Objectives:

2. ???? ??? ???? ?????? ????? ????? ?????? ????? ??????? ????? ? ????? ?????

3. 3 Breastfeeding: The 1st Hour Save ONE Million Babies This PPT has been prepared for the Web Conference on Breastfeeding GOLD 2007, on the theme Breastfeeding the 1st Hour : Save 1 Million babies, the theme of WBW 2007.This PPT has been prepared for the Web Conference on Breastfeeding GOLD 2007, on the theme Breastfeeding the 1st Hour : Save 1 Million babies, the theme of WBW 2007.

4. 4 Objectives: Share some scientific data and ���.. To explain how important it is to mainstream support during first hour to ALL mothers to save ONE million babies with just ONE action, just ONE hour support and just ONE message�. .

5. 5 Background: about 36% of all child deaths are �neonatal� Lancet Neonatal series recognized 16 interventions and exclusive breastfeeding is one Early initiation of breastfeeding within one hour was not on the list New study presents increased risk of neonatal deaths in addition to earlier data on exclusive breastfeeding Poor coverage of Initiation of breastfeeding within one hour of birth , only 1 in 3. Nov 2005 Lancet did an article on tracking of child survival interventions; Initiation of breastfeeding within one hour of birth was added in the newborn health section You would note that more than one third of all child deaths occur during first month of life and Lancet had clearly recognized that exclusive breastfeeding is one of the interventions that does matter. The data was presented at the child survival countdown conference in London as a Poster presentation. And in 2005 Lancet did recognise the value in newborn health indicators it was included as you see in yellow lines . It is also important to note that many countries do not report first hour breastfeeding rates, or they are not available. There are only about 30% of mothers begin breastfeeding within one hour. The data conclusively points out the neglect of this practice and grossly under supported mothers across the world. We will talk more on this later�when we see the state of Initiation of BREASTFEEDING within one hour.You would note that more than one third of all child deaths occur during first month of life and Lancet had clearly recognized that exclusive breastfeeding is one of the interventions that does matter. The data was presented at the child survival countdown conference in London as a Poster presentation. And in 2005 Lancet did recognise the value in newborn health indicators it was included as you see in yellow lines . It is also important to note that many countries do not report first hour breastfeeding rates, or they are not available. There are only about 30% of mothers begin breastfeeding within one hour. The data conclusively points out the neglect of this practice and grossly under supported mothers across the world. We will talk more on this later�when we see the state of Initiation of BREASTFEEDING within one hour.

6. 6 Little History and commitments Following slide will take you back to 1992 �.Following slide will take you back to 1992 �.

7. 7 BFHI 1992: Step 4 was, �Help mothers initiate breastfeeding within a half-hour of birth� Lets recall 1992, BFHI the famous initiative launched worldwide, one of the 10 steps was on initiation breastfeeding within one hour. This step -4 actually called for support within a health care institution to make it happen .Why have we failed?(OPINION) More than 15 years later see where we stand ?. Is it enough for launching a campaign worldwide to gather at least 1 million people calling for this help.(Yes/No)Lets recall 1992, BFHI the famous initiative launched worldwide, one of the 10 steps was on initiation breastfeeding within one hour. This step -4 actually called for support within a health care institution to make it happen .Why have we failed?(OPINION) More than 15 years later see where we stand ?. Is it enough for launching a campaign worldwide to gather at least 1 million people calling for this help.(Yes/No)

8. 8 World Summit for Children Commitments: Millennium Development Goals (MDG) 4 calls for U-5 child mortality to go down to two thirds by 2015. UNICEF priority is in 60 countries ( U5MR>90/1000live births, or No. of U5 deaths >50,000 These 60 countries account for 91% of all neonatal deaths Almost all neonatal deaths occur in developing countries Lets se what are we committed to ! MDG 4 on child survival : The progress is slow in most countries.,91% of all neonatal deaths occur in these 60 countries which are UNICEF priority countries having most child deaths. This shows need of widespread action. if about 36% of all child deaths are neonates, don�t you think there is a need to scale action to reduce neonatal deaths? What's that action , the following slides that provide scientific evidence that may make it more clear to all including the policy makers or programme managers Lets se what are we committed to ! MDG 4 on child survival : The progress is slow in most countries.,91% of all neonatal deaths occur in these 60 countries which are UNICEF priority countries having most child deaths. This shows need of widespread action. if about 36% of all child deaths are neonates, don�t you think there is a need to scale action to reduce neonatal deaths? What's that action , the following slides that provide scientific evidence that may make it more clear to all including the policy makers or programme managers

