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It seemed that, if not earlier, she did have high blood pressure on the final ANC, without any specific administration, which was ten days earlier than her death. During her terminal sickness, she had pulmonary oedema on arriving on the frontline hospital. The elements undermining high quality are present in major care as well. The inadequate high quality of care and inconsistent approach to managing risks such as pre-eclampsia in primary care have been noted previously as a significant component in maternal mortality . These elements undermining quality of major care were obvious in this research as nicely. There was evidence of poor communication between main care and hospital; and nearly no suggestions from the hospitals to primary care settings.
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