 25 6 1 7 1 1 28 11 39

5-2014) DhuletaAnganwadi Kendra

Number 6 5 13 7

39 70

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Interaction with Anganwadi workers at RamgadhiAnganwadi Kendra – Meghraj (9-5-2014)

with pregnant and lactating women at VdagamAnganwadi

DhuletaAnganwadi Kendra – Bhiloda(14-5-2014)

Table –VI Education Profile

Education Literate Primary ( 1 to 8) Secondary ( 9 & 10 ) Higher Secondary ( 11th & 12th ) PTC Total

Table: VII Trimester wise Segregation (for

Trimester First Trimester (1 to 3 Month )Second Trimester (4 to 6 Month )Third Trimester ( 7 to 9 Month )Total

Table: VIII Economic Status

Card Holder PregnantBPL 11 APL 17 Total 28

Table: IX The respondents’ awareness about schemes

Rudimentary Information of Yes No Total

Pregnant Lactating Total 6 3 9 8 1 9 10 2 12

4 4 8 1 1

28 11 39

wise Segregation (for pregnant women)

Number % First Trimester (1 to 3 Month ) 4 14.3 Second Trimester (4 to 6 Month ) 14 50.0 Third Trimester ( 7 to 9 Month ) 10 35.7

28 100

Pregnant Lactating Total 5 16 6 23 11 39

respondents’ awareness about schemes

Schemes Number Percentage 19 49 20 51 39 100

Duleta-PallaAngawadi Kendra

Bhiloda (14-5-2014)

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DungarvadaAnganwadi Kendra - Modasa (7-5-2014)

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Table X

“108” EMRI Aravalli Dist. - April 2011 to March 201 4

Delivery Assisted by EMT Taluka 2013-2014 2012-2013 2011-2012 Total Bayad 28 37 40 105

Bhiloda 10 10 16 36 Dhansura 20 11 22 53

Malpur 18 19 21 58

Meghraj 22 29 32 83 Modasa 16 11 27 54 Grand Total 114 117 158 389

Source: GVK – EMRI Gujarat – narendrasinh_gohil@emri.in – 17th May 2014 at 10:50 AM

� “A Woman seeking benefits under Kasturba Poshan Sahay Yojana can open up a saving account in a bank on production of a letter issued by a medical officer. This procedural amendment by the government has made it easier for the pregnant women to avail benefit under this scheme.”

� “If a medical officer performs his/her duty properly and establishes a rapport with the rural folk; he/she can contribute in encouraging pregnant women for institutional delivery.”

� “There is a need to lessen burden of administrative work of a medical officer; so as to enable him/her to pay adequate attention to his/her basic duties.”

- Medical Officers

� “Sometimes, non-availability of grant for the scheme makes it difficult to provide timely benefits to the Women”

� “There is awareness among rural women about institutional delivery at accredited private hospitals under “Chiranjeevi” Scheme.”

� “Some beneficiaries do not open up a saving account on time; resulting into delay in providing them monthly incentive under the schemes like KPSY and JSY.”

-Female Health Workers

The Respondents “In Verbatim”

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� Most of the women are not fully aware of various health schemes floated by the Govt. and they do not know the nomenclature of these schemes.

� The pregnant and lactating women are found to possess only rudimentary knowledge of the schemes.

� It is found that there is a lack of interest among women in availing benefits of schemes like T.H.R. under I.C.D.S. and the A.W.W.s have to make extra efforts to persuade the target groups to get benefits under these schemes.

� F.H.W.s, A.W.W.s and Asha workers are found to play an appreciable role in implementation of schemes for pregnant and lactating women. However, they have to face some bottlenecks at the ground level.

� A craze for a male child is prevalent not only among elderly family members / in laws but also among young newly married women.

� The pregnant women in the rural areas, which are part of universe of the present study, have been found to approaching the local PHC/Sub centre for regular check up and treatment for ailments commonly associated with pregnancy.

� There is a trend to register pregnancy at PHC/Sub centre, Anganwadi; as it is mandatory to produce “Mamata Card” to avail benefit of free institutional delivery at a private hospital under Chiranjeevi Scheme.

