Facilitators and barriers to the effective implementation of the individual maternal near-miss case reviews in low/middle-income countries: a systematic review of qualitative studies

Background The maternal near-miss cases review (NMCR), a type of clinical audit, proved to be effective in improving quality of care and decreasing maternal mortality in low/middle-income countries (LMICs). However, challenges in its implementation have been described. Objectives Synthesising the evidence on facilitators and barriers to the effective implementation of NMCR in LMICs. Design Systematic review of qualitative studies. Data sources MEDLINE, LILACS, Global Health Library, SCI-EXPANDED, SSCI, Cochrane library and Embase were searched in December 2017. Eligibility criteria for selecting studies Qualitative studies exploring facilitators and/or barriers of implementing NMCR in LMIC were included. Data extraction and synthesis Two independent reviewers extracted data, performed thematic analysis and assessed risk of bias. Results Out of 25 361 papers retrieved, 9 studies from Benin, Brazil, Burkina Faso, Cote D’Ivoire, Ghana, Malawi, Morocco, Tanzania, Uganda could be included in the review. The most frequently reported barriers to NMCR implementation were the following: absence of national guidelines and local protocols; insufficient training on how to perform the audit; lack of leadership, coordination, monitoring and supervision; lack of resources and work overload; fear of blame and punishment; poor knowledge of evidenced-based medicine; hierarchical differences among staff and poor understating of the benefits of the NMCR. Major facilitators to NMCR implementation included: good leadership and coordination; training of all key staff; a good cultural environment; clear staff’s perception on the benefits of conducting audit; patient empowerment and the availability of external support. Conclusions In planning the NMCR implementation in LMICs, policy-makers should consider actions to prevent and mitigate common challenges to successful NMCR implementation. Future studies should aim at documenting facilitators and barriers to NMCR outside the African Region.