sixty nine of the 70 girls who died at this peak referral hospital had been first seen at a decrease level hospital; 36 had spent at least 24 hours at a frontline hospital before being transferred on. Of the 70 deaths that occurred at this hospital, 55 were to girls whose place of residence was exterior of town where it is positioned. The causes of demise for these 70 ladies included PE/Eclampsia (27%), haemorrhage (17%), infection (30%) and others (30%—including CVD, ARDS, embolism, SLE, TB, cancers, SLE and so on.). In East Java, there have been 529 maternal deaths in 2017 and 522 in 2018. The MMR differed substantially across the districts from a high of 301 to less than 50 in six districts.
This has helped us to revise the paper, which now focuses on the root-cause analysis, highlighting causes of poor high quality of care resulting in maternal …
