Maternal mortality in Andhra Pradesh normal working hours. This also did not material- ize due to the shortage of staff and poor monitor- ing. Facilities were not strengthened in the labour- rooms, and overall improvement of the PHCs did not take place. With a focused programme strictly implemented and monitored, the story of the family-planning programme by the state within a short time could perhaps be replicated for achieving childbirths in institutions rapidly. However, the quality of care is a major concern. The PHCs in Andhra Pradesh today are not ready to handle the increased de- mand for services generated by higher awareness and monetary incentives. The increasing number of childbirths in private institutions is an outcome of this problem. The case study of Medak is a clear proof of the poor functioning of PHCs designated as round-the-clock service centres. The state ap- pears to be fumbling to design and implement a comprehensive maternal and child health strategy. Low focus on midwifery Midwifery is critical to maternal health in any so- ciety because 85% of pregnancies are normal and usually end in safe outcome for the mother and the baby. The presence of a cadre of skilled midwives is conducive to the provision of quality maternal health services during a normal childbirth and timely referral for women with complications lead- ing to reduction of maternal deaths. Midwives were available in India at the time of in- dependence and were active in maternal and child health. A cadre of midwifery tutors was also pres- ent. Later, midwifery teaching became integrated into the general nursing syllabus and gradually be- came invisible in designation, teaching or practice profession. Those working in labour-rooms became known as labour-room nurses, maternity nurses, obstetric nurses, or simply staff nurses. In the pe- riphery, the ANM was the key service provider for maternal and child health services in the periphe- ry—PHC and Subcentres. The midwifery compo- nent of her role gradually became diluted. The pro- cess of de-skilling nurse-midwives in the periphery is associated with the stress on family planning. This decline in midwifery and the poor quality of maternal health are closely linked. Two policy changes in the country during the 1970s resulted in the drastic decline in the quality of mid- wifery training and practice. The need for speeding up implementation of the family-planning pro- gramme meant that many more health centres and Volume 27 | Number 2 | April 2009 Prakasamma M ANMs were required rapidly. To suit these needs, the Indian Nursing Council revised the ANM syllabus and reduced the duration from 24 months to 18 months. Private organizations were allowed to start ANM training schools. There was a mushrooming of ANM training schools in Andhra Pradesh from 14 in the 1970s to 114 in the late 1980s. In the early 1990s, one-third of the schools for training multi- purpose health workers in the country were located in Andhra Pradesh. Most of these had no faculty, classrooms, or demonstration laboratories to teach maternal and child health. The new cadre was called Multipurpose Health Worker (MPHW) (F). The existing ANMs were given a short orientation training and were redesignated as MPHWs (F). The nursing and midwifery com- ponent of the ANM became invisible not only in their new designation but in the loss of skills and functions. They were told that achievement of the family-planning targets, with focus on female steri- lization, was their main responsibility, especially since they were paid from family-planning funds. Strong action was taken if they did not achieve the monthly target of family-planning cases but no ac- tion was taken if they did not assist in deliveries or visit postnatal mothers. As a direct outcome of this policy shift, community perception of ANMs changed from maternal and child healthcare pro- viders to family-planning workers. Technical supervision at the field level also became diluted. Public-health nurses (PHNs) as a cadre with higher qualifications were discontinued due to union pressure in 1990, and health visitors were promoted as PHNs without further training and designated as PHN (non-teaching). The course for the Lady Health Visitors for two and a half years was discontinued in the 1970s, and a six-month promo- tional course was started according to the Indian Nursing Council (INC) guidelines. This course was further shortened to six weeks in Andhra Pradesh leading to deterioration of nursing and midwifery supervision in rural areas. Results of a study of nursing and midwifery in Andhra Pradesh in 2005 showed that nursing schools were inadequately equipped with models, books, and teaching-aids (21). Teachers had lost most basic skills of midwifery and pedagogy. As a result of inadequate support and gradual dilution, midwifery training and practice today are of low quality. There is no evidence of commitment of the state for improving the quality of midwifery services. Training of staff nurses is underway in the 231