� “Mamata Divas” is regularly celebrated once a month on the fixed day and a sizeable number of pregnant women and lactating women take part in it. Thus, “Mamta Divas” has become a buzz word among rural women.

� There is a modicum of awareness about beneficial effects of institutional delivery among rural folk.

� There is a tendency among the rural families to get primiegravida admitted in a private obstetrics and gynecology hospital covered under Chiranjeevi Scheme where as a second or multi gravida is admitted in a Govt. hospital.

� Dependence on unskilled and untrained Midwife for delivery of a child in rural areas has considerably decreased. Midwives are found in remote areas of the tribal belt. These untrained midwives are persuaded by medical officer to bring pregnant women for institutional delivery under Chiranjeevi scheme.

� Incentives like providing “A baby kit” containing a small quilt, cloths and a diper for a new born whose delivery is conducted at CHC/PHC under NRHM and one kg. Jaggery and one kg. mung to pregnant and lactating women under “Gram Snajivani Yojana” have yielded good results to encourage rural women to opt for an institutional delivery.

� A number of women in the last stage of pregnancy; take advantage of “108” EMRI services in the rural areas of Gujarat. (See table -X )

Findings and Observations

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Due to time constraint; the present study suffers from smallness of the sample and the universe. However, the study would open up avenues for an in depth study on the same theme for sociologists, medical professionals, academicians and activists.

The following team members helped the researcher prepare this study and he ought to express gratitude to them for their valuable and timely support.

• Ms. BijalBangdiwala, Research officer S.R.C.W., Gujarat

• Ms. Himali Joshi, Asst. State Coordinator S.R.C.W., Gujarat • Mr. GauravThakkar, Asst. State Coordinator S.R.C.W., Gujarat

• Mr. RikeshPanchal, Block Coordinator PSK, Bayad

• MMR – Maternal Mortality Rate

• IMR – Infant Mortality Rate

• MDG – Millennium Development Goals • ICDS – Integrated Child Development Scheme

• JSY – JananiSurashaYojana • IGMSY - Indira Gandhi MatritvaSahyogYojana

• KPSY – Kasturba PoshanSahayYojana • PSK – Poorna Shakti Kendra

• NMEW – National Mission for Empowerment of Women

Acknowledgment

Limitation of the study

Abbreviations

Dr. Dinesh P Kapadia Deputy Secretary Govt. of Gujarat, India Qualification:- B.S.A.M, LL.B., M.A. (Sociology) Ph.D:- “The Problems of the constabulary in Gujarat; Socio economic profile of living and Experience:- Total 24 years of services in different Departments, Secretariat Gujarat state, India

� Health & Family Welfare Department� Agriculture & Cooperation Department (Additional Charge as Honorary administrative advisor

PavitraYatradhamVikas Board)� In Personal Staff of Ministers� General Administrative Department� Home Department � Social Justice and Empowerment Department� Legal Department � Joint Director, S.I.R.D/SPIPA, Ahmedabad� Managing Director, Gujarat Thakor&KoliVikas Nigam, Gandh

Presently - Director, Gender Resource Centre, Women & Child Development Department, to till date) Paper Presentations at National Level

� “Global warming” at National Institute of Technical Teachers Training and ResearChandigarh-India. The year 2009

� “Implementation of Mahatma Gandhi National Rural Employment Guarantee Scheme and training programs under it in Gujarat” The Year 2009

� “Development of model village through panchayati raj institute” the year development Hyderabad India.

� “An analytical study on Political Empowerment of elected women representatives of PRIs in Bardoli Tehsil in Surat district of Gujarat” National Seminar, N.T.T.T.R.I., Chandigarh, 8, March, 20

� “Socio-economic Inclusion of Women Selected Areas of Gujarat” at 167th June, 2013

� “A Background of conceptualization ofScenario in Gujarat” at One Day Workshop on Gender Issues, A.T.I. Mysore, Govt. of Karnataka on 7June, 2013

� Paper presentation at International Conference on Women and Millennium Development mainstreaming a sine qua non for Sustainable development” A study on fruitfulness of “Mission Mangalam” scheme in the selected areas of Gujarat.”

