Changing epidemiology of maternal mortality in rural India: time to reset strategies for MDG-5

Changing epidemiology of maternal mortality in rural India:

time to reset strategies for MDG-5

Pankaj Shah1, Shobha Shah1, Raman V. Kutty2 and Dhiren Modi1

1 Community Health Department, SEWA-Rural, Jhagadia, India2 Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology,Thiruvananthapuram, India

Abstract objective To understand changes in epidemiology of maternal mortality in rural India in the

context of increasing institutional deliveries and implementation of community-based interventions

that can inform policies to reach MDG-5.

methods This study is a secondary analysis of prospectively collected community-based data of

every pregnancy and its outcomes from 2002 to 2011 in a rural, tribal area of Gujarat, India as part

of safe-motherhood programme implemented by voluntary organisation, SEWA Rural. The

programme consisted of community-based interventions supported by a first referral unit, and

promotion of institutional deliveries. For every maternal death, a verbal autopsy was conducted. The

incidence rates for maternal mortality according to place, cause and timing of maternal deaths in

relation to pregnancy were computed. Annual incidence rate ratios (IRR) and 95% confidence

intervals, adjusted for caste and maternal education, were estimated using Poisson regression to test

for linear trend in reduction in mortality during the study period.

results Thirty-two thousand eight hundred and ninety-three pregnancies, 29 817 live births and 80

maternal deaths were recorded. Maternal mortality ratio improved from 607 (19 deaths) in 2002–2003 to 161 (five deaths) in 2010–2011. The institutional delivery rate increased from 23% to 65%.

The trend of falling maternal deaths was significant over time, with an annual reduction of 17%

(adjusted IRR 0.83 CI 0.75–0.91, P-value <0.001). There were significant reductions in adjusted

incidence rate of maternal deaths due to direct causes, during intrapartum and post-partum periods,

and those which occurred at home. However, reductions in incidence of maternal deaths due to

indirect causes, at hospital and during antepartum period were not statistically significant. Most

maternal deaths are now occurring at hospitals and due to indirect causes.

conclusion Gains in institutional deliveries and community-based interventions resulting in fewer

maternal deaths due to direct causes should be maintained. However, it would be essential to now

prioritise management of indirect causes of maternal mortality during pregnancy at community and

hospitals for further reduction in maternal deaths to achieve MDG-5.

keywords skilled birth attendance, maternal mortality ratio, epidemiology, institutional delivery,

Millennium Development Goal-5

Introduction

The epidemiology of maternal mortality is well known

(Ronsman et al. 2006). Most maternal deaths occur in

poor countries and are clustered around delivery and the

immediate post-partum period, although there are varia-

tions depending upon the population. The majority of

deaths occur due to direct causes such as bleeding, hyper-

tensive disorders and infections (Ronsman et al. 2006).

Guided by epidemiology of maternal mortality, institu-

tional delivery has been promoted to prevent maternal

deaths at the time of delivery (Bale et al. 2003; WHO

2005; Campbell & Graham 2006). India launched Janani

Suraksha Yojana (JSY) in 2005–2006, a conditional cash-

transfer programme to promote institutional deliveries.

Under JSY, a woman living below the poverty line is enti-

tled to Rs. 700 (US $ 14) in rural areas and Rs. 600 in

urban areas if she delivers in a public or accredited pri-

vate health facility. JSY is implemented through commu-

nity-based front-line workers who also are incentivised

for motivating women for delivering in a health facility

(Ministry of Health & Family Welfare 2005). Some state

568 © 2014 John Wiley & Sons Ltd

Tropical Medicine and International Health doi:10.1111/tmi.12282

volume 19 no 5 pp 568–575 may 2014

governments in India initiated their own schemes, such as

free emergency transportation for women in labour to

reach a hospital and innovative public–private partner-

ship (called Chiranjeevi scheme in Gujarat) to involve

obstetricians from private sector (Mavalankar et al.

2009). At the same time, cadres of village-based front-

line workers were established in all villages to motivate

women to deliver at health facilities and facilitate deliv-

ery of community-based-interventions (National Rural

Health Mission 2013). These efforts have resulted in a

significant increase in the institutional delivery rate from

24.4% in 2005 to 61% in 2010 (Office of Registrar Gen-

eral, India 2008, 2010). The maternal mortality ratio

(MMR) has fallen from 407 deaths per 100 000 live

births in 1997–1998 to 212 in 2007–2009 (Sample regis-

tration system, Office of Registrar General, India 1998,

2012). The increase in institutional deliveries with

improved referral linkages is one of the important reasons

thought to have resulted in reduction in MMR in India

(Kumar et al. 2010).

