Maternal mortality in Andhra Pradesh state each year. Repeated requests to the district health officials and others (healthcare providers, district administrators, women health volunteers, and NGOs) revealed only a small portion of the expected deaths in each district. There was no uni- formity in numbers. Only about 10% of the esti- mated maternal deaths in Andhra Pradesh were identified for 2006 up to February 2007, indicating the low priority for reporting and registering mater- nal deaths. Of 336 deaths identified, the research team conducted a review for 148 maternal deaths that could be traced back to their houses. The full details of the remaining maternal deaths were not available for analysis. State-level primary data on maternal deaths and the factors contributing to deaths were obtained from social audits conduct- ed for these 148 deaths. A detailed analysis of secondary data relating to maternal deaths, availability of health services, use of facilities, and government interventions in the state during the last two decades was conducted. Some reports used were: three rounds of the NFHS, SRS data, census data, and departmental reports of the Government of India and the Government of Andhra Pradesh. Findings of research and project reports conducted in the state were also used. Pro- gramme-related data for the last 20 years were col- lected, reviewed, and analyzed and were included in the paper wherever applicable. RESULTS Results of the study are presented under the follow- ing three sections: a. Infrastructure, facilities, and personnel for ma- ternal health service-delivery in Andhra Pradesh and the awareness and use of facilities by the community, specifically women. b. Maternal mortality in Andhra Pradesh, includ- ing efforts at estimation, the medical causes, and social factors contributing to maternal deaths. c. Government interventions for reducing mater- nal mortality and morbidity, including different programmatic efforts over the last two decades. Infrastructure, facilities, and personnel for mater- nal health services and awareness and use of fa- cilities by the community, specifically women Started in the erstwhile Hyderabad state under the Nizam rule before the independence of India, the tradition of maternal and child health service-de- livery continued after the merging of Hyderabad into the Indian Union. The state followed the same Volume 27 | Number 2 | April 2009 Prakasamma M pattern of community development as in the rest of the country. A steady growth of public-health institutions took place—Subcentres, PHCs, and hospitals increased in number. A number of train- ing centres were established to produce doctors, nurses, health visitors, and ANMs to work in these health centres. However, maternal health services gradually took a back seat in the priorities of the health system. Maternal and child health became integrated into family planning, following national guidelines that placed primary emphasis on mea- sures to control population growth. Structure of health services in Andhra Pradesh Andhra Pradesh has a wide network of health fa- cilities organized in a three-tier manner—primary, secondary, and tertiary—each managed by a dif- ferent administrative structure within the health department. • The Directorate of Health is responsible for pre- ventive, promotive and basic curative healthcare services throughout the state. Primary health services are provided under this system through a network of 1,570 PHCs and 12,522 Subcentres (Table 3). The Rural Health Statistics Bulletin, 2007 reported that each PHC covers a popula- tion of 35,287 and an area of 172.16 sq km, on an average, supports about 8-10 Subcentres, and provides institution-based primary medical care, maternal and child care, immunization and family-planning services (5). Each Subcen- tre covers a population of 4,424 and an area of 21.59 sq km and provides outreach services. Over the last two decades, the number of Sub- centres doubled from 6,125 to 12,522, and the number of PHCs rose three times from 555 to 1,570. • Although the number of health facilities has in- creased in the state, there is a shortage of staff in these facilities, especially nurse-midwives ac- Table 3. Growth of health facilities in And- hra Pradesh, 1981-2005 Period 1981-1985 1985-1990 1992-1997 1997-2002 No. of Subcentres 6,125 7,894 10,568 10,568 Functioning as on September 2005 12,522 PHCs=Primary Health Centres No. of PHCs 555 1,283 1,335 1,386 1,570 223