Quality issue: 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.
Initial assessment: Providers have limited experience with clinical audits and perceive them as a way to punish individuals.
Choice of solution: Near-miss case reviews were introduced. Discussing near-miss cases might be less threatening to providers than discussing maternal deaths because the women survived.
Implementation: The quality of audits was evaluated against explicit criteria in three pilot maternities.
Evaluation: 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.
Lessons learned: 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.