Globally around 80% of maternal deaths (MD) occur due to complications during pregnancy, birth, and post-birth [1]. Most of the MDs are preventable by the approach which starts at individual homes and continues at health facilities, equipped for appropriate, effective and timely interventions and continues back at their homes. Many rural women, specially, those who live in extreme poverty, do not have access to appropriate, and affordable health facilities. Sometimes they do not use the available health facility because of their own beliefs, or they are not able to use the facility due to the regulations in the health system.

Study setting

Service villages around the village with health facility, study center.

Study design

This is an observational study.

Inclusion study sample

All maternity related deaths in villages being served during the decade just over.

In view of the persisting high maternal, perinatal and child mortality in the villages in central part of a region ably well doing province, a health facility was created in one of the villages. Hospital-based multispecialty health services were started with a concept of social accountability of the medical institute situated in the nearby district. It was soon realized that for a real impact on the maternal health, it was essential to provide community-based mother and child services. Attempts were made to provide community based basic prenatal care, guidance and advocacy to each pregnant woman for safe pregnancy, safe birth, and safe post birth by once a month visit by nurse midwives (NM) to each village. NM were assigned to fixed villages to have rapport. Each pregnancy was followed for outcome, irrespective of the place, type of birth and outcome. Over a decade details of maternity related deaths have been analyzed. Study is analysis of records of maternal death cases kept on regular basis as soon as death occurred, not a planned study. Analysis was essential for future actions. And on analysis which needed no approvals it was felt that information needed sharing.

As per base data collected in the first year, there were 56% home births in the villages being served, 27.07% at public health facilities, 10.39% at referral base hospital, which was the study center and 06.54% at other places. After a decade, in the recent year, there were 19% home births, 61.55% at public health facilities, 17.10% at referral base hospital, and 2.35% at other places. Maternal mortality ratio (MMR) in the base data year was 300 and in 2022-2023 it was 71. Facility based births have increased and overall situation is improving but preventable MDs have still occurred. So, it was decided to do a detail analysis of each case, for further actions to prevent MDs. Table 1 depicts information about gravidity (number of pregnancies) and parity (number of viable births) across different age groups, maximum maternal death cases, 46 (85.1%), were women of age 20-29 years. As per gravidity/parity status, maximum maternal deaths cases were primigravida 21 (38.9%) (Table 1).

Analysis of information was also done about the gestational age at the first antenatal checkup and the status at the time of death in context of duration of pregnancy. Of 34 pregnant women who had their first antenatal checkup at or before 14 weeks, maximum number of deaths had occurred beyond 37 weeks gestation postnatally. Understanding of the relationship between the timing of antenatal care and the status of pregnancy at the time of death provided valuable insights about quality care because deaths occurred in spite of almost timely first checkup (Table 2).

Maternal deaths across various demographic and socioeconomic variables revealed that majority of the women 52 (96.29%) belonged to lower economic class and only 2 (3.7%) from lower middle class. Majority 29 (53.70%) had studied up to primary level, 2 (3.7%) women were illiterate, 17 (31.48%) had studied up to secondary level, and 6 (11.11%) had higher secondary level with no death case was a graduate. Total 32 (59.3%) women died due to direct causes, mostly due to postpartum hemorrhage after home births, with anemic state. Seventeen (31.5%) women died of indirect causes. Overall, there was correlation between education and causes of maternal deaths, with indirect causes more among illiterate or primary school educated. All the 4 cases of MDs who were adolescent girls, had direct causes (100%). For the women between 20-29 years, (46 cases), 24 (52.21%) deaths were due to direct causes, 17 (37%) due to indirect causes, and 5 (10.9%) due to unspecified causes. Regarding education, out of 29 cases with primary education, 17 deaths (58.6%) were due to direct causes, mainly PPH, 7 (24.1%) due to indirect, mainly cardiogenic shock because of pulmonary embolism, heart disease, sepsis, anemia and 5 (17.2%) were due to unspecified causes. Of the total 54 cases, 52 (96.2%) deaths cases were women of low economic status, 30 deaths (55.6%) were due to direct causes mainly PPH, 17 (32.7%) due to indirect, and 5 (9.6%) unspecified. This detailed breakdown enables a deeper understanding of the relationship between various demographic factors and maternal deaths, guiding about targeted interventions to address specific factors (Table 3). Out of total 54 maternal deaths, maximum death cases were postnatal, 40 (74%). However, 14 (26%) women died undelivered. Out of 40 postnatal deaths 27 (67.5%) had live births and 10 (25%) intrauterine deaths and 3 (7.5%) still births with 5 (22.7%) neonatal deaths (Table 4). Table 5 depicts details of all 54 death cases with crux of the problems.

