Technical skills on performing NMCR were on average fair

Local protocols were on average present and used

Recommendations were usually developed, with several SMART15 characteristics (achievable, realistic and time-bound)

Most maternity teams were able to analyse efficiently a NM case, and to develop relevant recommendations to improve quality and organisation of care and follow-up their implementation

Case definition not complying with national definition

Lack of existence and use of local protocols for case analysis

Some lack of knowledge and skills in NMCR methodology

Case summary, case reconstruction door-to-door, case analysis (including getting to the real point, and "what we did good", and identifications of the underlying reasons using the ‘why-but-why’) not performed well performed in all facilities

Recommendations not fully SMART (often not specific nor measurable)

Staffing at all levels (including midwives and nurses) was involved and in some cases encouraged by facilitator to actively participate in the review process

Session participants were mostly those involved in care provision of the case reviewed, and, generally, felt free to ask questions and express their opinions

NMCR mostly happened on a regular basis

An excellent national plan for implementation was developed

Appropriate normative regulations were developed through regular NMCR sessions

By 2015, 90% of maternity facilities were trained and implementing NMCR

There was sustained support from MoH; WHO and partners (also in country C)

Lack of local written procedure for NMCR

Irregular meetings in some facilities

Lack of involvement of staffing who managed the case

Lack of a regional/national coordination and/or continuity in facilitator/coordinator role and/or support from them

Lack of trained interviewers

Absence of local leaders

Lack of support from hospital manager in organisation of the NMCR and in the implementation of the recommendation

Lack of follow-up on previous recommendations

Lack of production, dissemination and discussion of results of the NMCR cycle

Lack of periodical evaluations of the quality of the NMCR

When evaluations of the quality was performed, no mechanism ensured that resulting recommendations were taken up

Basic BTN principles were respected in most facilities, including confidentiality

Multidisciplinary approach to case reviews was evident in most facilities

Managers offered substantial support to organisation of NMCR sessions and implementation of recommendations

Staff found this method useful to improve quality and organisation of care

Midwives role as participants, but also as coordinators and facilitators

Interviews became a routine in most facilities (in particular in country C)

Facilitators succeeded to create and maintain an open and non-threatening environment during sessions; staff felt free to put forward (or ask) questions and express their opinions (also country C)

The point of view of women was always collected and presented; some interviews were of excellent quality (also country C)

Professionals were praised in case of good care

In some cases lack of respect of other people’s opinion, persistence of blaming, persistence of a wrong attitude that suggested ‘judging others’, rather than moving towards thinking ‘the review is about us’

Lack of active participation in the discussion

Insufficient involvement of mid-level staffing

Lack of the interviews with woman in some facilities

Even where the interview was collected, women’s view were not taken into account when recommendations were implemented

Staff not always praised when quality and appropriate care given

Staff considers developing recommendations a mere formality, they were not eager to implement them, and take on the role and the responsibility to change practice.

Persistence of a system that advocates punishment in some facilities