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Many ladies remained at a frontline hospital when their situation had already deteriorated beyond the degree to which the employees had been able to handle. Monitoring of health companies for his or her readiness to offer efficient companies for ladies who arrive with complications has been emphasised in suggestions to enhance quality of care . Despite most Indonesian ladies now receiving antenatal care on the nationally recommended four occasions and being delivered by expert birth Health news attendants, the nation’s maternal mortality ratio is estimated as 177 per one hundred,000 stay births. Recent research in a rural district of Indonesia has indicated that poor service quality because of organizational and personnel elements is now a major determinant of this high MMR. The present analysis is an in-depth evaluation of attainable health service organizational and quality of care associated causes of demise among 30 ladies admitted to a peak referral hospital in a major Indonesian metropolis.