PURULIA, India In Sindri village in a dirt-poor district of eastern India, Manohar Kumbhakar and his family are still mourning the death of his wife, who died in childbirth aged 25 while being treated by a local quack.
"I don't know what he did to my daughter-in-law. The quack kept me outside the room and later, after almost two hours, he said she had to be taken to a hospital," said Kumbhakar's mother, Helubala. "He later denied he had any role in the treatment."
Every year, about 78,000 mothers die in childbirth and from complications of pregnancy in India, according to the United Nations Children's Fund (UNICEF).
The figures illustrate how poor women in rural India have largely been left behind by India's economic boom which has lifted millions of people out of poverty.
India's maternal mortality rate stands at 450 per 100,000 live births, against 540 in 1998-1999. The figures are way behind India's Millennium Development Goals which call for a reduction to 109 by 2015, according to UNICEF.
By comparison, fellow Asian giant China's maternal mortality rate has dropped to below 50.
UNICEF's 2009 State of the World's Children report, which was released in January, said India's fight to lower maternal mortality rates is failing due to growing social inequalities and shortages in primary healthcare facilities.
Millions of births are not attended by doctors, nurses or trained midwives, despite India's booming economy which grew at nearly 9 percent in each of the past three years.
Around two-thirds of Indian women still deliver babies at home. Women from the lower castes suffer the most as they are often denied access to basic healthcare.
"It (the maternal mortality rate) is definitely not going down fast enough," Avinash Kumar, Campaign and Policy Coordinator for Oxfam India, told Reuters.
Traditional midwives such as 50-year-old Chapa Sahis are often the only help available for women in labour in remote areas. UNICEF and local authorities offer dais proper training, but Sahis' qualifications are minimal.
"I am not a doctor or even a trained nurse. I have some training to cut the cord with a blade. A doctor can always save many mothers," she says.
Maternal deaths are avoidable with the help of skilled health personnel, adequate nutrition, better medical facilities and family planning, medical groups say.
But poor women, especially in rural India where fertility rates are higher and teenage marriages are common, face an uphill battle to overcome lack of access to medical care.
Indian women get married at a median age of just 17 years. Among women aged 15-19, 16 percent have already begun childbearing, according to the 2005-2006 National Family Health Survey NFHS.L.
"The younger a girl is when she becomes pregnant, the greater the health risk for herself and baby," said Ann M. Veneman, UNICEF's executive director.
UNICEF said nearly half the women who die during pregnancy and childbirth in Purulia, in West Bengal state, have no formal schooling.
"Women get pregnant very early with no preparedness to cope with childbirth, at times failing to recognise the signs when they should go to a hospital," said Alpana Mahato, a local nurse.
Women are often sent home prematurely from health facilities, or do not visit them because of a view that the woman was not sick enough to justify the trip, said UNICEF. When they do go, women in labour sometimes face extortion.
"We have found health centre staff in Uttar Pradesh demanding money from poor women for delivery. Many were turned away from the centres and were forced to give birth on the road or the hospital compound," said Jashodhara Dasgupta of Health Watch, a network of activists.
Women's food intake across South Asia must improve if the region's high maternal mortality rate is to drop. More than half of Indian women have anaemia, another potential killer during childbirth, compared to 24 percent of men, the NFHS study said.
"Nutrition and anaemia are huge factors in the MMR (maternal mortality rate)," UNICEF's Kumar said. "Inside the homes, women are the last to get food. They are much more vulnerable and that is why they are dying."
(Writing and additional reporting by Matthias Williams; Editing by Megan Goldin)