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 scientific information contained in the medical information on 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 into identified. Maternal death audits are needed to assess health providers components that contribute to poor outcomes . Research undertaken within the Kutai Kartanegara district of Indonesia has demonstrated that the root-causes lie primarily …