Putting theory into practice: the introduction of obstetric near-miss case reviews in the Republic of Moldova

Abstract

The quality of obstetric services remains a major issue in the Republic of Moldova. Services are well staffed and intensively used but do not deliver the expected outputs. Providers have limited experience with clinical audits and perceive them as a way to punish individuals. Near-miss case reviews were introduced. Discussing near-miss cases might be less threatening to providers than discussing maternal deaths because the women survived. The quality of audits was evaluated against explicit criteria in three pilot maternities. On average one case was discussed every 5-6 weeks. Information from women's interviews was presented at all meetings, although the quality of the women's interviews was low. The weakest aspect of care was monitoring and follow-up treatment; the majority of proposed actions concerned the availability or compliance to protocols (52-69%). Proposed actions were consistent with prior analysis (95-100%), formulated in a clear and measurable way (58-90%), but the rate of failure to identify important actions was quite high in one facility (33%). Actions were more likely to be implemented when they concerned organization and management, drugs and supplies and least likely when they concerned staff. It is relatively easy to build capacity in organizing obstetric 'near-miss' audits, but more difficult to ensure that discussions are transposed into actions. In settings with no tradition of patients' involvement, increased attention should be given to providers' capacity to tackle patient-related factors.