Maternal mortality in Andhra Pradesh able round-the-clock when there were no facilities to stay. Women stated that they did not go to the PHCs for childbirth since there were no service pro- viders or facilities. Maternal mortality in Andhra Pradesh Estimating MMR The problem of high MMR continues in Andhra Pradesh despite the increase in health infrastruc- ture. There is still no clear figure of how many women actually die or face severe complications, or survive but suffer life-long morbidity due to poor- quality care. Due to the difficulty in studying and calculating the MMR accurately, there are huge dis- parities in the reported MMR figures for India and for Andhra Pradesh. Disagreement prevails among surveys, national registration systems, and individ- ual researchers of the estimated statistics on mater- nal deaths. However, there is an agreement among health professionals, researchers, NGOs, and pro- gramme managers on two issues—that MMR is higher than reported and that there are critical gaps in information due to flaws in monitoring, record- ing, and reporting morbidity and mortality. Estimates of MMR from some studies on maternal deaths in Andhra Pradesh, particularly, findings of two similar studies in the state, need mention. The study conducted in 1984 in Anantapur district gave a figure of 830 (10). A similar study conducted 20 years later in rural Medak district reported a fig- ure of 431 (11). Although findings of other studies were reported, the findings cannot be compared due to the differences in study site or methodolo- gy. Mahapatra and others studied causes of death patterns in Andhra Pradesh using the sisterhood method and estimated 256 per 100,000 livebirths (12). A survey of maternal deaths in five districts of Andhra Pradesh during 1995-1996 gave a figure of 712 for the survey area with wide variations among the five districts (13). Medical causes of maternal deaths Bleeding and eclampsia persist as the two main causes of maternal deaths in Andhra Pradesh. The early classic study of maternal deaths in Anantapur district by Bhatia in 1984 showed puerperal sepsis as responsible for the highest percentage (30.5%) of maternal deaths (10). Results of the study in Medak 20 years later in 2003 showed that pregnancy- induced hypertension, including eclampsia, was responsible for the highest percentage (28.86%) of maternal deaths while sepsis was responsible for only 14.75%. Over time, sepsis as a cause gradu- ally declined with increasing use of antibiotics and 226 Prakasamma M better hygiene as a result of promotion of ‘five cleans’ during childbirth. Mahapatra and oth- ers in 2000 listed abortion and sepsis as two major causes of 52,158 deaths of women aged 15-44 years (12). Haemorrhage continues to contribute a large proportion of maternal deaths—about one-fifth of the women die due to haemorrhage. Social factors contributing to maternal deaths The clustering of maternal deaths in socially-vul- nerable groups was a striking finding of a study in Mahaboobnagar and Medak districts in Andhra Pradesh (14). The study compared 100 normal childbirths with 100 survivors of complications and 50 cases of maternal deaths. Nearly three- quarters (70%) of women who died had no formal education compared to 44% among normal cases. Only 20% of women who died had studied up to primary level compared to 51% of survivors. There were nearly twice as many women belonging to the scheduled castes (SCs) and scheduled tribes (STs) (socially-underprivileged groups) among death cases (48%) compared to survivors (25%) or women who delivered normally (27%). Findings of the study on maternal deaths in five districts of Andhra Pradesh also showed that wo- men from scheduled castes and tribes were the greatest affected, and they together constituted half (50.74%) of maternal deaths identified in the study (13). The ability to obtain treatment for complications was observed as a major difference between survi- vors and victims of maternal deaths in a study of factors contributing to maternal deaths conducted in three states: Andhra Pradesh, Madhya Pradesh, and Orissa, coordinated by the Foundation for Re- search in Health System in 2002 (15). As part of this study, 170 maternal deaths were compared with 300 survivors of maternal complications. Based on in-depth interviews and social audits in the homes of victims and survivors, common complications were reported by the surviving women or by rela- tives of those who had died, such as postnatal fever, prolonged labour, oedema, and postnatal bleeding. Prolonged labour and convulsions were the major causes of death in the case of victims, and abnormal position and prolonged labour were the complica- tions in the case of survivors. It was reported that survivors were successful in seeking and obtaining treatment in time compared to death cases. Of the 148 deaths followed-up as part of this case study, 66.2% died after reaching the hospital, 20.3% died on way to the hospital, and 13.5% died JHPN