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Objectives  To estimate the incidence of maternal morbidity during labour and the puerperium in rural homes, the association with perinatal outcome and the proportion of women needing medical attention.

Design  Prospective observational study nested in a neonatal care trial.

Setting  Thirty-nine villages in the Gadchiroli district, Maharashtra, India.

Sample  Seven hundred and seventy-two women recruited over a one year period (1995–1996) and followed up from the seventh month in pregnancy to 28 days postpartum (up to 10 visits in total).

Methods  Observations at home by trained village health workers, validated by a physician. Diagnosis of morbidities by computer program.

Main outcomes  Direct obstetric complications during labour and the puerperium, breast problems, psychiatric problems and need for medical attention.

Results  The incidence of maternal morbidity was 52.6%, 17.7% during labour and 42.9% during puerperium. The most common intrapartum morbidities were prolonged labour (10.1%), prolonged rupture of membranes (5.7%), abnormal presentation (4.0%) and primary postpartum haemorrhage (3.2%). The postpartum morbidities included breast problems (18.4%), secondary postpartum haemorrhage (15.2%), puerperal genital infections (10.2%) and insomnia (7.4%). Abnormal presentation and some puerperal complications (infection, fits, psychosis and breast problems) were significantly associated with adverse perinatal outcomes, but prolonged labour was not. A third of the mothers were in need of medical attention: 15.3% required emergency obstetric care and 24.0% required non-emergency medical attention.

Conclusions  Nearly 15% of women who deliver in rural homes potentially need emergency obstetric care. Frequent (43%) postpartum morbidity, and its association with adverse perinatal outcome, suggests the need for home-based postpartum care in developing countries for both mother and baby.