Despite these achievements, India is not on track to

reach the Millennium Development Goal-5 (MDG-5),

which is to reduce number of maternal deaths by 75%

between 1990 and 2015 (United Nations 2012). At this

critical juncture, it would be important to understand

changes in epidemiology of maternal deaths to evaluate

current strategies and guide development of new ones to

achieve MDG-5. The objective of this study was to

examine changes in epidemiology of maternal mortality

in context of increasing institutional deliveries and imple-

mentation of community-based interventions in a rural

block of Gujarat, India from 2002 to 2011. We tested

the hypothesis that there was no change in incidence of

maternal deaths, its causes, time and place in this popula-

tion before and after 2004.

Methods

Study setting

This study is based on prospectively collected community-

based data by field-based front-line workers (FLWs) of

SEWA Rural. SEWA Rural (SR) is a voluntary organisa-

tion in Jhagadia block of Gujarat state in western India.

The population of Gujarat was almost 60 million in 2011,

and per capita annual income was Rs. 22 553 (US $ 450)

(Government of Gujarat 2010, 2012). Gujarat’s MMR

was 148 and infant mortality rate was 50/1000 live births

with institution delivery rate of 56% in 2007–2009(Ministry of Health & Family Welfare 2010, 2012; Office

of Registrar General, India 2012). After collecting baseline

information for 2 years from 1 April 2002 to 30 March

2004, SEWA Rural implemented a family-centred safe-

motherhood and new-born survival project for 7 years

from 1 April 2004 to 31 March 2011 which catered to the

entire Jhagadia block consisting of 168 villages with a

population of 175 000, which is mainly tribal, rural and

poor (SEWA Rural 2011; Kutty et al. 2013).

Community-level interventions were implemented by

FLWs and traditional birth attendants (TBAs) to provide

antepartum, intrapartum and post-partum care. The fol-

lowing method was used to ensure completeness of preg-

nancy registration: The FLWs conducted house-to-house

visits in her village every week and registered all new

pregnancies. Additionally, two cluster supervisors made

monthly door-to-door field visits in all villages to find

and register any remaining new pregnancies, which might

have been missed by FLWs. This resulted in more than

90% complete pregnancy registration of the expected

number of registration based on birth rate of Gujarat.

The FLW visited a pregnant woman five times antepar-

tum and nine times post-partum. During home visits,

FLW’s responsibility was to ensure early registration of

pregnancy, satisfactory birth-preparedness and complica-

tion-readiness, complete antepartum check-up, identifica-

tion and referral of high-risk mothers, counselling of

woman and her family in case of unintended pregnancy

with availability of referral services for termination of

pregnancy, motivate the mother for delivery at hospital,

safe delivery by trained TBA in case of home delivery,

immediate newborn care and post-partum follow-up of

mothers and neonates up to 6 weeks after delivery. Com-

plicated cases were referred to the SEWA Rural hospital,

which is a government and UNICEF approved first refer-

ral unit (FRU) providing Comprehensive Emergency

Obstetrics and Newborn Care attending to almost 2400

deliveries every year. Along with SEWA Rural’s efforts,

Governments of India and Gujarat introduced various

schemes during the same time period to promote

institutional deliveries as described above.

Data collection

Front-line workers used a data collection card to record

information related to demographics, risk factors, deliv-

ery of services, place of delivery, pregnancy outcome and

survival status at 6 weeks post-partum. FLWs also

recorded every maternal death and all female deaths in

their village. Maternal death was defined as ‘[t]he death

of a woman while pregnant or within 42 days of termi-

nation of pregnancy, irrespective of the duration and site

of the pregnancy, from any cause related to or aggravated

by the pregnancy or its management but not from acci-

dental or incidental causes’ (WHO/UNICEF/UNFPA/

© 2014 John Wiley & Sons Ltd 569

Tropical Medicine and International Health volume 19 no 5 pp 568–575 may 2014

P. Shah et al. Changing epidemiology of maternal mortality in rural India

World Bank 2010). A verbal autopsy tool, consisting of

open and close ended questions, was developed by SEWA

Rural based on prevalent WHO guidelines for conducting

verbal autopsy for maternal deaths (WHO 1994). An

experienced supervisor visited the deceased woman’s

home within 1 month of death and conducted a verbal

autopsy by interviewing close family members, TBA and

those who were present at the time of death. Once the

field team confirmed occurrence of maternal death, a

team consisting of a senior obstetrician–gynaecologist,public health professionals and field staff discussed every

