Table 3

Strengths and weaknesses observed in the quality of the NMCR implementation

TechnicalIn all countries:
  • 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)

Especially in country E:
  • 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)

OrganisationIn all countries:
  • 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

Especially in country E:
  • 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

Regional NMCR coordinators were established
  • 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

AttitudeIn all countries
  • 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)

Especially in country E:
  • 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

  • BTN, beyond the numbers; MoH, Ministry of health; NM, near miss; NMCR, near-miss case review; SMART, specific, measurable, achievable, realistic and time-bound.