One night in late March, about 24 weeks into her pregnancy, Sulekha Lohar woke feeling ill. Sharing a bed with her husband and two young sons, she felt her chest pounding and her legs swell. She began convulsing. After about an hour, her husband, not knowing what to do, decided to seek help from his parents.
Too poor to own a phone, Bhangru Lohar left his wife in bed and rushed from his humble home with a tin roof and mud floors down a dark, dirt path of the Ghorijan Tea Estate in upper Assam, past the piles of firewood, bamboo fences and homes of other tea workers, to his parents' house. He woke his father, Rama Lohar, who woke the neighbors, and the men decided to bring Sulekha to the tea company's health center, according to Bhangru and Rama, who independently told the Pulitzer Center this story.
There are three ways in which necessary treatment for pregnant mothers can be delayed that increases the chances of a maternal death, according to maternal health specialists. The first delay can occur when the mother or family first decides to seek appropriate medical care for a pregnancy or labor complication.
After Sulekha's family and neighbors made a decision, they returned to her house, placed her in a thela or handcart normally used to carry wood and pushed her from their neighborhood, called a labor line, to the company hospital.
After about 15 minutes, they reached the facility, which is called a hospital but is only equipped to perform basic care like immunizations.
It was still the middle of the night, and the only person there was a gatekeeper, who went to alert a medical professional. About 25 minutes later, a nurse arrived, evaluated Sulekha and referred her to Assam Medical College, Dibrugarh, a referral hospital.
The tea garden ambulance took Sulekha, her husband, parents-in-law and community health worker to the hospital.
The trip lasted an hour because of the condition of the roads.
The second delay, according to health specialists, can occur when a pregnant woman tries to reach medical care but gets held up by lack of transportation or poor infrastructure.
At the hospital, doctors determined that Sulekha, who was in a state of unconsciousness by the time she arrived, had severe anemia, high blood pressure and convulsions, according to the hospital's handwritten medical records.
"She was a very bad case," said Dr. Milon Taye, an assistant professor in the Obstetrics and Gynecology Department of Assam Medical College, Dibrugarh, after reviewing her records.
The staff on duty told Sulekha's family that she needed a blood transfusion, but the hospital did not have her type of blood available, said her husband and father-in-law.
The third delay can occur when the mother reaches the health institution and faces setbacks in being admitted or getting timely treatment due to inadequate facilities or supplies, poorly trained medical staff or lack of money.
Assam Medical College, Dibrugarh, has seen a decrease in maternal deaths in the past few years as a result of having more blood available, better health conditions and awareness in the communities they serve and successful family planning efforts, according to Dr. Taye. (See this project's previous story on family planning in Assam.) He said he was not permitted to release statistics on the hospital's maternal morality rate.
Statewide, Assam has the highest maternal mortality rate in India at 480 deaths per 100,000 live births. The government's National Rural Health Mission has been trying to improve maternal health in the country through a variety of measures including providing incentives to women to give birth in medical facilities and training community health workers, like the woman who accompanied Sulekha to the hospital.
Despite the improvements, challenges such as lack of adequate supplies remain.
"The facility is definitely better compared to earlier, but you cannot say that there will never be any scarcity of blood in this blood bank," Dr. Taye told the Pulitzer Center.
As Sulekha's medical condition worsened, her husband Bhangru got into the hospital bed with her, while his father returned to the ambulance and went searching for blood. They drove around Dibrugarh, stopping at blood bank after blood bank, trying to secure blood for Sulekha.
At 8:15 a.m., while Bhangru cradled his wife's head in his arms and Rama searched for blood, Sulekha slipped away.
Sulekha, about 26 years old and the mother of two young boys, was a casualty of all three delays.
It has been a little over a month since Sulekha's death. Bhangru and the couple's two boys now sleep on the same wooden bed, just the three of them. Bhangru, sitting hunched over with his hands clasped together outside his father's home, says his boys wake in the middle of the night, screaming for their mother. Bhangru tells them their mother is gone, and they cry louder.
This reporting was sponsored by a grant from the Pulitzer Center on Crisis Reporting.
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