maternal death to ascertain cause of death. A primary

and secondary cause of death was assigned and coded by

the team based on International Classification of Dis-

eases-10. The information from the verbal autopsy tool

was entered into to a database at headquarters. Quality

and completeness of data were monitored by programme

managers, obstetricians and statisticians during weekly

meetings, field visits and by comparing field-level data

with SEWA Rural hospital records.

Variables of interest and statistical analysis

Statistical software ‘R’ and STATA 10 were used for

analysis and creating figures (StataCorp 2007; R Core

Team 2012). Information about all pregnancies, preg-

nancy outcomes and maternal deaths among all women

who were resident of the project areas was included for

this study. Every primary cause of death was categorised

in one of two categories: direct and indirect causes.

Deaths from direct causes were defined as ‘those resulting

from obstetric complications of the pregnant state (i.e.

pregnancy, labour and the puerperium), from interven-

tions, omissions or incorrect treatment, or from a chain

of events resulting from any of the above’. Deaths from

indirect causes were defined as ‘those resulting from a

previously existing disease or a disease that developed

during pregnancy and which was not due to direct obstet-

ric causes but which was aggravated by the physiological

effects of pregnancy’ (WHO/UNICEF/UNFPA/World

Bank 2010). Intrapartum period was considered from

onset of labour to end of third stage of labour (Stedman’s

medical dictionary 2005). Institutional delivery rate was

defined as number of deliveries in institution per 100

deliveries including live and still births.

We chose incidence rate of maternal deaths per

100 000 pregnancies for the analysis instead of MMR.

Because a large proportion of maternal deaths occurred

during antepartum period and was due to unsafe abor-

tion where delivery did not take place, MMR (which is

number of maternal deaths per 100 000 live births) was

not sufficient to capture these deaths for analysis.

The incidence rate of maternal deaths per 100 000

pregnancies was estimated by dividing the number of

maternal deaths by total number of pregnancies accord-

ing to place, cause and timing of maternal death in rela-

tion to pregnancy. The trend in reduction in maternal

deaths over the study period was tested using Poisson

regression with calendar year entered in the model as a

single, continuous variable while adjusting for maternal

education and caste. Annual incidence rate ratios (IRR)

covering 2002–2011 with 95% confidence intervals are

reported for each type of maternal death. Changes in pro-

portion of maternal deaths according to its time, place

and cause were also displayed in form of a bar diagram.

Ethical considerations

This study is based on secondary analysis of data col-

lected for project monitoring; thus, ethical review was

not sought. Permission from the scientific committee of

SEWA Rural was obtained as it hosts the data.

Results

In total, 32 893 pregnancies were registered from 2002 to

2011. There were 29 837 (90.7%) live births, 613 (1.9%)

still births, 827 (2.5%) surgical terminations of pregnan-

cies and 1616 (4.9%) spontaneous abortions. Eighty

maternal deaths were recorded from 2002 to 2011. As seen

in Table 1, characteristics of women who had live births

during baseline and project periods were similar, except

literacy, caste and institutional delivery rate improved

during project period. Information about covariates such

as maternal age, caste and maternal education was missing

from 177 (0.5%), 253 (0.7%) and 1493 (4.5%) pregnant

women, respectively. Mean age of deceased women was

26 years, 10 (13%) had unwanted pregnancy and 70

(87%) of women belonged to a scheduled tribe. Only 18

(22%) women who suffered maternal death delivered at

hospital. There were 36 deaths (45%), which occurred

before delivery either during antepartum period or due to

unsafe abortion practices. Twenty-three (28.8%) women

had to seek care at two or more hospitals. Figure 1 shows

the reduction in MMR over time against the institutional

delivery rate. MMR declined sharply during first 4 years

of project; however, a plateau was observed afterwards.

The initial sharp reduction was due to fewer women dying

from haemorrhage (from 11 to 1) and unsafe abortion

(from five to one). The trend in fall of number of maternal

deaths over the study period was significant (P < 0.001).

