Demographic household surveys in Nepal between 1996 and 2006 indicate potentially large decreases in the pregnancy-related mortality ratio and raise hopes that Nepal may be on track to meet Millennium Development Goal 5. Between 2002 and 2006, 23,478 pregnant women in Sarlahi District, Nepal, were followed through pregnancy to 42 days postpartum. The pregnancy-related mortality ratio (PRMR) was estimated directly, comparing deaths among women during pregnancy or within 42 days of pregnancy termination to livebirths. In a separate household survey, 13,319 married females reported on the pregnancy history of 28,829 sisters, allowing for a concurrent comparison of estimation methodologies. In the prospective study, there were 121 pregnancy-related deaths and 23,662 livebirths (PRMR = 511, 95% confidence interval: 425, 611). In the household survey, participants reported 396 deaths among sisters, 87 (22.0%) of which were pregnancy related, and 116,491 person-years of exposure (PRMR = 529, 95% confidence interval: 419, 638). Two independent estimates collected with different methods in the same geographic area over similar time periods resulted in similarly high estimates of mortality that are approximately twice the current national estimate. Access to life-saving maternal health interventions remains low in rural Nepal, and continued efforts are necessary to ensure equitable and country-wide progress toward Millennium Development Goal 5.