Despite the avoidable nature of maternal mortality, unacceptably high numbers of maternal deaths occur in developing countries. Considering its preventability, maternal mortality is being increasingly recognised as a human rights issue. Integration of a human rights perspective in maternal health programmes could contribute positively in eliminating avertable maternal deaths. This study was conducted to explore socio-cultural and service delivery–related dimensions of maternal deaths in rural central India using a human rights lens.Social autopsies were conducted for 22 maternal deaths during 2011 in Khargone district in central India. The data were analysed using thematic analysis. The factors associated with maternal deaths were classified by using the ‘three delays’ framework and were examined by using a human rights lens.All 22 women tried to access medical assistance, but various factors delayed their access to appropriate care. The underestimation of the severity of complications by family members, gender inequity, and perceptions of low-quality delivery services delayed decisions to seek care. Transportation problems and care seeking at multiple facilities delayed reaching appropriate health facilities. Negligence by health staff and unavailability of blood and emergency obstetric care services delayed receiving adequate care after reaching a health facility.The study highlighted various socio-cultural and service delivery–related factors which are violating women's human rights and resulting in maternal deaths in rural central India. This study highlights that, despite the health system's conscious effort to improve maternal health, normative elements of a human rights approach to maternal health  were not upheld. The data and analysis suggest that the deceased women and their relatives were unable to claim their entitlements and that the duty bearers were not successful in meeting their obligations. Based on the findings of our study, we conclude that to prevent maternal deaths, further concentrated efforts are required for better community education, women's empowerment, and health systems strengthening to provide appropriate and timely services, including emergency obstetric care, with good quality. As the year 2015 begins, the debate on the likelihood of achieving the Millennium Development Goals (MDGs) is gaining momentum. The UnMaternal health is prominently appearing on policy agendas of the Government of India (GOI) and the state government in Madhya Pradesh–15. HowThe first organised initiative for maternal health care delivery in India was taken in the nineteenth century wherein the British colonial government condemned the natives for the enormously high maternal mortality rate and started the Lady Dufferin Fund in 1885 for providing maternity services. This was followed by the ‘women medical service’ by the British colonial government in 1914, wherein the government accepted its responsibility to provide maternity services. However, the availability and use of these services remained limited .The GOI launched the Child Survival and Safe Motherhood Programme (CSSM) in 1992 with support from the World Bank and United Nations Children's Fund (UNICEF). It focussed on CSSM services such as prevention of anaemia, antenatal care, immunisation, early detection and treatment of obstetric complications, delivery by trained personnel, institutional deliveries, and setting up of First Referral Units (FRUs) and referrals for institutional deliveries . It madeThe period from 2000 to 2005 experienced many developments at international, national, and subnational levels. The announcement of MDGs that have improving maternal health as one of the goals contributed to encouraging the country to prioritise maternal health on the policy agenda. Three major national policies were adopted by the GOI during this period – the National Population Policy 2000, the National Policy for Empowerment of Women 2001, and the National Health Policy 2002 – and all of them endorsed the GOI's target of reducing the MMR to 100 maternal deaths per 100,000 live births , 29–31.As part of the NRHM, a scheme called Janani Express has been implemented since 2006 in which all pregnant women are provided free transportation from their homes to health facilities and for referral to higher facilities for delivery. The Janani Express is funded by the GOI under the NRHM. For this, ambulances of government hospitals are used, and private vehicles are also hired by the government on contract and attached to hospitals for transportation of pregnant women for delivery. The pickup, drop-off, and referral of pregnant women by these vehicles are done free of cost. Under the scheme Janani Suraksha Yojana, started in 2006, all women from rural and urban areas are provided cash incentives of INR 1,400 (US $24) and INR 1,000 (US $17), respectively, for institutional deliveries in government health facilities as well as in accredited private health facilities . The AnnUnder the NRHM, Janani Shishu Suraksha Karyakram (the Mother and Child Protection Programme) also has been implemented in the state since 2011; under this programme, the women are entitled to services in government health institutions free of cost, namely delivery care, including caesarean sections, drugs, diagnostics, food, and treatment of sick newborns up to 30 days. They are also entitled to exemption from user charges, and are offered free drugs and consumables, free diagnostics, free diet during their stay in the health institutions , free provision of blood, free transport from home to health facilities, free transport between facilities in case of referral, and free drop-off from health facilities to home after delivery. These schemes and programmes are in place with additional financial provisions to make them operational. However, challenges and constraints at the implementation level may restrain the use of services. Some of these challenges may include a lack of human resources, especially the technical specialists; an unequal distribution of health facilities in urban and rural areas; ensuring a regular supply of drugs and consumables in health facilities; poor quality of referral services; and low competence levels of birth attendants at providing emergency obstetric care , 34, 