Maternal Mortality in Tribal Communities: A Five-Year Verbal Autopsy and District Audit: Causes, Care-Seeking Cascade, Predictors of Death, and Intervention Pathways in One Hundred and Forty-Two Maternal Deaths

Maternal mortality in tribal communities of central and northern India remains substantially higher than national averages despite sustained reductions in nationwide maternal mortality ratios over recent decades. The persistent inequity reflects structural access barriers, cultural practice patterns, and operational challenges in extending high-quality obstetric care to dispersed forest and hill communities. We conducted a 5-year verbal autopsy and district audit across five tribal districts (2020-2024), with structured investigation of 142 maternal deaths (130 confirmed for analysis) and matched-control case-control analysis. Postpartum haemorrhage (38.5%), eclampsia (19.2%), and puerperal sepsis (15.4%) were the leading direct causes. The care-seeking cascade demonstrated substantial losses at every step only 32% of women recognised their complication as dangerous, only 18% reached comprehensive emergency obstetric care, and only 9% received treatment within an hour of arrival. MMR across the audit districts fell over the 5-year period but persistent geographic gradients remained, with the forested district showing 358 maternal deaths per 100,000 in the final audit year compared with 132 in the peri-urban tribal district. Strongest predictors of maternal death included no antenatal care, home delivery, distance to CEmOC, severe anaemia, and lack of birth preparedness. ASHA worker contact and maternity cash scheme access were strongly protective.

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