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Organisational and personnel elements contributed to all 30 deaths. Table 2 summarises the findings of the in-depth evaluation of the maternal dying audit, data collected by the district departments of health, and the clinical information contained within the medical records at the referral hospital. For a further reduction in MMR and for improved being pregnant outcomes, it is important that the root-causes of this stagnation turn out to be recognized. Maternal dying audits are needed to assess health services elements that contribute to poor outcomes . Research undertaken within the Kutai Kartanegara district of Indonesia has demonstrated that the root-causes…
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