Rural women with obstetric complications access many health providers in Koppal, the poorest district in the state of Karnataka, south India. Yet they die. Based on insights derived from case studies of women seeking emergency obstetric care and participant-observation of government health services, this article highlights service delivery constraints that underlie the persistence of high levels of maternal mortality in Koppal. Weak information systems, discontinuity in care, unsupported health workers, haphazard referral systems and distorted accountability mechanisms are identified as critical service delivery problems. For example, maternal deaths are under-reported and not reviewed, antenatal care and institutional delivery are not linked to post-partum or emergency obstetric care, and health workers use inappropriate injections but don't treat anaemia or sepsis. Families waste valuable time and resources accessing many providers but fail to get effective care, and blame is laid on lower-level health workers and women for not accessing institutional delivery. Lastly, the role of administrators and politicians in ensuring functioning health services is obscured. While important supply and demand-side reforms are being implemented, these do not constructively engage with informal providers nor address systemic service delivery constraints. Critical managerial change is required, without which new budgetary allocations will be squandered with little impact on saving women's lives.