Meeting the community halfway to reduce maternal deaths? Evidence from a community-based maternal death review in Uttar Pradesh, India

BACKGROUND: Uttar Pradesh (UP) is the most populous state in India with the second highest reported maternal mortality ratio in the country. In an effort to analyze the reasons for maternal deaths and implement appropriate interventions, the Government of India introduced Maternal Death Review guidelines in 2010. METHODS: We assessed causes of and factors leading to maternal deaths in Unnao District, UP, through 2 methods. First, we conducted a facility gap assessment in 15 of the 16 block-level and district health facilities to collect information on the performance of the facilities in terms of treating obstetric complications. Second, teams of trained physicians conducted community-based maternal death reviews (verbal autopsies) in a sample of maternal deaths occurring between June 1, 2009, and May 31, 2010. RESULTS: Of the 248 maternal deaths that would be expected in this district in a year, we identified 153 (62%) through community workers and conducted verbal autopsies with families of 57 of them. Verbal autopsies indicated that 23% and 30% of these maternal deaths occurred at home and on the way to a health facility, respectively. Most of the women who died had been taken to at least 2 health facilities. The facility assessment revealed that only the district hospital met the recommended criteria for either basic or comprehensive emergency obstetric and neonatal care. CONCLUSIONS: Life-saving treatment of obstetric complications was not offered at the appropriate level of government facilities in a representative district in UP, and an inadequate referral system provided fatal delays. Expensive transportation costs to get pregnant women to a functioning medical facility also contributed to maternal death. The maternal death review, coupled with the facility gap assessment, is a useful tool to address the adequacy of emergency obstetric and neonatal care services to prevent further maternal deaths.