Background: The Indian government institutionalized the Maternal Death Review (MDR) process at the facilities and community level to identify the medical causes and socio-economic, cultural, and gaps in the health system that caused the delay in such deaths. However MDSR remains a statutory procedure; keeping aside main purpose of identifying the preventable cause. Methods: Mixed design study (Cross-sectional & qualitative designs) was conducted in the community from December 2021 to January 2022 (2 months) in the Kheda district. Situational Analysis of the existing maternal death review mechanism & Verbal Autopsy of maternal deaths that occurred during 1st April 2020 to 31st March 2021 were carried out. Results: There has been a rising trend in maternal mortality rate in the Kheda district for the last two years. 60% of maternal deaths were due to direct obstetric causes like hemorrhage, eclampsia, sepsis etc. 7.5% of maternal deaths occurred at home, while 22.5% of maternal deaths occurred en route. Ignorance of medical advice, Delay in reaching an appropriate medical facility and receiving inadequate treatment were the common contributing factors found in the qualitative analysis. Conclusion: Data accuracy & completeness, Governance and operational failures were identified as major contributing factors in the poor processing of Maternal Death Review (MDR). Identifying high-risk cases, appropriate referral & transport, up-gradation of hospitals, and monitoring of health services can reduce maternal mortality