9. 9 Ghana Study findings and other evidence

10. 10 Risk of neonatal mortality according to time of initiation of breastfeeding In addition to the survival value of breastfeeding in addition to shown by the Lancet series in 2003, new evidence from Ghana study points out that if ALL mothers begin breastfeeding within one hour 22% of newborn deaths can be cut. Mortality of newborn babies increases 6 times, if it is delayed to 72 hours. Lets see what it means in numbers in the next slide�In addition to the survival value of breastfeeding in addition to shown by the Lancet series in 2003, new evidence from Ghana study points out that if ALL mothers begin breastfeeding within one hour 22% of newborn deaths can be cut. Mortality of newborn babies increases 6 times, if it is delayed to 72 hours. Lets see what it means in numbers in the next slide�

11. 11 1st hour initiation cuts 22% of all deaths The study suggests if we are able to increase initiation rates for ALL babies, more than 1 million newborn deaths could be reduced, meaning a major contribution it can make to achieving the national goals to reduce IMR , U5MR and the MDG4 How the authors have done the calculation may be the next question you all would be wanting to know.The study suggests if we are able to increase initiation rates for ALL babies, more than 1 million newborn deaths could be reduced, meaning a major contribution it can make to achieving the national goals to reduce IMR , U5MR and the MDG4 How the authors have done the calculation may be the next question you all would be wanting to know.

12. 12 Potential Mechanisms: Suckling shortly after birth have a greater chance of successfully establishing and sustaining breastfeeding throughout infancy. However, the effect of early initiation persisted after controlling for established neonatal breastfeeding patterns. Early feeding with non human milk proteins may severely disrupt normal gut function Rich immune and non-immune components that are important for early gut growth and resistance to infection. Promotion of warmth and protection may reduce the risk of death from hypothermia. In this slide potential mechanism is explained. The authors of the Ghana study also explain the "Potential Mechanisms". Early initiation of breastfeeding could affect neonatal mortality risk by at least four mechanisms, the lower rate of mortality in those who initiated early may have occurred because mothers who suckle their babies shortly after birth have a greater chance of successfully establishing and sustaining breastfeeding throughout infancy. However, the effect of early initiation persisted after controlling for established neonatal breastfeeding patterns. Secondly, early feeding with non-human milk proteins may severely disrupt normal gut function; thirdly, early human milk is rich in a variety of immune and non-immune components that are important for early gut growth and resistance to infection. Fourthly, promotion of warmth and protection may reduce the risk of death from hypothermia. In this slide potential mechanism is explained. The authors of the Ghana study also explain the "Potential Mechanisms". Early initiation of breastfeeding could affect neonatal mortality risk by at least four mechanisms, the lower rate of mortality in those who initiated early may have occurred because mothers who suckle their babies shortly after birth have a greater chance of successfully establishing and sustaining breastfeeding throughout infancy. However, the effect of early initiation persisted after controlling for established neonatal breastfeeding patterns. Secondly, early feeding with non-human milk proteins may severely disrupt normal gut function; thirdly, early human milk is rich in a variety of immune and non-immune components that are important for early gut growth and resistance to infection. Fourthly, promotion of warmth and protection may reduce the risk of death from hypothermia.

13. 13 Key findings of the study: Sample more than 10,000 babies 30% of the study population initiated breastfeeding after day 1 (late initiation) 30% were not exclusively breastfed in the neonatal period Exclusive breastfeeding was associated with a 4 fold reduction in risk of death when compared to infants who were fed solids or other milk. This confirms previous findings. Key findings of the study include: 30% of the study population initiated breastfeeding after day 1 (late initiation) and 30% were not exclusively breastfed in the neonatal period, Exclusive breastfeeding was associated with a 4 fold reduction in risk of death when compared to infants who were fed solids or other milk, which confirms previous findings. Key findings of the study include: 30% of the study population initiated breastfeeding after day 1 (late initiation) and 30% were not exclusively breastfed in the neonatal period, Exclusive breastfeeding was associated with a 4 fold reduction in risk of death when compared to infants who were fed solids or other milk, which confirms previous findings.

