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Table 2 Summary of methods to conduct near-miss assessment

From: Developing a framework to review near-miss maternal morbidity in India: a structured review and key stakeholder analysis

Methods

Approach

Near-miss case review

An in-depth understanding particularly of the entire process of care conducted at the local level that includes administrative, managerial aspects, as well as the opinion of the patient about the care she received. Such reviews can identify the combination of factors at the facility and in the community that contributed to near-miss cases. There are three aspects to conducting case reviews of near-miss cases: First using the “gate to gate” approach from admission to discharge, a case may be observed throughout her stay. The method can help to identify the physical locations of any delay and also during what time period it occurred. Secondly, analysis of a sample of cases based on the medical records to understand the overall functioning of the health facility and the gaps in providing care. Thirdly, interviews with women who had near-miss events to understand the woman’s account of her care [17],[19]. The method provides a holistic assessment of the health system from both the demand and supply side and also the issue of quality improvement can be looked at from a multi-disciplinary approach, bringing clinical and non-clinical staff together in a common forum. The patient’s perspective gives the opportunity for survivors to share their experience and views. The main constraint is sustainability as the process requires a significant amount of time and resource and there are challenges in embedding it as part of a routine surveillance system [11],[17].

Confidential enquiries into near-miss cases

An anonymous investigation of a representative sample of near-miss cases. Reviewing of data by an independent expert panel helps to identify causes and avoidable or remediable factors associated with near-miss morbidity [23],[24]. The method allows a group to understand the factors contributing to poor outcomes and to learn lessons for the future by assuring confidentiality and not reporting details of individual cases thus preventing punitive action [11],[24].

Criterion-based clinical audit

In this method prior agreement is reached of a list of concise criteria for good quality care, based on available evidence and resources. All records of women are reviewed to determine the care received against these explicit criteria. It is used as a part of the quality improvement process to improve patient care and outcomes through systematic review of aspects of the structure, processes, and outcomes of care [25],[26]. The key strength of the method is that data can be obtained retrospectively from case notes or registers, it is easy to interpret and the quality of care based on agreed criteria of best practice can be assessed. The main challenge is that retrospective collection of information might be problematic due to poor documentation [27].

Structured review (South African Model)

This method involves review of all cases of severe morbidity focusing on three main areas: patient-related problems, administrative problems and clinical care [12]. The method is useful as care can be assessed over six distinct periods; antenatal, intrapartum and postnatal care, and three phases related to emergency care;admission, resuscitation and anaesthesia. The method also helps to identify barriers at both patient-related as well as health systems levels [28].

Home-based interviews

Women are interviewed at home within one month of discharge. Two groups of women may be interviewed: those who are identified as part of facility near-miss reviews and women who have not been identified by near-miss reviews [28]. The method provides the perspective of the user of services and can identify delays at family and community level. The main challenge is women’s willingness to share experience with health system representatives. Moreover a woman may not be able to narrate her whole experience due to her physical state. Interviews with women needs trained data collectors and time and resources in locating the women for interview and analysing the data.