Exploring the sustainability of obstetric near-miss case reviews: a qualitative study in the South of Benin.

INTRODUCTION: near-miss case reviews are one of a number of audit approaches currently being used and evaluated by those with an interest in reducing high rates of maternal mortality in developing countries. Researchers are beginning to take an interest in issues relating to the sustainability of audits. OBJECTIVE: to develop an understanding of the barriers and facilitators to the sustainability of obstetric near-miss case reviews in five hospitals in southern Benin. DESIGN AND METHODS: semi-structured interviews were designed to explore health workers' and policy makers' views and experiences of the sustainability of near-miss case reviews aimed to improve quality of care and reduce maternal mortality. SETTING: five hospitals in three regions in the south of Benin. PARTICIPANTS: two Ministry of Health officials and eight health-care workers involved in a feasibility study conducted in 1998-2001 that introduced near-miss case reviews. ANALYSIS: framework analysis to identify themes. FINDINGS: while all participants believed in the importance and value of audit, all hospitals had stopped performing near-miss case reviews within two years of completing the feasibility study. Ten qualitative interviews identified six themes relating to the sustainability of case reviews: clear advantages in ensuring quality of care, fear of blame and punishment, availability of resources, training, supportive hospital work environment, and broader policy issues. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: implementing and sustaining audit is a complex intervention that requires careful planning and consideration. It is important to consider both the content and the context in which audit takes place when developing strategies for sustainability.