14. 14 Importance of Findings: An additional 2.5 fold reduction in risk of death was demonstrated in babies who survived to day 2 who initiated breastfeeding on the first day of life (early initiation) compared to infants who initiated after the first day of life (late initiation). This type of effect of early initiation has never been reported. An additional 2.5 fold reduction in risk of death was demonstrated in babies who survived to day 2 who initiated breastfeeding on the first day of life (early initiation) compared to infants who initiated after the first day of life (late initiation). This type of effect of early initiation has never been reported. Translating these benefits to the whole population of neonates (breastfed and not breastfed) means that 16% of neonatal lives can be saved if all babies were breastfed from day 1, and 22% if breastfeeding were started within the first hour. Neonatal mortality was also shown to increase markedly with delay in beginning breastfeeding. Recall the earlier graphic ! And further discussion will reveal the potential survival value. According to the authors such an effect of timing of first breastfeeding on child survival has not been reported earlier and thus makes an addition to existing data on child survival. The data was not there when Lancet series did the work in 2003. An additional 2.5 fold reduction in risk of death was demonstrated in babies who survived to day 2 who initiated breastfeeding on the first day of life (early initiation) compared to infants who initiated after the first day of life (late initiation). This type of effect of early initiation has never been reported. Translating these benefits to the whole population of neonates (breastfed and not breastfed) means that 16% of neonatal lives can be saved if all babies were breastfed from day 1, and 22% if breastfeeding were started within the first hour. Neonatal mortality was also shown to increase markedly with delay in beginning breastfeeding. Recall the earlier graphic ! And further discussion will reveal the potential survival value. According to the authors such an effect of timing of first breastfeeding on child survival has not been reported earlier and thus makes an addition to existing data on child survival. The data was not there when Lancet series did the work in 2003.

15. 15 What it means? Translating these benefits to the whole population of neonates (breastfed and not breastfed) means that: 16% of neonatal lives can be saved if all babies were breastfed from day 1, and 22% if breastfeeding were started within the first hour.

16. 16 Global impact of increases in coverage and promotion of early initiation of breastfeeding in less developed settings. Projected absolute numbers of lives saved and the proportion of neonatal deaths avoided if 99% of infants initiated breastfeeding during the first hour or during the first day of life. ** Only 38 of the 60 countries had data available on initiation of breastfeeding within 1 hour and 1 day of birth. The neonatal mortality rate for these 38 countries ranged from 15-70/1,000 live births. For rest of 22 countries regional averages were used **Karen M Edmond, Ellie C Bard, Betty R Kirkwood, Meeting the millennium development goals for child survival: global impact of early initiation of breastfeeding on neonatal mortality. (Un published) This presentation was made at the Child Survival Countdown in London 2005, s a poster.This presentation was made at the Child Survival Countdown in London 2005, s a poster.

17. 17 Authors� Intervention Models A and B : Lives saved estimated for universal coverage: 99%, and 90% A : BF initiated within one hour 99% : 1.11 million lives saved, 31% of all newborn deaths, and 11% of U5 child deaths 90%: 0.972 million lives saved, 27% of all newborn deaths and 10% of U5 child deaths B: BF initiated within one day 99% : 0.866 million lives saved, 24% of all newborn deaths, and 9% of U5 child deaths 90%: 0.580 million lives saved, 19 % of all newborn deaths and 7% of U5 child deaths

18. 18 Risk of newborn deaths BF Initiated Ad OR Attributable Risk 1st hour 1 - Day 1 , later 1.44 31% After Day 1 2.88 65.3% Day 1 vs. later 2.40 58.3% This slide shows the details of how they reached these numbers, with 2 models. They calculated attributable risks.This slide shows the details of how they reached these numbers, with 2 models. They calculated attributable risks.