35.According to the estimates of the World Health Organization (WHO), 88 to 98% of maternal deaths are preventable . ConsideThe international covenants underscore the indivisibility of human rights. Several international covenants recognised the right to health and health care , 48. TheSeveral organisations and scholars have also conducted holistic assessments of maternal mortality and brought more clarity on human rights in the context of maternal health. The major contributions in this regard have been from the WHO, the UN Human Rights Council, Amnesty International, Paul Hunt, and UN Special Rapporteur on Right to Health, among others , 50–54.A rights-based approach to maternal health identifies the centrality of a just and effective health system ensuring that maternal, reproductive, and sexual health services, goods, and information are available, accessible , acceptable , and of good quality . It aimsAccording to the recent technical guidance issued by the UN Human Rights Council, a human rights–based approach to maternal health identifies rights holders and their entitlements, and corresponding duty bearers and their obligations, and promotes strengthening the capacities of both rights holders to make their claims and duty bearers to meet their obligations . The priA rights-based approach to maternal health calls for a critical investigation of the factors associated with maternal deaths from a human rights perspective. The present study is part of a larger study exploring maternal health in Madhya Pradesh state, India. The objective of this study was to explore socio-cultural and service delivery–related dimensions of maternal deaths in rural central India using a human rights lens. The human rights approach has been previously used for exploring maternal mortality in various settings , 58, 59,The Khargone district was selected for this research due to its mix of tribal and other population groups in rural areas, the proportion of maternal deaths  in all deaths of women in the reproductive age group, and the status of health services similar to the situation in the state , 60, 61.According to the Indian Census 2011, the district has a population of 1,872,413 with 953,433 males and 918,980 females. The district has 84% rural and 16% urban population. The population density of the district is 233 persons per square kilometre. The decadal growth rate of population in the district during 2001 to 2011 was 22.8%. The total literacy rate among the 7-year-olds and older is 64%. A huge gender gap exists in literacy rates in the district, as the male and female literacy rates are 74 and 53.7%, respectively . The thiThe major sources of health care services in the district are government health facilities. As of March 2010, there were one district hospital, two civil (sub-district) hospitals, 10 community health centres, 54 PHCs, and 273 sub-health centres in the district . Normal The district has 123 medical doctors, including specialists. Out of them, 37 doctors are posted at the district hospital Khargone, 15 doctors are posted in two sub-district hospitals, and the rest are posted in community health centres and PHCs in rural areas of the district. The district has 367 staff nurses posted at the district hospital, community health centres, and PHCs in the district. The district also has 285 auxiliary nurse midwives posted at sub–health centres in the district. All of these service providers can perform normal vaginal deliveries, whereas the caesarean deliveries are performed by specialist doctors only.This research was designed as a qualitative study. Social autopsies were conducted for 22 cases of maternal deaths during the months from July to November 2011 in the Khargone district of Madhya Pradesh state–64. FamIn this paragraph, we describe the adaptions made to the verbal autopsy tool for social autopsy purposes. We included both structured and open-ended questions in the questionnaire to bring in the qualitative dimension. Information on background characteristics of the deceased women and their families; history of any existing illnesses prior to pregnancy; pregnancy history; antenatal care; complications during pregnancy, abortion, labour, delivery, or the postpartum period; injury; and care seeking for obstetric complications that led to death were obtained through structured questions. In addition, open-ended questions were asked to collect the open history, wherein the respondents were prompted to narrate all the facts related to the complications that led to death and the care seeking for those complications. This qualitative part of the tool was an attempt to elicit the perceptions of respondents about the factors and conditions surrounding the maternal deaths. The respondents were encouraged, in this part of the interview, to reconstruct and describe the most relevant aspects of the circumstances that led to maternal deaths. The interviews were conducted from 2 weeks to up to 1 year after death. The questionnaire was pre-tested in one of the neighbouring districts in the state prior to its use for data collection in the present study. Based on the pre-testing, we modified some of the existing questions and added some new questions in the tool based on the experience of the field testing to address the overall research questions.The cases of maternal deaths were purposively selected using the government records and community informants to cover a large spectrum of scenarios and circumstances associated with maternal deaths. Single interviews were conducted with eight husbands, four mothers-in-law, one father-in-law, and one sister-in-law of deceased women. In eight interviews, more than one respondent was present. In five interviews, husbands and mothers-in-law responded. In one interview, the husband and husband's younger brother were present; and, in one interview, the husband and brother-in-law of the deceased woman jointly responded. The mother-in-law, father-in-law, and husband of a deceased woman jointly responded in one interview.A total of 22 maternal deaths were studied in this study. The respondents were selected based on their presence with the deceased women during the development of complications, transportation to health facility, treatment, referral, and death. We first approached the respondents