India’s maternal mortality figures are among the highest in the world. The reasons for this are not hard to find.

When a pregnant woman, Vaishali (not her real name), died in a village in Gujarat, we decided to examine the circumstances that led to her death. We asked healthcare professionals and the sarpanch in the village if they could identify the events that caused her death. Not only were they clueless about the cause of Vaishali’s death, they also showed no interest in discussing how such deaths could be prevented. Worse, it took them a month to report the death. It was only when we wrote to the district health officer that he ordered an autopsy. But this was two months after Vaishali died. We realised that if we wanted to know the circumstances that led to her death, we would have to speak directly to members of her family.

Vaishali, age 23, was poor, barely literate, and belonged to a tribal community. She was detected to be pregnant during the third month of her pregnancy and came to live with her parents. A month later, an auxiliary nurse midwife prepared an antenatal card to record her physical signs and immunisation status. According to the card, Vaishali had received three antenatal examinations, had her blood group checked and was vaccinated against tetanus. In the last trimester of her pregnancy, she was detected to have mild anaemia for which she was prescribed iron and folic acid.

Her pregnancy had reached full term in November 2007, when she began to have labour pains at 8 pm. Her mother sought help from a local dai trained by a non-government organisation working to reduce maternal mortality in the district. The dai explained the complications associated with a first pregnancy and urged a hospital-based delivery.

The nearest healthcare facility, a cottage hospital, was 15 km from the village. Vaishali’s family took her there around 9 pm. The medical officer at the hospital, trained in basic gynaecology, found that the foetus had no heartbeat. Vaishali said that she had felt no foetal movements either. The medical officer thought that she might need a caesarean section and blood transfusions, which could be provided at a bigger hospital, so Vaishali was moved to the district hospital an hour later, only to find that the district hospital had no gynaecologist. The nurse at the hospital directed that Vaishali return to the community health centre (CHC). She was therefore re-admitted to the CHC in the early hours of the morning.

Six hours later, a blood test revealed that she had an uncommon blood group. The blood bank officer suggested that Vaishali be sent to the big city of Surat where she could get the required blood group should transfusions be required. However, she delivered a still-born baby before she could be transferred to the Surat hospital, began to bleed heavily and her blood pressure dropped. Critically ill and in shock, she arrived at the Surat civil hospital at 6  pm and died a few hours later.

Vaishali had sought healthcare from five public hospitals, rural and urban, in a single day but failed to get the medical care that could have saved her life.

Vansada block in which the village is situated has a population 1,50,000, but lacks a blood bank. During an emergency, people have to travel long distances to get blood. We don’t think that pregnant women who could bleed heavily during or after childbirth will ever survive in this village.