Too far, too little, too late: a community-based case-control study of maternal mortality in rural west Maharashtra, India.

Maternal deaths account for 13% of all deaths among reproductive-aged women in India. 121 maternal deaths identified through multiple-source surveillance in 400 villages in Maharashtra were prospectively enrolled during 1993-95 in a population-based case-control study comparing deaths with the survivors of similar pregnancy complications. Mothers who died took significantly longer to seek care and to make the first health contact after deciding to seek care. They also travelled significantly farther through more health facilities before appropriate treatment was started. Multivariate analysis showed the negative effect of excessive referrals and the protective effect of living in rather than away from villages having a resident nurse in the village having an educated husband and a trained attendant at delivery and being at the womans parents home at the time of illness. Domestic violence was the second largest cause of deaths in pregnancy more than two-thirds of maternal deaths were underreported in official records and liveborn infants of maternal deaths had a significantly higher risk of dying during the first year of life. Information-education-communication efforts to increase family preparedness for emergencies decentralized obstetric management with effective triage and a restructuring of the referral system are needed.