Maternal mortality in Andhra Pradesh of women who availed of antenatal care at home from traditional birth attendants (TBAs) reduced sharply (6,7). The percentage of women who did not avail of any antenatal care fell from 12.2% to 5.2 % during this period. Deliveries attended by doctors rose from 36.6% during NFHS 1 to 73.3% during NFHS 3 but deliver- ies attended by nurses-midwives did not undergo a change (Fig. 3). During the same period, the share of deliveries attended by dais fell from 33.9% to 7.5%, and those attended by relatives and others fell from 15.9% to 4.7%. Prakasamma M Fig. 3. Assistance during delivery 100 90 80 70 60 %50 40 30 20 10 0 5 . 0 .6 5 6 3 3 . 3 7 Doctor .217 .316 .112 Nurse/ midwife NFHS 1, 1992-1993 NFHS 2, 1998-1999 NFHS 3, 2005-2006 9 . 33 .56 2 TBA 5 . 7 9 . 5 1 .38 .74 Relatives and others Fig. 2. Percentage of women receiving antenatal care from different providers NFHS=National Family Health Survey; TBA= Traditional birth attendant 110 100 90 80 70 60 %50 40 30 20 10 0 9 . 1 6 5 . .11 87 8 NFHS 1, 1992-1993 NFHS 2, 1998-1999 NFHS 3, 2005-2006 0 2 9 .4 .5 0 2 . 12 .37 .25 .40 .67 .68 Health professionals Doctor Home No ANC ANC=Antenatal care; NFHS=National Family Health Survey In-depth study of maternal health facilities and services in Medak district The work in Medak carried out by the Academy for Nursing Studies up to December 2007 illustrates that none of the 26 PHCs that were to be open on a 24-hour x 7-day basis was adequately staffed or equipped for round-the-clock maternal and neonatal services (8) (Table 6). The Indian pub- lic health standards of 2006 for PHCs require two doctors and three staff nurses for round-the-clock services (9). These were managed with a few basic instruments as delivery-sets were not available. The labour-rooms were disorganized and dusty; some had cobwebs. Even basic equipment, such as blood pressure apparatus, had to be shared with the ward. There was very little consideration for pri- vacy with broken windows and no curtains. Staff positions were particularly inadequate. The in- frastructure was inadequately used. The average Volume 27 | Number 2 | April 2009 number of deliveries per month was 11 (no deliver- ies were being conducted in four of the 26 PHCs). Perceptions and opinions of care providers and women revealed several problems. Staff nurses in the 24-hour PHCs had difficulties in manag- Table 6. Shortfall of personnel in Medak district, 2007 Required % of PHC per- according Available shortfall sonnel to IPHS 2 medical officers per PHC 3 staff nurses or nurse- midwives per PHC 52 78 23 32 55.76 58.97 IPHS=Indian public health standards; PHC=Pri- mary Health Centres ing childbirth services since they had to carry out many other activities and could not provide round- the-clock coverage. They neither received technical guidance and support nor had adequate equip- ment and supplies. They had to stay alone during night duties with poor security. No vehicle was available to refer emergencies. Hospital staff did not give priority to women even when staff nurses referred them. Doctors in the 24-hour PHCs stated that equipment was not available so they could not provide quality service. They complained that vil- lagers brought women in labour in the last minute, pleaded to conduct delivery in the PHC, and crea- ted a problem if anything went wrong. They also reported that it was difficult for them to be avail- 225