A/HRC/14/20/Add.2 69. Maternal deaths are underreported, whether they occur in public and private facilities or outside any facility. There are numerous reasons for this major problem, including a lack of familiarity with the legal reporting requirements and “a culture of fear of reporting events with a negative outcome”.45 Improving data on maternal mortality should be seen as part of a wider challenge: strengthening the national health information system. In the meantime, women are dying in childbirth and during pregnancy – uncounted and unreported. 70. India’s current arrangements for recording maternal deaths fall short of the Government’s responsibilities arising from the rights to life and health. The literature suggests numerous measures that could be taken to address this unacceptable state of affairs.46 The next section outlines one of them: maternal death reviews. 2. Maternal death reviews – “plus” 71. Knowing the statistics on levels of maternal mortality is important, but it is not enough. It is imperative to know what happened, why it happened and how the maternal death could have been averted. In Beyond the numbers, WHO set out five approaches to the collection of this information by way of maternal death reviews or audits.47 Versions of these approaches are already in place in some parts of India. The government of Tamil Nadu, for example, has had a system of maternal death reviews for over 10 years. Since 2005, some districts in Rajasthan (Dholpur, Tonk and Udaipur), as well as five other states, have introduced, with UNICEF support, a form of maternal and perinatal death reviews known as verbal autopsies. Since then these reviews have been rolled out in some other states, including parts of Maharashtra. The National Rural Health Mission promotes infant and maternal death reviews or audits.48 72. One of the advantages of maternal death reviews is that, as well as improving the accuracy of maternal mortality data, they are personalized: they record and investigate the particular death of an individual woman. Also, they provide an opportunity to look beyond the narrow medical causes of death and review social, economic, cultural, institutional, systemic and other factors. Maternal death reviews have been established and practised by health professionals in numerous countries, and they have a good track record in many health systems. 73. However, they are not without difficulties. For example, a small study of verbal autopsies in one district of Gujarat found incomplete reporting and no efforts by the district health office to analyse and use the information to avoid future maternal deaths.49 Also, if they lead to the punishment of individual health workers, they run the risk of aggravating the non-reporting of maternal deaths. For this reason, both Beyond the numbers and the UNICEF project in India on verbal autopsies strongly favour a confidential process, with WHO stating clearly that “these reviews seek only to identify failures in the health-care system. They must never be used to provide the basis for litigation, management sanctions or blame.”50 There will be occasions, however, when the review discloses serious professional misconduct by particular health workers that has to be considered and 45 46 47 48 49 50 GE.10-12866 Ibid., p. 29. See, for example, Puwar, Raman and Mavalankar, “Situational analysis”, and Human Rights Watch, No Tally. See WHO, Beyond the Numbers: Reviewing Maternal Deaths and Complications to Make Pregnancy Safer (Geneva, 2004). India, National Rural Health Mission, p. 67. Puwar, Raman and Mavalankar, “Situational analysis”, p. 24. WHO, Beyond the Numbers, p. 2. 17