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

A total of 121 maternal deaths, identified through multiple-source surveill ance in 400 villages in Maharashtra, were prospectively enrolled during 199 3-95 in a population-based case-control study, which compared deaths with t he survivors of similar pregnancy complications. The cases took significant ly longer to seek care and to make the first health contact after the decis ion to seek care was taken. They also travelled significantly greater dista nces through a greater number of health facilities before appropriate treat ment was started. Multivariate analysis showed the negative effect of excessive referrals and the protective effect of the following: residing in and not away from the village; presence of a resident nurse in the village; having an educated hu sband and a trained attendant at delivery; and being at the woman's parents ' home at the time of illness. Other significant findings showed that death s due to domestic violence were the second-largest cause of deaths in pregn ancy, that more than two-thirds of maternal deaths were underreported in of ficial records, and that liveborn infants of maternal deaths had a markedly higher risk of dying in the first year of life. This study points to the need for information-education-communication (IEC) efforts to increase family (especially male) preparedness for emergencies, decentralized obstetric management with effective triage, and a restructur ing of the referral system.