Figure 2(a) shows primary causes of all 80 maternal

deaths. Of all 41 maternal deaths due to indirect causes,

21 occurred antepartum, two intrapartum and 18




post-partum. Sickle cell anaemia, severe anaemia, malaria

and ectopic pregnancy were some of the most common

causes of maternal deaths, which occurred during ante-

partum period. Eighty-four per cent of the deaths, which

occurred antepartum, were due to indirect causes. Of 11

deaths due to unsafe abortion practices, eight occurred

during first 4 years and only three deaths occurred in last

5 years.

The proportion of deaths, which occurred antepartum,

at hospitals and due to indirect causes has increased

(Figure 3). Major causes of maternal deaths occurring in

hospital were sickle cell disease (21%) and haemorrhage

(21%). Of 38 maternal deaths at hospital, 60% occurred

on the day of admission. Most maternal deaths are now

occurring because of indirect causes and at hospitals

throughout pregnancy.

As seen in Table 2, there was a 17% reduction in

adjusted incidence rate of maternal deaths annually (IRR

0.83, CI 0.75–0.91, P < 0.001). There were significant

reductions in adjusted incidence rate of maternal deaths

every year due to direct causes, during intrapartum, post-

partum period and those which occurred at home. How-

ever, annual reductions in incidence rate of maternal

deaths occurring during the antenatal period (adjusted

IRR 0.89, CI 0.76–1.05, P-value 0.16), at hospital

(adjusted IRR 0.92, CI 0.81–1.05, P-value 0.22) and due

to indirect causes (adjusted IRR 0.93, CI 0.82–1.05,P-value 0.23) were not significant.

Discussion

The epidemiology of maternal mortality underwent a

major shift in Jhagadia block during last decade.

Understanding of this change in epidemiology provides

important lessons for way forward to reach MDG-5 in

India. There is a reduction in overall, time, cause and

place-specific incidence rate of maternal deaths.

Table 1 Profile of all women who had live birth (n = 29 837) inJhagadia block from 2002 to 2011

Baseline

(2002–2003and 2003–04)

Project period

(2004–05 to

2010–11)

Live births, n 6356 23 481

Mean maternalage (years)

25 24

Scheduled tribe (ST)

women, n (%)

4404 (69%) 17 357 (74%)*

Illiterate women,n (%)

3029 (48%) 8685 (37%)*

*P-value <0.001.

600

400

200

060

4020

0

% h

ospi

tal d

eliv

ery

MM

R/1

00 0

00

02–03

19

16

1210

6

Numbers indicatetotal maternal deaths

4 5 53

PROJECTSTARTED

JSY & CYSTARTED

EMRI SERVICESSTARTED

04–05 06–07YEAR

08–09 10–11

Figure 1 Maternal mortality ratio (MMR) and institutionaldelivery rates from 2002 to 2011 in Jhagadia block (Population:

175 000). JSY, Janani Suraksha Yojana; CY, Chiranjeevi

Yojana; EMRI, Emergency Management and Research Institute

free ambulance services.

Ectopic-3 ( 3.75%)

Haemorrhage - 18 ( 22.5 %)

Hepatitis - 3( 3.75)Hypertensive

Disorder-3 (3.75%)

Malaria-3 ( 3.75%)Others-14 (17.5%)Puerpereal Sepsis-3

( 3.75%)

Severe Anaemia-8( 10.0%)

Sickle Cell Disease-10

( 12.5%)

Unsafe Abortion-11 ( 13.7%)

Pulmonary embolism- 2 (2.5)%

Tuberculosis,- 2 (2.5%)

0

100

200

300

400

500

600

700

800

All Cause MMR Direct Causes MMR Indirect Causes MMR

MM

R w

ith 9

5% C

I BaselineDuring project

(a)

(b)

Figure 2 Causes of maternal deaths in Jhagadia block, (n = 80)

(a) Primary cause of death between 2002 and 2011 (b) All-cause

and cause specific maternal mortality ratio (MMR) for baselineand project period.




