Assessing maternal and neonatal near-miss reviews in rural Nepal: an implementation research study to inform scale-up.

Aim: To understand how maternal and neonatal near-miss reviews could be implemented and scaled-up in rural communities through the existing district health system in Nepal.

Methods: Mixed methods with a modified time series evaluation design were used. The World Health Organization maternal and neonatal near-miss criteria used in multicountry surveys were adapted and used to define maternal and neonatal near-miss cases.

Results: The World Health Organization near-miss criteria were mainly applicable at the district hospital setting, but further adaptations were needed for community-level birthing centres, as organ dysfunction and critical intervention criteria were not found appropriate. In birthing centres, disease-based criteria were applicable for maternal near-miss review, and danger and clinical sign-based and condition at birth criteria were applicable for neonatal near-miss review. Primary barriers to implementation were attrition of trained staff due to the frequent transfer of healthcare providers, and time constraints of district hospital medical doctors for case-by-case reviews as they were often busy in hospital and in their private clinics.

Conclusion: Adapted maternal and neonatal near-miss review process implementation in Nepal is feasible through the existing government health system.