in person, explained the objectives of the study to them, and fixed an appointment with them for an interview based on their availability and convenience. The power dynamics of familial relationships may have influenced the data in the form of dominant responses from the elder family members, as we included more than one relative or family member as respondents in the interviews. However, we tried to create such an environment during the interviews in which all respondents provided their views and no participant dominated the responses. Along with the first author, a physician and a social worker were involved in data collection. The interviews were conducted in the houses of the deceased women. We did not pre-decide the number of cases of maternal deaths.A total of 22 cases of maternal deaths were followed up, and data collection stopped when we felt that saturation was reached (new information regarding the research question stopped emerging from the interviews). All interviews lasted between 75 and 120 min. In order to elucidate or elaborate some responses, follow-up interviews and phone calls were made in some cases. We examined a sub-set of narratives by discussing them with the informants to check the accuracy and ensure the quality of data. To protect the informants from harm in terms of the distressing nature of interviews, we took informed consent, assured them about anonymity, and told them that they were free to withdraw at any time or refuse to answer any specific question; we also arranged debriefing of informants after conducting interviews. The standard WHO definition of maternal death was used for this study .All interviews were conducted in the Hindi language and were tape recorded. The recordings of the interviews were transcribed verbatim and translated into English. To maintain anonymity, the verbal autopsies of individual cases of maternal deaths were assigned code numbers from 1 to 22. The data were analysed by using thematic analysis , 72. ThoWe applied the ‘three delays’ framework of Thaddeus and Maine to organise the findings of this study . This frEthical approval for the study proposal was obtained from the Ethics Committee of the Bhopal Regional Technical Centre of the Family Planning Association of India. Approval from the concerned government authorities was also obtained. Informed verbal consent was taken from each respondent after explaining the study objectives and assuring them of the confidentiality of their identity. Permission from all respondents was taken for recording the interviews. All the interviews were conducted at least 2 weeks after the death, which is the culturally prescribed mourning period in the area. The respondents were also told that they were free to decide not to answer any questions and were free to stop the interview and withdraw from the study at any time, and this decision would not affect the respondent or his or her family in any way. All the respondents were also asked whether they could be contacted again for any clarification if required, and all of them agreed to it.A total of 22 cases of maternal deaths were studied. The average age of the deceased women was 26.3 years, ranging from 19 to 40 years (SD=5.4). A total of 20 out of 22 deceased women were between 19 and 34 years of age. Six of the 22 women were illiterate, seven studied for up to 5 years, and nine women studied for 6–11 years. None of them received higher education. Half of the deceased women were from scheduled tribes and scheduled castes, and the other half were from general castes and other backward classes which are socio-economically better off than the first half. More than half  of the wThe data from social autopsy interviews showed that the major causes of maternal death were haemorrhage in nine cases, sepsis in three cases, eclampsia in two cases, obstructed labour in one case, abortion in one case, severe anaemia in two cases, and other conditions in four cases. All 22 women tried to access medical assistance for occurrence of obstetric complications. Because the focus of this article is on the socio-cultural and service delivery dimensions of maternal deaths, detailed descriptions of the results related to medical causes of maternal deaths are not provided here. The findings of the qualitative part of this study are presented in the remainder of this section using the ‘three delays’ framework. Relevant quotations from the interviews are provided in italics.This delay was determined by the interval between the occurrence of an obstetric complication and when the decision to seek care was made. The analysis showed that half of the deceased women in the study experienced delay in seeking medical assistance after becoming aware of the obstetric complications.She was fine so we thought that there was no need to take her to any health facility. It was her second pregnancy and the first delivery happened without any problem. She started complaining about pain in the day at 12.30 PM but we waited at home in the hope of a normal delivery. When she did not deliver till evening and the whole night passed and the pains increased, we took her to the primary health centre in the next day early morning at 5.30 AM. (Case 9)The respondents perceived that they underestimated the severity of complications based on the experiences of previous deliveries of the deceased women and other women in their families, and they considered the problems to be normal without understanding their severity. This underestimation led to delay in deciding to seek medical assistance for childbirth which contributed to maternal deaths. The mother-in-law of a deceased woman reported that:My daughter in law was pregnant for the first time. As per our family tradition she was taken to her paternal home by her parents in the seventh month of her pregnancy. In the ninth month, one afternoon she started to have abdominal pain that continued for the day and night. She requested to be taken to a hospital but her parents wanted to take our consent before taking her to hospital as in our families consents of in-laws and husband of married daughter are considered to be a must for any important decision about a married daughter's health. For this they sent someone to our village in the next day morning, and I and my husband