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.
Keywords: facilitators and barriers; low and middle income countries; near miss case review; systematic review.
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