Academic Sessions at state & National Level

“Citizens Charter and its Significance” The Tribal Rights with focus on S.C/S.T (Prevention of Atrocity Act, 1989) Gender Sensitization and legal provisions

2012 Two sessions on “Human Trafficking from Gender Perspective” BijuPatnayak Police Training Academy,

Bhuvneshwar, Govt. of Orissa on 28Act 2013 – RTCs of SPIPA (Gandhinagar, Vadodara & Ahmedaba

“The Problems of the constabulary in Gujarat; Socio economic profile of living and

Total 24 years of services in different Departments, Secretariat Gujarat state, India Health & Family Welfare Department Agriculture & Cooperation Department (Additional Charge as Honorary administrative advisor

radhamVikas Board) In Personal Staff of Ministers General Administrative Department

Social Justice and Empowerment Department

Joint Director, S.I.R.D/SPIPA, Ahmedabad Managing Director, Gujarat Thakor&KoliVikas Nigam, Gandhinagar

Director, Gender Resource Centre, Women & Child Development Department, Paper Presentations at National Level

“Global warming” at National Institute of Technical Teachers Training and ResearIndia. The year 2009

“Implementation of Mahatma Gandhi National Rural Employment Guarantee Scheme and training programs under it in Gujarat” The Year 2009 “Development of model village through panchayati raj institute” the year 2010 at National institute of rural development Hyderabad India. “An analytical study on Political Empowerment of elected women representatives of PRIs in Bardoli Tehsil in Surat district of Gujarat” National Seminar, N.T.T.T.R.I., Chandigarh, 8, March, 20

economic Inclusion of Women – A peep into fruitfulness of Govt. Schemes at Zero Ground, in Selected Areas of Gujarat” at 16th Thinkers & Writers forum organized by Skotch Foundation, Mumbai on

“A Background of conceptualization of Gender Equity and legal Provisions with focus on PWDVA 2005Scenario in Gujarat” at One Day Workshop on Gender Issues, A.T.I. Mysore, Govt. of Karnataka on 7

Paper presentation at International Conference on Women and Millennium Development mainstreaming a sine qua non for Sustainable development” A study on fruitfulness of “Mission Mangalam” scheme in the selected areas of Gujarat.”

Academic Sessions at state & National Level ns Charter and its Significance”-2006 NIRD, Hyderabad

The Tribal Rights with focus on S.C/S.T (Prevention of Atrocity Act, 1989)- 2006 NIRD, HyderabadGender Sensitization and legal provisions-National Disaster Response force VI battalion

Two sessions on “Human Trafficking from Gender Perspective” BijuPatnayak Police Training Academy, Bhuvneshwar, Govt. of Orissa on 28th September 2013 – “Sexual Harassment of Women at Work Places”

RTCs of SPIPA (Gandhinagar, Vadodara & Ahmedabad) Gujarat.

The Researcher

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“The Problems of the constabulary in Gujarat; Socio economic profile of living and serving conditions”

Agriculture & Cooperation Department (Additional Charge as Honorary administrative advisor-

Director, Gender Resource Centre, Women & Child Development Department, Ahmedabad (2012

“Global warming” at National Institute of Technical Teachers Training and Research (N.T.T.T.R),

“Implementation of Mahatma Gandhi National Rural Employment Guarantee Scheme and training

2010 at National institute of rural

“An analytical study on Political Empowerment of elected women representatives of PRIs in Bardoli Tehsil in Surat district of Gujarat” National Seminar, N.T.T.T.R.I., Chandigarh, 8, March, 2013

A peep into fruitfulness of Govt. Schemes at Zero Ground, in Thinkers & Writers forum organized by Skotch Foundation, Mumbai on

Gender Equity and legal Provisions with focus on PWDVA 2005- Scenario in Gujarat” at One Day Workshop on Gender Issues, A.T.I. Mysore, Govt. of Karnataka on 7th

Paper presentation at International Conference on Women and Millennium Development Goals “Gender mainstreaming a sine qua non for Sustainable development” A study on fruitfulness of “Mission

2006 NIRD, Hyderabad National Disaster Response force VI battalion- Gandhinagar-

Two sessions on “Human Trafficking from Gender Perspective” BijuPatnayak Police Training Academy, “Sexual Harassment of Women at Work Places”