went with him. Then we took her to a government hospital [community health centre]. We reached there by the evening. The doctor checked her and said that the foetus had already died. Doctor conducted delivery in which she delivered a stillborn baby and within a few minutes after it she started a lot of bleeding and she died. (Case 16)Some respondents [mothers-in-law] observed that the lack of participation of the parturient in decision making regarding accessing maternal health care also deterred and delayed the women from receiving timely delivery services.This was the third pregnancy of my wife. Our second baby was delivered two years back in a government hospital. I took her to the government hospital where she was admitted. The beds were not enough in the hospital for all pregnant women admitted in that hospital therefore she was asked to sleep in the corridor. […] Doctors were there but they did not come to examine my wife. Her examination was done by a nurse. My wife kept complaining about pain but nobody paid attention to her situation. […] Because of this kind of experiences we decided this time [for the third pregnancy] not to go to hospital for a normal delivery and waited for delivery to happen at home. But when she did not deliver and had severe pains we had to take her to the government hospital. (Case 4)In some cases, the families of the deceased women perceived the quality of delivery care provided in government hospitals as poor based on the previous negative experiences of deceased women and other women in their families. Relatives of some deceased women were hesitant to take the pregnant women to the government hospital even if they were aware of the free availability of delivery care in these hospitals. The husband of a deceased woman narrated:This theme reflects the factors associated with the delay in reaching health facilities once the decision was made to seek care. This delay was determined by the difference of time between the decision to seek care and reaching the health care facility (where the woman received obstetric care). In some cases, significantly less time was taken in reaching the health facility, but there was a first delay that already complicated the cases. Twenty-one of the 22 women got delayed in reaching an appropriate health facility for obstetric care due to various obstacles. This delay reduced the likelihood of their survival. Transportation issues become very important in acute and time-limited conditions such as haemorrhage and other direct causes of maternal deaths. One woman died on her way to the first health facility, 12 died in health facilities, and 8 women died during the referral from one health facility to another health facility.She had no problems during the pregnancy and when the pregnancy was of eight months, she started having pains. We took her to the district hospital by a private vehicle. The doctors at district hospital told us that her condition was serious as she was severely anemic. Three bottles of blood were arranged by us and given to her but her condition did not improve. We were told by the doctors to take her to Indore medical college. […] We took her to the medical college by a private vehicle as no government vehicle was made available from the hospital. We were told that the ambulance was not available. […] It took us around one hour to arrange a private vehicle. On the way she delivered a dead child in the vehicle. There was also excessive bleeding. […] Later just after some time she passed away in the vehicle. (Case 13)The respondents mentioned various problems related to transportation. Despite the government's provision of free transportation to bring women from their homes to health facilities and referral to higher facilities, vehicles were not available on some occasions. Women also faced transportation problems even after reaching the first health facility. Their referrals were delayed due to either the unavailability of a vehicle or the reluctance of health care staff to provide free transportation. A father-in-law narrated:When my wife told us about her pains and breathlessness, we decided to take her to the government hospital. We made a call on the telephone numbers of Janani Express but we were told that the vehicle was running out of fuel. Then we looked for a four wheeler but when we did not find a vehicle we took her to the community health centre on a motor cycle. (Case 21)Problems in proper implementation of the free transportation scheme, such as a lack of fuel for the Janani Express vehicle due to a lack of proper management and supervision, were reported by the respondents, and these delayed women from reaching health facilities for appropriate delivery care. The husband of a deceased woman shared:We were not aware about the free vehicle facility provided by the government for delivery at the health centre. Therefore, we tried to arrange a private vehicle from the nearby village, which took me two and half hours. Then we started to take her to the government hospital. But on our way to the hospital, she had very strong pain and bleeding. Then she died in the vehicle. (Case 12)Lack of awareness regarding the availability of free transportation was also mentioned by a few respondents.The doctor admitted her but did not provide any treatment for three hours and she constantly kept complaining about severe pain and also started bleeding heavily. Then we [the family members] decided to take her to another hospital for services. (Case 18)Care seeking at multiple facilities or multiple referrals by health care providers also contributed in delaying access to timely and appropriate care. Thirteen of the 22 women accessed services from more than two health facilities, because either they were referred from one facility to another or their families took them for care to more than two health facilities. Some participants mentioned that they themselves had to take the deceased women to more than one facility as they were not satisfied with the care provided in the first facility. The husband of a deceased woman narrated that:One day she suddenly started to feel pains and we took her to a health centre [primary health centre] from where she was referred to another health center [community health center]. This transportation was done