Reduction in maternal deaths due to direct causes after

promotion of institutional deliveries has been observed in

other countries (Cross et al. 2010). Two separate

estimates from the Government of India stated that direct

causes were responsible for 73% and 66% of deaths,

though this was before a sharp increase in institutional

65.71%

40.00%31.25% 33.33% 40.00%

34.29%

60.00%68.75% 66.67% 60.00%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2002–04(n = 35)

2004–06(n = 15)

2006–08(n = 16)

2008–10(n = 9)

2010–11(n = 5)

Pro

port

ion

of m

ater

nal d

eath

Year (n = number of maternal deaths)

2002–04(n = 35)

2004–06(n = 15)

2006–08(n = 16)

2008–10(n = 9)

2010–11(n = 5)


2002–04(n = 35)

2004–06(n = 15)

2006–08(n = 16)

2008–10(n = 9)

2010–11(n = 5)


Deaths due to indirect causesDeaths due to directcauses

60.00% 60.00%50.00%

33.33%20.00%

40.00% 40.00%50.00%

66.67%80.00%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pro

port

ion

of m

ater

nal d

eath

Deaths at hospital

Deaths at home and on-the-way

28.57%13.33%

43.75%33.33%

60.00%

71.43%86.67%

56.25%66.67%

40.00%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pro

port

ion

of m

ater

nal d

eath

Deaths during intra and post partum period

Deaths during ante partum period

(a)

(b)

(c)

Figure 3 Proportion of maternal deaths

according to (a) cause, (b) place and (c)

time of death recorded in Jhagadia block,2002–11 (n = 80).




delivery rate (Ministry of statistics & programme imple-

mentation, Government of India 2005; Office of Regis-

trar General 2008). Two hospital-based studies in North

India reported that indirect causes were responsible for

18% (total number of maternal deaths in study = 1223)

and 51% (total number of maternal deaths in

study = 192) of deaths, respectively (Bhattacharyya et al.

2008; Jain et al. 2009). A nationwide sample survey in

India observed that 23.4% deaths occurred during ante-

partum period, 21% deaths were due to indirect causes,

and 59.1% deaths occurred in health facilities in 2003

(Institute of research in medical statistics, Indian council

of Medical research 2003).

The trend observed in this study might be due to

reduction in deaths due to direct causes occurring around

the time of delivery because of increase in institutional

delivery (or skilled birth attendance) (UNFPA & Univer-

sity of Aberdeen 2004). Community-based efforts aimed

at early identification of unintended pregnancies followed

by sensitive counselling might have helped pregnant

women and their families to make the right decisions and

avoid unsafe abortions. Large reduction in number of

deaths at home and increase in institutional deliveries

might have contributed towards increase in proportion of

maternal deaths at hospital; however, absolute risk of

dying at hospital has fallen.

The findings of this study are important for plan-

ning, implementing and evaluating current and future

safe-motherhood interventions and research. Existing

efforts to promote institutional and safe deliveries

along with increasing coverage and quality of commu-

nity-based interventions should continue. However,

study of maternal deaths in Jhagadia block provides a

‘best case scenario’ for maternal mortality with high

coverage of community-based interventions and increase

in institutional deliveries supported by referral linkages

with functional FRU. Even with that, MMR in Jhag-

adia (161) was slightly more than the India’s MDG-5

target (MMR of 109 deaths/100 000 live births) (Sam-

ple Registration Survey 2011). Therefore, it might be

essential to prioritise management of indirect causes of

maternal mortality during pregnancy for further reduc-

tion in maternal deaths now if India is to achieve

MDG-5.

There is increasing concern regarding the ‘third delay’,

which occurs after a woman reaches a health facility,

especially now as institutional deliveries and proportion

of maternal deaths in hospitals are increasing

Table 2 Maternal deaths in Jhagadia block, by cause, time and place: 2002–2011* (number and incidence per 100 000 pregnancies)

2002–2003and

2003–2004

2004–2005and

2005–2006

2006–2007and

2007–2008

2008–2009and

2009–2010 2010–2011 Annual trend, 2002–2011

Number of deaths (incidence of maternal mortality)

Adjusted incidence

rate ratio† (CI) P-value

Maternal deaths (overall) 35 (520) 15 (186) 16 (218) 9 (122) 5(146) 0.83 (0.75–0.91) <0.0001Maternal deaths due to

direct causes

25 (372) 6 (74) 5 (68) 3 (41) 2 (58) 0.72 (0.61–0.83) <0.0001

Maternal deaths due to

indirect causes

12 (178) 9 (112) 11 (150) 6 (81) 3 (88) 0.92 (0.81–1.05) 0.23

Maternal deaths duringantenatal period

10 (149) 2 (25) 7 (95) 3 (41) 3 (88) 0.89 (0.75–1.04) 0.16

Maternal deaths during

intranatal and post-natal

period

25 (371) 13 (161) 9 (123) 6 (81) 2 (58) 0.79 (0.7–0.9) 0.0002

Maternal deaths at home

and on the way

21 (312) 9 (112) 8 (109) 3 (41) 1 (29) 0.74 (0.64–0.85) <0.001

Maternal deaths at

hospital

14 (208) 6 (74) 8 (109) 6 (81) 4(117) 0.91 (0.81–1.05) 0.22

Total number of

pregnancies

6730 8048 7331 7362 3422 –

*2002–2003 refers to 1/4/2002–31/3/2003; 2003–2004 refers to 1/4/2003 to 31/3/2004; 2004–2005 refers to 1/4/2004 to 31/3/2005;

