Strengths and weaknesses of national confidential case reviews of maternal and newborn morbidity and mortality

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Confidential case reviews have been established as a means to improve the quality of maternity care for several decades. Impacts of these programmes, while difficult to demonstrate, have been observed on maternal and neonatal mortality rates, maternity policy and clinical practice. At a national level, maternal and newborn case review programmes identify messages to improve care through multidisciplinary review of medical records of all, or a sample, of mothers and infants who have died or have a specific morbidity. The major strength of such national programmes is that they allow lessons to be identified to improve care at all levels of the health system from national government policy to individual clinical practice. However, strengthening translation of recommendations into action, whether through a more active link with implementation processes or further development of dissemination strategies grounded in implementation science, is an important continuing focus.