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Poor software of protocols, poor data flow from frontline hospitals to the peak referral hospital, delays in emergency care, and delays in management of deteriorating sufferers had been the primary contributing elements to these deaths. Pyramidal referrals additionally contributed, as many ladies have been initially referred to hospitals where their situation couldn’t be successfully managed. While generic quality enchancment measures, particularly training and monitoring for rigorous software of scientific protocols will help improve the situation, the districts and hospitals must develop capability to evaluate their local scenario. Unless local organisational components, staff information and skill, blood and blood product availability, and native causes for delays in offering care are identified, it will not be potential to successfully cut back the opposed pregnancy outcomes.