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Pyramidal referrals also contributed, as many ladies had been initially referred to hospitals the place their condition could not be successfully managed. While generic high quality improvement measures, notably training and monitoring for rigorous utility of scientific protocols will help improve the state of affairs, the districts and hospitals need to develop capability to assess their local situation. Unless native organisational components, staff data and ability, blood and blood product availability, and native Health news causes for delays in offering care are identified, it is probably not attainable to effectively reduce the adverse being pregnant outcomes. An important limitation was we didn’t have access to the medical data on the frontline hospitals. Organisational and personnel elements, at each major care and within the hospitals, now contribute to virtually all maternal deaths in Indonesia. While ANC in primary care continues to be of less than optimum high quality, most deaths are preventable if the hospital care is of optimum quality.

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ANC quality requires much attention, and the employees need assist and supervision for protocol-based care and sustained administration of risks. The frontline hospitals’ midwifery units need protocols for evidence-based care to be displayed throughout. The hospital must be engaged in reviewing deaths, close to misses and deterioration. An inappropriate interpretation of the pyramidal referral policy, whereby major care suppliers referred the deteriorating affected person to a frontline hospital when she actually wanted referral hospital care, was a contributing factor in lots of the deaths. A review by Singh et al identified that “ referrals are haphazard and a pregnant lady at excessive danger or with issues didn’t get the required EmOC and had to go through a number of referrals earlier than reaching the appropriate institution”.