19. 19 :Concluding finding Neonatal mortality could be reduced by 24% if 99% of infants initiated breastfeeding on day 1 of life and by 31% if 99% of initiation was within the first hour. Numbers of lives saved were estimated to be 867,000 and 1,117,000 in these two cases." The model is based on a single dataset; Similar data from other countries should be collated/collected as a priority. If risks from Ghana are confirmed EARLY BF initiation should be added to key child survival interventions & monitored. Potentially about 30% of newborn deaths (10% of U5 deaths) might be prevented with universal coverage of BF initiation within the 1st hour The paper goes logically from one step to the next to show that, in global terms, over one million lives would be saved if all newborns younger than one month were breastfed within the first hour of life.�They concluded that promotion of early initiation of breastfeeding has the potential to make a major contribution to tackling the millennium development goal for child mortality. They called for policy changes to effect promotion, coverage and reporting of early initiation of breastfeeding, as well as exclusive breastfeeding, which must improve at all levels; global, national and sub national. The paper goes logically from one step to the next to show that, in global terms, over one million lives would be saved if all newborns younger than one month were breastfed within the first hour of life.�They concluded that promotion of early initiation of breastfeeding has the potential to make a major contribution to tackling the millennium development goal for child mortality. They called for policy changes to effect promotion, coverage and reporting of early initiation of breastfeeding, as well as exclusive breastfeeding, which must improve at all levels; global, national and sub national.

20. 20 Other benefits of the ONE hour !!!

21. 21 Benefits to both women and babies: Nourishment and its first immunization. Production of milk enough for the next feed. It makes use of the baby�s sucking reflex (which is strongest during the 1st hour) to establish proper latching. Prevent blood loss in the women. Provides the skin-to-skin contact and warmth that babies need most, particularly premature and low birth weight babies. It is more beneficial for low weight babies because they are more likely to die, and they need more support at birth to be able to suck well. Early skin-to-skin contact and the opportunity to suckle within the first hour or so after birth are both important. Some contact cannot be avoided when attempting breastfeeding but contact itself does not necessarily result in immediate suckling. Mothers need to be supported for achieving both contact and suckling which are so closely interrelated. It has an important bearing on survival and development of babies. The infant who is in close contact with its mother can suckle when it shows signs of readiness, such as suckling movements, which are often present during the first hour of birth. It has been observed that the suckling reflex of the newborn is at its height twenty to thirty minutes after birth. If the infant is not fed then the reflex diminishes rapidly only to reappear adequately forty hours later. This may be called � The fourth stage of labour� which includes putting the baby to breast after birth and ensuring the intake of colostrum by the neonate. The exact time of initiation of breastfeeding has been suggested right from birth in the delivery room itself to about an hour after delivery. Also the antibody content of colostrum is at its maximum during the first twelve postpartum hours making it relevant. Early breastfeeding has a physiological effect on the uterus as well, causing it to contract . The effect of skin-to-skin and suckling contact immediately after birth increases the median duration of breastfeeding by 2 � months.In a sample of Norwegian infants, 69% of those who were suckled at birth were still being nursed at the age of 3 months, compared to only 47% of those who were first suckled after six hours. Early skin-to-skin contact and the opportunity to suckle within the first hour or so after birth are both important. Some contact cannot be avoided when attempting breastfeeding but contact itself does not necessarily result in immediate suckling. Mothers need to be supported for achieving both contact and suckling which are so closely interrelated. It has an important bearing on survival and development of babies. The infant who is in close contact with its mother can suckle when it shows signs of readiness, such as suckling movements, which are often present during the first hour of birth. It has been observed that the suckling reflex of the newborn is at its height twenty to thirty minutes after birth. If the infant is not fed then the reflex diminishes rapidly only to reappear adequately forty hours later. This may be called � The fourth stage of labour� which includes putting the baby to breast after birth and ensuring the intake of colostrum by the neonate. The exact time of initiation of breastfeeding has been suggested right from birth in the delivery room itself to about an hour after delivery. Also the antibody content of colostrum is at its maximum during the first twelve postpartum hours making it relevant. Early breastfeeding has a physiological effect on the uterus as well, causing it to contract . The effect of skin-to-skin and suckling contact immediately after birth increases the median duration of breastfeeding by 2 � months.In a sample of Norwegian infants, 69% of those who were suckled at birth were still being nursed at the age of 3 months, compared to only 47% of those who were first suckled after six hours.

