Maternal mortality in Andhra Pradesh The Government of Andhra Pradesh also launched a Free Bus Pass Scheme under which nearly 0.8 mil- lion rural pregnant women received free bus passes to enable them to travel to the nearest hospital for antenatal care and delivery. Another recent deve- lopment is the Health Information Helpline. A toll- free number (104) has been dedicated to answer calls of people at all times round-the- year through a public-private partnership with the Health Man- agement Research Institute of the Satyam Founda- tion. DISCUSSION Analysis of factors responsible for maternal mortality in Andhra Pradesh The major factors for the persistently high MMR are the low awareness among women and families about risks and low access to resources and services. The failure of the public-health system at the grassroots level to provide a skilled birth attendant for every childbirth is also a critical factor in the current high infant mortality rate (IMR) and MMR as shown in the case study of Medak. In addition, the gradual but steady withdrawal of skilled ser- vices and service providers from the community to more centralized urban areas has reduced access to qualified care for underprivileged groups. This case study postulates the following key hypotheses for the persistently high MMR and then discusses each briefly: • Low priority to maternal health due to dispro- portionately heavy focus on female sterilization resulted in inadequate efforts at reducing mater- nal mortality, especially in the last decade. This included low emphasis on monitoring, report- ing, and analyzing maternal deaths. • Inadequate emphasis on strengthening periph- eral health facilities resulted in negligence to- wards and decline of primary health facilities, and women gradually moved away from gov- ernment facilities. • Low priority to development of midwifery per- sonnel resulted in extreme shortages in skilled maternal care providers in the hospital and com- munity. • The low status of women—low age at marriage and low literacy levels of girls—did not generate demand for high-quality maternal health ser- vices at the periphery and delayed prompt treat- ment-seeking. 228 Prakasamma M Low priority to maternal health compared to population control The findings of the NFHS 3 (2005-2006) indicate that Andhra Pradesh is ahead of the country as a whole in terms of provision of maternal healthcare but is lagging behind Kerala and Tamil Nadu. Fig- ure 4 and 5 depict the situation of maternal health services in the three states. The data are especially striking in the percentage of deliveries conducted in institutions and assisted by health professionals. Only 68.6% of women in Andhra Pradesh deliv- ered in institutions compared to 99.5% in Kerala and 90.4% in Tamil Nadu according to the NHFS 3 data. Although there is a steady improvement in Andhra Pradesh in the percentage of deliveries at- tended by health personnel, the figure of 74.2% in Andra Pradesh is far behind Tamil Nadu (93.2%) and Kerala (99.7%). Fig.4. Births assisted by a doctor/nurse/LHV/ ANM/other personnel 1 . .37 94 2 8 . 5 6 2 . 4 7 7 .2 .9 3 9 9 100 80 60 % 40 20 0 100 80 60 %40 20 0 9 . 8 4 3 . 9 6 2 . 0 9 3 . 4 3 3 . 4 6 9 . 8 8 NFHS 1 1992-1993 Andhra Pradesh NFHS 2 1998-1999 Tamil Nadu NFHS 3 2005-2006 Kerala ANM=Auxiliary Nurse Midwife; LHV=Lady Health Visitor NFHS=National Family Health Survey Fig. 5. Percentage of institutional births in diffe- rent states 8 . 9 4 9 . 2 .3 9 9 7 6 . 8 6 5 . .04 99 9 NFHS 1 1992-1993 NFHS 2 1998-1999 NFHS 3 2005-2006 Andhra Pradesh Tamil Nadu Kerala NFHS=National Family Health Survey JHPN