MMR, the number of women who die per 100,000 live births, during pregnancy, or within 42 days of termination of pregnancy, irrespective of the duration and the site of pregnancy from any cause related to or aggravated by pregnancy or its management, excluding accidental or incidental causes, birth and post birth. It varies greatly across the regions, due to the differences in preconception health of women, anemia, women’s, education, economic status, variations in care during pregnancy, birth, post birth, access to emergency maternity care, and other factors which affect mother’s and baby’s health. Providing appropriate comprehensive care by skilled healthcare providers at home or, close to the places of their residence, is well recognized strategy to facilitate care and birth at health facility. However, in spite of the system, women either do not go to any health facility or by-pass the available facility because of the lack of resources of the household or health system’s policies, or the readiness of the nearest facility to provide care with available teams, right attitude of women’s, families and community service providers, transfer system, and so on. However, beliefs also have big impact on their decisions of utility of services and birth places. Agrawal et al. [3] reported that each year in India, roughly 28 million women experienced pregnancy and 26 million live births occurred, and an estimated 67,000 MDs occur and one million new-born die. India has shown an appreciable decline in MMR from 398 in the year 1997-98, to 254 in 2004-06, 130 in 2014-2016, and 113 in 2016-18 according to the special bulletin on Maternal Mortality in India [4]. As per the National Health Policy (NHP) document 2017, the national target for MMR was 100 by 2020, which has not been achieved, worst is that in some States, MMR is still very high. However, in some States, target of 70 has been achieved but in such States also, there are black dots, like the one in the province of study villages [5]. So, it is essential to have continuous surveillance and response for each region. In order to achieve the National Rural Health Mission and Millennium Development Goal of less than 100 MMR everywhere, there is a need to accelerate the pace of decline of MMR [6]. When services were initiated in the rural and remote region, MMR was 400, and in the State, MMR was 68 [7] and 2019-2020 MMR was 46 and in 2020-2021 it was 57 and in 2021-2022 it was 113 and in 2022-2023 it was 61 [8]. In the villages being served in 2013-2014 it was found 300, however there were challenges in collecting information when services were started and 162 in 2019-20 and 148 in 2020-2021 and in 2021-2022 it was 53 and in 2022-2023 it was 25, over all in the region it was 188 in 2020-2021, 190 in 2021-2022 and unfortunately 264 in 2022-2023. So there has been impact of health facility and services. As is well known MD Reviews (MDR) and MD Surveillance Response (MDSR) are strategies to find gaps and accordingly take action to improve the quality of care and reduce maternal mortality, neonatal mortality, and severe illnesses and the same is being done in the villages. Analysis of the information of each death can identify the real cause, including the delays at various levels that contribute to MDs. The information needs to be used to adopt measures to fill the gaps in service delivery as well as service acceptance. In the region from where this information in being shared, there is extreme poverty and there are access problems. Over all 54 women who died over a decade have their own stories. The crux was severe anemia, in last few days of pregnancy, traumatic births at home, missed diagnosis at health facilities and women’s refusal to stay with health facility (Table 5). Looking at the situation it seems that having health facilities, and even community based maternal services will not change the scenario, unless social perspectives are taken care, be it women or their families and communities. It needs best of the counseling, focus group discussions, role plays, better understanding of many more things so that women may be made to understand the need of care and get timely appropriate care. Elimination of maternal deaths requires improvement as per the need in the pre-conception health and avoidance of clinical errors by refining clinical skills and increasing the availability and quality of services. Health providers need to be with updated knowledge. Most important, there has to be right attitude of healthcare providers, and they must have concern for each woman who seeks care. Analysis of records of deaths cases revealed that there were problems of communication, between health systems and women, knowledge and attitude at health facilities, and strong beliefs of women and families, about not staying with health facility, which lead to loss of lives. Women left hospitals and died on the way, or at home within hours of discharge from hospitals. Sometimes they were discharged by the healthcare providers without understanding the real problem. Some women took discharge against medical advice and died within hours of discharge. Women who died needed services which were not difficult to get even in the region with low resources. Some women did not seek care because of their beliefs or lack of faith in