22. ??????" ????? ????? (BONDING) ???? ?? ?????? ???? ?????? ?????? ??????? ??????? ???? ????? ??? ?????? ?? ????? ????? ???? ? ???? ?????? ?? ?????? ????? ?????. ????? ????? ???? ??? ?? ??? ???? ? ?? ???? ????? ???? ??? ? ?? ?? ???? ???? ?� ??? ?? ??? ????? ?? ??????? ????? ??? . ???? ????? ????? ?? ????? ????? ? ????? ??? ?????? ?????? ?? ????? ?? ?????? ? ????? ?? ????? . ?? ????? ?????? ? ????? ???? ? ????? ????? ?? ?????? ?????? ???? ?? ???? ? ?????? ??? ????? ?? ???? ???? ?? ???? . ??????"??????? ??? ?� ???? ?????? ????? ???? ?? ????? ????? ? ?????????? ?????? ?? ?? ????? ?????.  22

23. Crucial time & Sensitive period ????? ????? (BONDING) ???? ?? ?????? ???? ?????? ?????? ??????? ??????? ???? ????? ??? ?????? ?? ????? ????? ???? ? ???? ?????? ?? ?????? ????? ?????. ????? ????? : ?? ??? ???? ? ?? ???? ????? ? ?? ?? ???? ???? ?� ??? ?? ??? ????? ?? ???????.

24. ?????? ?????? ???? ????? ????? ????? ?????? ?? ????? ?? ?????? ? ????? ?? ????? . ?????? ? ????? ???? ? ????? ????? ?? ?????? ?????? ???? ?? ???? ?????? ??? ????? ?? ???? ???? ?? ???? .  � ????? ???? ?????? ????? ???? ?? ? ??????? ?????????? ?????? ????. 24

25. ??? ????????? ????? ?? ????? ??? ????? ????? ?????? ? ????? ????????� ????? ??? . ?? ??? ????? ???? ?????? ??? ????? ????? ?? ????? ??????? ?????? ?? ??????" ?? ??? ???? ?? ???? ??? ??? ??? ???� ??? ?????? ??????? (?????5) ???? ???????? ???? ?? ?? ?? ????? ???? ?? ?? ?????? ???? ???? ?? ???? ? ????? ???? ?? ?????? ?????? ??? ? ????? ?? ??? ???? ??? ????? ???? ? ????? ??? ???? ???. 25

26. ?? ???? ????

27. 27

28. ???????? ?? ???? �??? ?? ????? ?????? ????? ????: ??????? ??????? ? ????? ??????? ???? ????? ?? ??? ???? ?????? ??? ????? ?? ????????? ???? ???. ?????????? "???? ????? ??????????????? ??? ????? "?? ????? ???? ??? ? ???? ??????? ??? ? ??? ???? ????? ???? ??? . ??? ????? ?????????? ?? ??? ?????????? ??? ???? ???? ?? ????? ??????? ?????? ?????? ??????? ?????.

29. ???????? ?? ???? �??? ?? ????? ?????? ????? ???? (?????) : ??? ??? ??? ?????? ??? ????? ??? ????? ?? ??? ????? ????? ???? ????? ??? ? ?? ?????? ????? ?????? ?????? ???? ??????? ????? ?????? ?????? ??? . ?????? ????? ???? ??? ?????? ?? ?? ??? ????? ???? ? ????? ? ????? ?? ????? ? ???? ??????? ??????? ??? ?????? ??? ? ?? ????????? ???? ???. ?????? ?????? ??????? ?????? ?? ?????? ???? ????? ??? ??????? ????� ?? ??? ????? ???? ? ????? ???? ?? ??? ????? ?? ????? ?? ??????? ? ?????? ???? ?? ????? ??????? ??? . �

