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What is the quality of the maternal near-miss case reviews in WHO European Region? Cross-sectional study in Armenia, Georgia, Latvia, Republic of Moldova and Uzbekistan
  1. Alberta Bacci1,
  2. Stelian Hodorogea2,
  3. Henrik Khachatryan3,
  4. Shohida Babojonova4,
  5. Signe Irsa5,
  6. Maira Jansone6,
  7. Iurie Dondiuc7,
  8. George Matarazde8,
  9. Gunta Lazdane9,
  10. Marzia Lazzerini1
  1. 1 WHO Collaborating Centre for Maternal and Child Health, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
  2. 2 State Medical and Pharmaceutical University "N. Testemitanu", Chisinau, Moldova
  3. 3 WHO Country Office in Armenia, Yerevan, Armenia
  4. 4 Republican Perinatal Center, Tashkent, Uzbekistan
  5. 5 Pauls Stradins Clinical University Hospital, Riga, Latvia
  6. 6 Riga Stradins University, Riga, Latvia
  7. 7 Municipal Clinical Hospital Nr 1, Chisinau, Moldova
  8. 8 UNFPA Country Office, Tbilisi, Georgia
  9. 9 Division of Noncommunicable Diseases and Promoting Health through the Life-course, WHO Regional Office for Europe, Copenhagen, Denmark
  1. Correspondence to Dr Marzia Lazzerini; marzia.lazzerini{at}


Objectives The maternal near-miss case review (NMCR) cycle is a type of clinical audit aiming at improving quality of maternal healthcare by discussing near-miss cases. In several countries this approach has been introduced and supported by WHO and partners since 2004, but information on the quality of its implementation is missing. This study aimed at evaluating the quality of the NMCR implementation in selected countries within WHO European Region.

Design Cross-sectional study.

Settings Twenty-three maternity units in Armenia, Georgia, Latvia, Moldova and Uzbekistan.

Assessment tools A predefined checklist including 50 items, according to WHO methodology. Quality in the NMCR implementation was defined by summary scores ranging from 0 (totally inappropriate) to 3 (appropriate).

Results Quality of the NMCR implementation was heterogeneous among different countries, and within the same country. Overall, the first part of the audit cycle (from case identification to case analysis) was fairly well performed (mean score 2.00, 95% CI 1.94 to 2.06), with the exception of the ‘inclusion of users’ views’ (mean score 0.66, 95% CI 0.11 to 1.22), while the second part (developing recommendations, implementing them and ensuring quality) was poorly performed (mean score 0.66, 95% CI 0.11 to 1.22). Each country had at least one champion facility, where quality of the NMCR cycle was acceptable. Quality of the implementation was not associated with its duration. Gaps in implementation were of technical, organisational and attitudinal nature.

Conclusions Ensuring quality in the NMCR may be difficult but achievable. The high heterogeneity in results within the same country suggests that quality of the NMCR implementation depends, to a large extent, from hospital factors, including staff’s commitment, managerial support and local coordination. Efforts should be put in preventing and mitigating common barriers that hamper successful NMCR implementation.

  • maternal health
  • near-miss case review
  • standard-based assessment
  • quality of care
  • middle-income countries

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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  • Contributors AB and ML conceived the study, analysed the data and wrote the first draft of the paper. AB, SH, HK, SB, SI, MJ, ID, GM and GL collected data and contributed to the final draft of the paper. GL and GM contributed by procuring funds. All authors contributed to the final version of the paper.

  • Funding The assessment was supported by WHO Regional Office for Europe and UNFPA Regional Office for Eastern Europe and Central Asia.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Additional details on the country assessments can be obtained from the first author.

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