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Attended by thousands of advocates, medical leaders, folks with lived experience, and their households. The research group needs to thank the editors and the reviewers for their in-depth evaluations and very useful ideas. This has helped us to revise the paper, which now focuses on the root-cause analysis, highlighting causes of poor high quality of care leading to maternal deaths. The modifications are described intimately within the ‘response to reviewers’ document.

The current analysis is an in-depth evaluation of potential health service organizational and high quality of care related causes of dying amongst 30 women admitted to a peak referral hospital in a major Indonesian metropolis. Despite their condition being complicated or deteriorating, most of those ladies arrived on the hospital in a state the place it was feasible to prevent demise with good quality care. Poor utility of protocols, poor info circulate from frontline hospitals to the peak referral hospital, delays in emergency care, and delays in administration of deteriorating patients had been the principle contributing elements to those deaths. Pyramidal referrals also contributed, as many women Health news have been initially referred to hospitals where their condition could not be effectively managed. While generic quality enchancment measures, notably coaching and monitoring for rigorous software of medical protocols will help enhance the state of affairs, the districts and hospitals need to develop capacity to assess their native state of affairs. Unless native organisational factors, staff data and ability, blood and blood product availability, and local causes for delays in providing care are identified, it may not be attainable to successfully cut back the adverse being pregnant outcomes.