30. ?? ?????? ?? ?????? ????? ????? ?? ??? : ?????????? ?????? ?????? ????? ?????????? ?? ?? ????? ??? ???? ??? ????????? ?? ????? ????? ?????? ???????? ??? ?????? ? ????? ????? ????? ???? ???? ??? ???? . ???? ???? ??????28-25 ???? ????????? ? ???? ????? ???? . ???? ????? ???????? ???? ? ???????? ????? ????? . ??? ???? ????? ???? ???? ???? ???? ???? ??? ?? ??? ???? ? ????? ????. ???? ?? ?????? ???? ????????? ? ?? ????? ???????? ???? . ?? ???? ????? ??? ?? ???? ???? ???? ???? ?? ???? ?????? ?? ????? ???? ???? ?????? ???? ? ???? ????? ????? ? ?????????? ?? ????. 30

31. ?????? ?????(?????) ??? ??????? ?? ??????? ?????? ??? ??????????? ?? ??? ???? ?????? ? ?????? ??????? ???. ?????? ????? ??? ??????? ? ???? ?? ????? ?????? ?????? ?? ????? ?? ?? ??????? ???? ???? ?? ???? ???? ? ????? ?????? ???? ?? ?? ? ????? ?? ??????? ??????? ???? ???. ?? ????? ????? ?? ????? ????? ???? ???? ? ??? ?? ??? ??????" ???? ????? ????? ?? ????? ???? ? ???? ???? ????? . 31

32. ???????? ?? ?? ???? ????? ?? ???? ??? ??? ???? ????? ? ????? ?? ?????" ??????? ??? ? ???? ?? ????? ????? ????? ?????? ???? ??? (????? ????? ?? ???? ???????? ??? ???? ????? ???? ???????? ???? ?????)� ??? ??? ?????? ????????????????? ???? ????? ????? ?? ??? ??? ???? ??? ????? ?????? ????? ????? ??? ?????? ????? ( ??????? ????? ) ???? ???? .??? ???? ????? ?? ????? ??? ????? ???????? ??? ?? ???? ???? ??? ? ?? ?? ?? ??? ??? ? ????? ?? ?? ??????? ??? ?? ( ?? ?? ?? ????? ) ? ???? ???? ?? ?????? ????? ??? . ?? ???? ???? ???? ?? ???? ? ???? ????? ?? ?????????? ??????? ???? ?� ???? ?????????? ???? ?????? ??? .???? ??? ????? ??? ???? ? ????? ? ????? ???? ????? ???? ? ???? ? ????? ?? ????? ??? ? ???? ???????? ????.??? ??? ??? ????? ?? ??????? ??? ????? ?? ??? ?????????? ?? ? ?? ????? ????????? ??? ???.?????? ??? ??? ???? ? ?? ????? ????? ? ???? ???? ? ??????? ?? ??? ???? ?? ???? ????? ? ????? ????? ???? ?? 15 ????? ????? ????? ???.????? ??????? ???? ???? ???? ? ????? ? ???? ???? ?? ????? ? ?????? ????? ???? ???? ? ????? ? ????? ???? ???? ? ???? ???? ?? ??? ????? ????? ??? . 32

33. ?????? ?????(?????) ??? ?????? ?? ??????? ??? ???? ???? ???? ??????? ???? ????? ??? ????: ?? ????? ??? ???? ?? ?? ?? ??? ??? ? ????? ?? ?? ??????? ??? ?? ( ?? ?? ?? ????? ) ? ???? ???? ?? ?????? ???? ???? ???? ?? ???? ? ???? ?????: ???? ?????????? ???? ?????? ??? ??? ????? ??? ???? ? ????? : ????? ???? ????? ???? ? ???? ? ????? ?? ????? ??? ? ???? ???????? ????. 33

34. ?????? ?????(?????) ??? ??? ??? ????? ?? ??????? ??? ????? ?? ??? ?????????? ?? ? ?? ????? ????????? ??? ???. ?????? ??? ??? ???? ? ?? ????? ????? ? ???? ???? ? ??????? ?? ??? ???? ?? ???? ????? ? ????? ????? ???? ?? 15 ????? ????? ????? ???. ????? ??????? ???? ???? ???? ? ????? ? ???? ???? ?? ????? ? ?????? ????? ???? ???? ? ????? ? ????? ???? ???? ? ???? ???? ?? ??? ????? ????? ??? . 34

