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An essential limitation was we did not have entry to the medical records at the frontline hospitals. Organisational and personnel factors, at each primary care and in the hospitals, now contribute to nearly all maternal deaths in Indonesia. While ANC in major care remains to be of less than optimum quality, most deaths are preventable if the hospital care is of optimum high quality. There is a need to develop capability to evaluate the native conditions throughout the hospitals and districts by method of organisational and personnel elements that undermine quality of care. There is also a have to plan and provide well timed and effective take care of concomitant illnesses.

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