ROBERTO SCHMIDT / AFP / Getty Images A newborn baby sleeps in her mother's arms at a community health center near the Indian city of Lucknow on Oct. 31, 2011

In March, Preeti Singh almost died giving birth. The 22-year-old resident of a village about a half hour’s drive from New Delhi was pregnant with twins and planned to give birth with the help of an untrained midwife. When things went wrong during the delivery, she rushed to three government hospitals in search of help before her family decided to take out a loan for $1,000 to send her to a private hospital. Singh and one of the twins survived. “Giving birth is not easy,” she says. “But maybe if I was taken to a hospital to give birth or a competent dai [midwife] was there, it would not have been so traumatic and my other child would have been saved.”

Indeed, with basic maternity care, many lives in India would be saved. According to a 2010 study by the Harvard School of Public Health, 150,000 deaths could be prevented by 2015 if Indian women had access to better family planning and health care during their pregnancies and deliveries. But that medical help has yet to arrive. A new report by Save the Children suggests that, despite India’s booming economy, the country is still one of the most high-risk places in the world to give birth. It ranked India as the fourth worst country among 80 less developed nations in its survey, with nearly half of all births taking place without a trained health professional. “Even though India has made efforts to improve maternal health by encouraging institutional deliveries and taking other measures,” says Thomas Chandy, the head of Save the Children India, “the benefits have not yet appeared to bring about a shift.”

What’s frustrating, advocates say, is that the findings are in many ways old news — India has been trying to improve levels of maternal health for years. Though figures show the maternal mortality rate dropped by 66% from 1990 to 2010, India still has by far the highest number of women dying during childbirth on the planet each year, with 56,000 deaths in 2010, according to a U.N. report on maternal-mortality trends. In neighboring China, which has a similarly large population, just 6,000 mothers died during childbirth in the same year. Even poorer countries in the region are catching up to India. India’s maternal mortality rate in 2010 was 200 women per every 100,000 live births, which was even with Burma and slightly better than Bangladesh (240 deaths per 100,000 live births). Nepal, meanwhile, had just 170 deaths per 100,000 births.

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Experts say this indicates a fundamental problem with India’s development strategies. “During the last 20 years or so, India has grown much richer than Bangladesh. But during the same period, Bangladesh has overtaken India in terms of a wide range of basic social indicators,” Nobel laureate Amartya Sen and his fellow economist Jean Drèze argued in an article in the Indian magazine Outlook last year.

So what’s India doing wrong? To find out, researchers have looked at one of the country’s largest and most lauded programs, the Janani Suraksha Yojana, or Mothers Protection Initiative, which offers free transportation for pregnant women to and from hospitals, blood transfusions, medicine, food and even cash rewards of up to $30 for those who choose to give birth in a government hospital. A study published in the Lancet in June 2010 found that, despite some successes, the program often didn’t reach the poorest of poor women because of gaps in India’s basic health infrastructure and a top-down approach that resulted in a lot of well-meaning laws but not much work at the ground level increasing awareness and training poor communities to understand and deal with maternal emergencies.

Aparajita Gogoi, national coordinator of the White Ribbon Alliance for Safe Motherhood, an advocacy alliance of 1,000 organizations, says people in rural areas and urban slums must be taught how to recognize such emergencies and where to take women to get lifesaving care. “If they take her to a primary health care center, a few miles away, that’s unequipped for such emergencies, it is as good as writing on her death certificate,” Gogoi says.

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Such community involvement seems to have worked in Bangladesh, where the government has built up comprehensive programs for pre- and neonatal care for expecting mothers and improved education for women in collaboration with nonprofit organizations. As a result, the number of women giving birth in hospitals has increased from just 9% in 2001 to 23% in 2010, and deliveries in rural areas were also made safer. “We identify women from each village who are then trained as health workers to take care of basic emergencies in normal deliveries. For difficult pregnancies, we link up with private-sector facilities where we have program officers who guide them through the entire process,” says Mahabub Hossain, executive director of the Dhaka-based BRAC, a nonprofit organization that has helped the government address the maternal-mortality problem. “Our health structure is based around community health workers.”

A few Indian states are leading the way. Kerala, Tamil Nadu and Maharashtra have already reached the U.N. Millennium Development Goal of bringing their maternal mortality rates down to 109 women per every 100,000 live births, while several other states — Andhra Pradesh, West Bengal, Gujarat and Haryana — are close to achieving it. These states have done the best at tackling problems like child marriages and female illiteracy — two factors that also contribute heavily to maternal mortality rates. Kerala state, for instance, boasts a female literacy rate of 92%, as well as the lowest maternal mortality rate in the country at 81 deaths per every 100,000 births.

India is pouring much needed revenues into improving health care as well. The government plans to boost spending by 2017 to about 2.5% of its GDP from the current 1.4%. However, money alone will not bring results unless it’s paired with effective training and education campaigns in at-risk communities. “India has wonderful policies on paper. We have the money too,” Gogoi says. “What we need to do is to turn these policies into action on the ground.” The next several years are critical, as they will show whether the advances made in states like Kerala can be replicated elsewhere — or whether India will slip even further behind its neighbors in terms of taking care of the lives of its women and children.

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