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In the case of at least 5 ladies, it appeared that the protocols for managing deterioration were both not obtainable or not used effectively. For example, a woman saved receiving the same ineffective medication for many days. For another woman, it appeared that the frontline hospital didn’t have an agreed protocol for managing pulmonary oedema and pulmonary embolism. In another case, the protocols for inverted uterus, heavy bleeding and extreme anaemia and hypovolemia have been both not obtainable or not utilized. The root-cause analysis was conducted on 30 deaths which occurred at the peak referral hospital in 2017 out of the total of 70 deaths in that location.

This in-depth review of knowledge on 30 women who died on the referral hospital discovered that entry to health companies, availability of employees for ANC and availability of senior staff on the hospitals were sufficient. It has been famous in different research that entry to obstetricians and medical doctors to attend ladies arriving with postpartum haemorrhage and severe pre-eclampsia is a significant concern . However, in the current analysis virtually all of the deaths occurred regardless of access to enough human sources on the tertiary hospital.

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