title: Changing epidemiology of maternal mortality in rural India: time to reset strategies for MDG-5.
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.
  
  
  CONCLUSIONS
  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 prioritize management of indirect causes of maternal mortality during pregnancy at community and hospitals for further reduction in maternal deaths to achieve MDG-5.
authors.affiliation: Community Health Department, SEWA-Rural, Jhagadia, India.
authors.forename: Pankaj
authors.initials: P
authors.lastname: Shah
authors.forename: Shobha
authors.initials: S
authors.lastname: Shah
authors.forename: Raman V
authors.initials: RV
authors.lastname: Kutty
authors.forename: Dhiren
authors.initials: D
authors.lastname: Modi
mesh_terms: D000328:Adult; D002423:Cause of Death; D003153:Community Health Services / Q000379:methods* / Q000706:statistics & numerical data; D036861:Delivery, Obstetric / Q000379:methods* / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D015994:Incidence; D007194:India; D063130:Maternal Death / Q000706:statistics & numerical data*; D008428:Maternal Mortality; D011247:Pregnancy; D015397:Program Evaluation / Q000379:methods* / Q000706:statistics & numerical data; D011446:Prospective Studies; D012424:Rural Population / Q000706:statistics & numerical data*; D035141:Voluntary Programs / Q000706:statistics & numerical data; D055815:Young Adult
keywords: Millennium Development Goal-5; epidemiology; institutional delivery; maternal mortality ratio; skilled birth attendance