by the Janani Express vehicle. In that health centre she was told that she had high blood pressure and she was referred to the District Hospital. By now the pains had increased and she was having perplexity and uneasiness. In the district hospital, without telling any reason they again referred her to the medical college. (Case 3)Some respondents also mentioned multiple referrals by the service providers. The mother-in-law of a deceased woman narrated:This delay was determined by the time taken to initiate definitive obstetric care once the women reached the health facility. Analysis of interview data revealed that 13 out of 22 deceased women experienced this delay.She started having pains and we took her to a health centre [community health center], where she delivered a baby by normal delivery. Four days later she complained of having foul smelling discharge from vagina along with blood. She also developed high fever. We took her again to the same health centre and from there they [Doctor and Nurses] referred her to the District Hospital. She was not treated well there and she was referred to the medical college without giving her any treatment. She died on the way to the medical college …. (Case 6)The respondents mentioned that the health staff showed negligence in immediately providing proper care, in treating obstetric complications, and during referrals. They also reported that some women were referred to other facilities unnecessarily, even without telling any reason to the family members who were accompanying the deceased women. The husband of a deceased woman narrated:She was in her eighth month of pregnancy. She started having pains so we took her to the nearest community health centre. We were told that there were no facilities to manage her problem in that health centre and they referred her to the district hospital. We arrived in the district hospital at night where she was advised [to have] surgery. Doctor told us that there was no blood available in the hospital, and he asked us to arrange three bottles of blood but we could arrange only two bottles. After the surgery the doctor told us that she died due to loss of blood. (Case 7)Some respondents also reported that the deceased women could not get appropriate obstetric care services, including blood transfusion in community health centres and the district hospital, to manage the complications in a timely manner, even after reaching the health facilities that are designated as comprehensive EmOC centres. The husband of a deceased woman reported:After home delivery she started bleeding and the placenta was not delivered so we took her to the district hospital one and half hour after delivery. By that time she had become unconscious and was continuously bleeding. When we reached the district hospital we were told to immediately take her to the medical college. We started to take her to the medical college after 30 minutes but she died en route to the medical college. (Case 2)In another case, the husband of a deceased woman explained:Health systems are not merely mechanical structures to deliver technical interventions; rather, they are considered to be core social institutions for respecting human rights , 77. EffThe factors influencing the delays emerging from our study and their linkages with the elements of a human rights approach to maternal health are illustrated in A human rights approach to maternal health acknowledges that health facilities, goods and services must be available in sufficient quantity . ResearcJanani Express Yojana to provide free transportation to women for institutional delivery . Related factors such as underestimation of complication symptoms by family members, lack of women's autonomy and negative perceptions regarding delivery services delayed the decision to access medical assistance in cases of obstetric complication, which resulted in maternal deaths. These results are similar to those reported by another study  conducteThe women's subordinate status is a key social determinant of poor maternal, sexual, and reproductive health, particularly in India , 82, 83.Economic accessibility in terms of affordability is a very crucial element of a human rights approach to maternal health. Other studies in Madhya Pradesh during the period 2002–2003, and in other Indian states from 2002–2003 to 2006–2008 , 65, 81,Perceptions of users regarding the maternal health care services tremendously influence the use of these services , 84. Ourinter alia, skilled medical personnel, scientifically approved and unexpired drugs and hospital equipment’ , dependability (taking the changes in the research process into consideration well), confirmability (grounding the interpretation well in the data), and transferability (applicability of the findings to other settings) . We tookOur study revealed that women attempted to access maternal health care services when obstetric complications happened, but there were various socio-cultural and service delivery–related factors that delayed their access to appropriate care and contributed to maternal deaths in rural areas of Madhya Pradesh. We observed that the interconnectivity of different factors and delays reinforced and maintained the poor availability, accessibility, acceptability, and quality of services observed in the three phases. This study indicates that normative elements of a human rights approach to maternal health  were not upheld. The deceased women and their relatives were unable to claim their entitlements, and the duty bearers were not successful in meeting their obligations despite their conscious efforts to improve maternal health in the state. The data suggest that further concentrated efforts for better community education and health systems strengthening to provide appropriate and timely maternal health services, including EmOC, with good quality may positively affect the reduction of maternal mortality in this setting. The findings of our study indicated that further streamlined efforts are required for women's empowerment for enabling them in decision making. The other actions recommended are strengthening of the transportation and referral services, bringing positive change to the attitudes of maternal health care providers, and establishing appropriate accountability mechanisms.