The birth of a wanted child should be an occasion of hope and joy. But for more than half a million women each year in India, pregnancy ends tragically, in death. For their families, the prospect of joy gives way to despair and anguish.

Thousands more women suffer illness, injury, and pain related to their pregnancies. UNICEF estimates that for every maternal death, there are 20 to 30 cases of maternal morbidity, including as many as 100,000 cases each year of obstetric fistulae. This condition, which causes incontinence, is relatively easy to repair with surgery, but can lead to social exclusion for impoverished women without access to corrective health care. Other complications of pregnancy and childbirth include uterine prolapse, infertility, hemorrhage, convulsions, vaginal scarring, and sepsis.

Tens of thousands of Indian women and girls are dying during pregnancy, in childbirth, and in the weeks after giving birth, despite government programs guaranteeing free obstetric care.

India is rightly renowned for its advanced medical technologies, including, ironically, those for surrogate pregnancy. Yet in 2005, the last year for which estimates are available, the World Health Organization highlighted that India had one of the highest rates of maternal mortality in the world. Human Rights Watch’s research found that tens of thousands of Indian women and girls are dying during pregnancy, in childbirth, and in the weeks after giving birth, despite government programs guaranteeing free obstetric care.

Uttar Pradesh state in northern India has the highest maternal mortality rates in the country because the government there has failed to identify and address shortcomings in health care delivery. But other Indian states, too, are struggling with these problems—and some have failed even to accurately count the number of pregnancy-related deaths, leading to a lack of critical information about where, how, and why women die. Until India can accurately quantify the problem, it cannot begin to prevent thousands of unnecessary deaths.

International and national efforts to reduce maternal mortality already span several decades. Most notably, in the 2000 Millennium Declaration, 189 countries pledged to achieve eight development goals by 2015, including a 75 percent reduction in maternal mortality. There is also global consensus about the medical interventions required to reduce the number of deaths, but it’s undoubtedly important to have a skilled birth attendant on hand, access to emergency obstetric care, and the ability to be referred to more specialized care as required.

Why do women continue to die needlessly? One reason is that so little is done to monitor how well health programs are implemented. The Indian government has identified maternal health as a key priority and developed programs to provide health care to pregnant women in rural areas. But as Human Rights Watch discovered, India has failed to oversee these programs in a manner that would allow the government to identify and correct deficiencies in unsuccessful programs—and replicate the methods of successful ones. In Uttar Pradesh, for example, Human Rights Watch documented how women die because of poor referral systems; time and again, we were told that women were referred to health facilities that could not provide them with adequate care. Many of these women then died while trying to reach a hospital or clinic that could provide life-saving treatment.

One important step toward a more effective response to maternal mortality is to give families an officially sanctioned way to complain about ineffective treatment. The goal should be to identify whether particular individuals or institutions are at fault for harm caused to women seeking maternal health care, to provide appropriate compensation to victims, and to spur corrective action. The inquiry should also look beyond individual actions of health-care providers to whether the state has established sufficient oversight of local programs.

Such accountability may seem abstract, but it can be the difference between life and death for pregnant women in India and around the world. Without it, the goal of dramatically reducing maternal deaths by 2015 is not likely to be met, and women will continue to needlessly die.

Kenneth Roth is the executive director of Human Rights Watch.

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