2005–2006 refers to 1/4/2005 to 31/3/2006; 2006–2007 refers to 1/4/2006–31/3/2007; 2008–2009 refers to 1/4/2008–31/3/2009; 2010–2011 refers to 1/4/2010–31/3/2011.†Estimate is based on the Poisson model treating calendar year as a single linear variable, adjusted for caste and education.




(Ramanathan 2009). It was observed in this study that

23 (28.8%) women had to seek care at two or more hos-

pitals. There are anecdotal reports where complicated

maternal cases would be referred from one facility to

another without established referral and communication

linkages; thus, resulting in frustration, higher cost, poor

quality of care and ultimately death, in some cases (Sri

et al. 2012). Strengthening referral and communication

linkages between community-level workers to first refer-

ral-facility and to higher referral centres along with

increasing quality of care to manage medial diseases dur-

ing pregnancy could be an important element of prevent-

ing deaths resulting from third delay in hospitals.

There is a concern regarding under-reporting of mater-

nal deaths, which occur during the antepartum period or

due to indirect causes globally (Cross et al. 2010). A

large number of deaths occurred antepartum in this

study, which emphasises importance of tracking every

pregnancy, counting every female death and getting infor-

mation about all epidemiologic aspects including cause of

death. The recently introduced online Mother and Child

Tracking System (MCTS) in India holds promise to track

every pregnancy and its outcome. The MCTS is an

online, name-based tracking system where information

about all pregnant women and children gets entered in

software, and each pregnant woman is tracked until final

outcome; thus, it aims to provide health-managers real-

time, up-to-date information about every pregnancy. Such

solutions could be studied regarding their effectiveness,

feasibility and scalability so that every maternal death is

counted and complete information about its determinants

is available.

One of the important limitations of this study is com-

paratively small sample size. In spite of that, there is a

clear and consistent trend of maternal mortality and

some of its epidemiological determinants. Considering the

predominantly tribal population of Jhagadia block, one

should be careful before generalising these findings to a

wider population. There always remains the concern

about completeness of data while calculating maternal

deaths. This study is based on prospectively collected

data having outcome information for all registered preg-

nancies, including large number of unintended pregnan-

cies. Additionally, SEWA Rural recorded every death

among women of all age groups. These facts give confi-

dence about completeness of reporting of all maternal

deaths. More than one reason might have contributed

towards occurrence of death and assigning single cause of

death can hide the importance of secondary but impor-

tant causes of death. Also, there are inherent limitations

of using verbal autopsy for assigning cause of death

including inadequate diagnostic accuracy for certain

diagnoses and its dependence on quality of data collec-

tion and standardisation (Garenne & Fauveau 2006).

Conclusion

Since 2004, there has been large reduction in number of

maternal deaths due to direct causes. However, it would

be essential to prioritise management of indirect causes of

maternal mortality during pregnancy at community level

and hospitals for further reduction in maternal deaths so

that MDG-5 can be achieved in India.

Acknowledgements

We thank the John D and Catherine T MacArthur Foun-

dation for generously supporting Safe Motherhood and

Newborn Survival Project. We are grateful to Drs. Maya

Hazra, Gayatri Desai and Lata Desai for their extra-

ordinary support throughout the project. We thank all

members of community of Jhagadia, including front-line

workers, link-workers, supervisors and government

health staff for their contribution. We are grateful to

Dr. Shivani Patel for her invaluable help towards

analysis.

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Corresponding Author Pankaj Shah, SEWA-Rural, Jhagadia, Bharuch District, Gujarat 393110, India. Tel.: +91 2645 220021,

+91 9426120316; Fax +91 2645 220313; E-mail: [email protected]




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Changing epidemiology of maternal mortality in rural India: time to reset strategies for MDG-5