Maternal mortality in Andhra Pradesh the females aged seven years and above are literate in the state. The mean age at effective marriage for females in Andhra Pradesh according to the 1999 SRS is 18.1 years—about one and a half years lower than the national figure of 19.6 years. This case study was carried out with the follow- ing three objectives: (a) analyze the slow reduction of maternal mortality in Andhra Pradesh in con- trast to achievement of demographic goals and in comparison with the neighbouring states—Tamil Nadu and Kerala; (b) contextualize the high ma- ternal mortality ratio (MMR) within the sociode- mographic and programmatic scenario of the state and assess the factors contributing to unsatisfactory achievements in the area of maternal health com- pared to huge successes in the area of population stabilization in terms of strategies chosen and op- portunities missed; and (c) design and implement sustained advocacy for cost-effective and compre- hensive strategies for achieving safe motherhood, including pilot interventions to showcase the best practices. MATERIALS AND METHODS The background work for this case study included analysis of qualitative and quantitative data, opinions of stakeholders, and advocacy meetings over a three-year period from 2005 to 2007. Both primary and secondary sources were used for anal- ysis. Two primary sources used were: a. An indepth study of maternal health serv- ices was conducted in one district—Medak—to gain specific insights into the functioning of the public-health system for maternal health serv- ices at the peripheral level. b. Tracking and auditing of 148 maternal deaths reported in 2006 in Andhra Pradesh was done to understand the contributory factors. Indepth study in Medak district Medak district was selected because it fell below the state average on most indicators, such as literacy, fe- male age at marriage, crude birth rate (CBR) (23.3), TFR (2.9), and female literacy (38.7%) (Table 2). Medak is a large district (9,700 sq km), located in the Telangana area, with a population of 2,670,097, according to the Census 2001. The district is pre- dominantly rural and agricultural with an urban population of only 14.4%. There are 45 mandals (smaller than blocks), 11 towns, and 1,225 vil- lages. The medical and health infrastructure of 222 Table 2. Demographic profile of Medak district Demographic profile Medak Urban population (%) CBR TFR Female Literacy Rate 14.4 23.3 2.9 38.7 Prakasamma M Andhra Pradesh 27.3 19.0 1.8 50.4 CBR=Crude birth rate; TFR=Total fertility rate the district consists of one district hospital, three area hospitals, and 10 Community Health Centres (CHCs). Primary healthcare is provided through 64 Primary Health Centres (PHCs) and 489 Subcentres. There is a wide network of private health facilities with two medical colleges attached with teaching hospitals and 120 nursing homes, or smaller hos- pitals. The district designated 26 of its 64 PHCs as round-the-clock centres for maternal and child health emergencies. Moreover, the Academy for Nursing Studies initiated a project in 2007 to pilot- test the operationalization of the 24-hour PHCs in the district in collaboration with the Government of Andhra Pradesh. Methods used for data collection Data were collected on facilities in hospitals and health centres, perceptions of women, and per- ceptions, knowledge, and skills of care providers. Trained midwifery and public-health staff made ob- servations and conducted focus-group discussions and interviews. For facility assessment, a checklist was prepared after discussion and inputs from mid- wifery and public-health experts for facility assess- ment of the 26 PHCs providing 24-hour service and 10 CHCs in Medak. Skill-management exercise was conducted for staff nurses, Auxiliary Nurse Mid- wives (ANMs), and medical officers in these facili- ties on key areas of the maternal and child health checklist. Interviews were also conducted with 15 medical officers, 41 staff nurses, and 28 ANMs in these facilities (26 PHCs and 10 CHCs). Focus-group discussions were conducted with health professionals. Separate guidelines were fol- lowed for different medical professionals, viz. medi- cal officers, ANMs, and staff nurses. Focus-group discussions were also held with women’s groups in four villages. State-wide tracking of maternal deaths The Sample Registration System estimated the MMR to be 195 per 100,000 livebirths (3). This means that about 3,000 maternal deaths take place for the nearly 16,00,000 livebirths in the JHPN