35. ?????? ?????(?????): ???? ???? ????? ????? ? ????? ????? ?? ????? ?????� ??????? ????? ????? ? ???? ? ????? ???? ???? ?? ???????? ??? ????? ??????? K ? ?????? ????? ????? ??? ????? ? ???? ??????? ??? ???? ?? ?? ???? ??????? ??? . ??????? ????? ?? 6 ???? ? ??????" ?? 24 ???? ??? ????? ????? ???? . ?????? ?????? ???? ?? ????? ????? ?????? ????? ??????? ? ?????? ?? ?? ??? ??? ?? ????? ?? ????? ? ?? ???? ???? . 35

36. ?????? ?????(?????): ?? ????? ?? ????? ????? ?? ????? ???? ???? ?????? ???? ???? ?? ???? ???? ???? . ?? ???? ????? ? ??? ????? ?? ?????? ???? ???? ?? ?? ?? ??? ?????? ????? ???? ???? ????. ??????? ???? ??? ??? ????? ????? ?? ? ????? ????? ????? ???? ( ?? ????? ??? ????? 1?2 ?????? ???) . ?? ??????? ???????? ?? ???? ??? ????? ????? ?? ???? ?????? ???? ????? ???? (?????3). ????? ????? ???? ?? ???? ?? ?? ??? ???? ???? ? ??? ????? ??? ?? ???? ????? ? ????? ????? ?? ??? ??? ????? ??? ???? ???? ????? ???? . ?? ???? ???? ?? ????? ??? ??? ?? ????? ?? ????? ? ?? ??????? ?? ????? ?????? ???� ????? ?? ????? ?? ???? ?? ???? ???? ? ????? ????? ???? ???� ?????? ????? ???.

37. ?????? ??????? ?? ?? ??? ????? ??: (??????? ?? ?? ??? ????? ?? ???? ???) ?? ??? ???? ????? ??? ?????????? ? ???? ????? ????? ???? ? ???? (????) ????? ???. ?????? ?? ????? ????? ?? ( ??????? ?? ??? ????? ) ??????? ?? ??? ???? ??? ????? ???? ? ????? ? ??????? ????? ????? ????? ???????? ????? ???? ?? ???? ?????? ????? ??? ??? ???? ???? . ?????? ???? ? ????? ?? ?????? ??????? ?????????? ? ?? ?? ??? ?????? ? ????? ?? ???? ???? ???? ??? ? ???? ???? ?? ???? ? ??? ?? ??? ???? ? ?????� ????? ??? . ????? ?? ??? ?? ???? ???? ?? ??? ????? ?????? ? ??? ????? ??? ????? ? ?????? ???? ?? ???? ?? ???? ?? ????� ??? ????? ? ??? ??? ?? ?????? ?? ????? ???? ????? ???. 37

38. ?? ??????? ?????? ????? ????? ??? ????: ???? ?? ???? ?? ???(RECOVERY) ? ??????? ???? ???? ?? ???? ?? ??? ? ????? ???? ???? ???? ? ????? ???? ????? ?? ???? ???? ????? ???? ???? ???. ?? ????? ?? ???? ???? ?? ???? ???? ? ????? ?????? ???? ? ????? ?? ??? ??????? ????? ???? ? ?? ??? ??? ?? ????? ????? ?? ?? ?????? ??? . ?? ????? ?? ???? ?? ???? ??? ???? ???? ? ????? ?? ????? ??? ? ??? ? ???? ??????� ??? ?? ?? ??? ???? ???? ?? ??? ? ???? ???? ?? ???? ???? ?? ?? ?????? ??? ? ?? ???? ?????? ???? ? ????? ??? ??? ?? ???? ? ????? ?????? ?? ????? ???? ???? ???. ?????? ???? ???? ?? ???? ???? ? ????? ????? ???? ????? ? ?? ????? ?? ???? ?? ???? ??? ???? ??? ?� ??? ?? ??? ?? ?????? ???? ???? ?? ??? ??? ???????? ????? ? ????? ?????? ?? ?? ? ??? ??? ????? ??? ? ?? ?? ?? ???? ?????? . 38