Pregnancy-related Deaths in India: Causes of Death and the Use of Health Services

Introduction: The distribution of the causes of maternal deaths, and the impact of facility-based obstetric care access (obstetric access) at the individual and population level in India have not yet been quantified. Objectives: (i) estimate the physician agreement for coding of maternal deaths; (ii) explain the distribution of maternal mortality in India; and (iii) quantify the effect of obstetric access on the probability of maternal death, accounting for effect modification of state level skilled attendant coverage. Methods: I used the nationally representative Million Death Survey (MDS) of the causes of death from 2001-3. I identified context-specific risk factors from the field reports to provide information on care patterns before deaths. The 1096 MDS maternal deaths were matched to 147 001 controls of non-fatal deliveries from a representative fertility survey. Findings: 1.Inter-rater reliability was substantial for two physicians assigning a cause of death. 2. Three-quarters of India's maternal deaths were clustered in rural areas of poorer states, although these regions have only half the estimated births in India. The distribution of major causes of maternal deaths (most notably hemorrhage, obstruction, sepsis, abortion) did not differ between poorer and richer states. Two-thirds of maternal deaths died seeking healthcare, most in a critical medical condition. 3. The probability of maternal death decreased with increasing skilled attendant coverage, among both women who had and had not accessed obstetric care. The risk of death among women who had obstetric access was higher (at 50% coverage, OR=2.32) than among those women who did not. However at higher population levels of coverage of safe birth, obstetric access had no effect. This effect appears to be driven partially by reverse causality, in which critical illness is shown to confound the association between care seeking and death. Conclusions: Simple MDS methods enable measurement of the levels, determinants of maternal deaths. Currently, obstetric access in India appears to be an indicator for inequitable access and poor quality even though it is a life-saving intervention. Reduction in maternal mortality in India will require expanded population-based coverage of skilled birth attendance and improved and early access to high quality obstetric care.Ph