the available health system. The extent of bypassing the nearest facility in a rural Ugandan setting was 29%, and was found to be associated, primarily with the readiness of the nearest facility to provide care as well as the wealth of the household. In these women also these two things played some role. Also, deaths are not always because of obstetric causes as pregnant women are not immune to other illnesses. During pregnancy disorders like, haemoglobinopathies or cardiac diseases become more dangerous. Also, something seriously needs to be done preconception for prevention and treatment of anemia, as it appears that most pregnant women were anemic, some even severely and very severely anemic during pregnancy. Of all the maternal death cases, 15 (27.78% of 54) had severe anemia (Hemoglobin <7 gms/dl) in the days before they died. Obvious reasons seem to be extreme poverty and lack of required food which lead to multiple deficiencies. Also, bio-fuel mass, which almost 80% of families use for cooking, hot water, bath and also for protection from cold in the villages, might be contributing to their anemia. WHO considers MMR of around 20, reasonable. Present study in rural areas revealed that a lot was needed to reach this goal. McConnell et al. [9] reported that at South Carolina, effects of an intensive home visiting program of the nurses on adverse birth outcomes for the intervention group were not significantly better for any maternal and newborn health, primary or secondary outcomes in the overall sample or in either of the pre specified subgroups. Assignment to participate in an intensive home visiting program of nurses did not significantly reduce the adverse birth outcomes. So, there are reasons not obvious. Shah et al. [10] reported that MMR reduced from 607 (19 deaths) in 2002–2003 to 161 (five deaths) between 2010–2011 in rural India. The institutional delivery rate increased from 23% to 65%. The trend of falling MD was significant over the times, with an annual reduction of 17%. There was significant reduction in adjusted MDs due to direct causes, during intrapartum and post-partum periods, and those which occurred at home. However, reduction in MDs due to indirect causes and during antepartum period were not statistically significant. In the present analysis 16 (29.6%) out of 54 women died due to PPH, one had placenta Previa not managed rightly, leading to hemorrhagic shock after birth and 2 women died of secondary PPH due to retained placenta. Shah et al. [11] reported that most MDs of rural India were occurring at hospitals and due to indirect causes. Anemia along with other hematological causes like sickle cell disease have been leading causes of maternal deaths often due to post-partum hemorrhage. In the present analysis 7 (12.9%) out of 54 women died due to Sickle Cell crisis. One woman landed up in sepsis preceding death. These women and their families refused hospital admission for intra and post-partum care. Total 15 (27.7%) out of 54 women died of eclampsia, (10 had intracranial hemorrhage, 4 with multi organ failure and one developed hemolysis elevated liver enzymes and low platelet count (HELLP) syndrome). The main issues in these cases were non-compliance to treatment advised. Other causes included undiagnosed placenta Previa, pyrexia of unknown origin, dengue and thrombocytopenia, heart disease, and gender-based violence too. Kinney et al. [12] opined that maternal and perinatal death surveillance and response (MPDSR) is health system’s process which entails the continuous cycle of identification, notification and review of maternal and perinatal deaths, followed by actions to improve service delivery and quality of care. The MPDSR system in India is to record and review all maternal and perinatal deaths but underreporting of deaths remains a major implementation challenge. Fear of blame and malpractice litigation among health workers are important factors in underreporting, suggestive of an increased humidification of birth care by taking MPDSR implementation as an entry point, an increasing public notion of MDs being caused by malpractice, and a tendency to perceive the judicial system as the only channel to claim accountability for MDs, the development of strategies to avoid personalized accountability for deaths. The same was tried in the remote rural region. Antecedent maternal disorders and fetal outcomes in cases of maternal deaths revealed that with mothers dying many babies are also lost. Out of 54 mothers, 14 died during pregnancy and 40 delivered in which 18 babies were lost.

Information reveals need of timely interventions aimed at prevention of maternal deaths and improving fetal neonatal outcomes by working on technical as well as nontechnical aspects.

Analysis of 54 deaths which occurred in the service villages over a decade revealed maximum MDs were amongst women of 20 to 29 years (46 (85.18%)), believed to be best years. Maximum deaths were in women with first pregnancy 21 (38.9%). Out of 54 women, 52 (96.2%) women were of low economic status. Most deaths were preventable even in the region with low resources.

Authors have no conflict of interest

Nil

Thanks are due to NM assigned villages and residents who have worked at rural hospital over the years on deputation from main institute in rotation.