Background
The number of Kazakhstani women who suffer from postpartum hemorrhages (i.e. excessive bleeding after childbirth) in the cities of Almaty and Astana increased between 2006 and 2007. Regular investigations of maternal death cases take place in Kazakhstan, in order for hospitals to learn and improve maternal care going forward. However, these investigations often focus on finding the “criminal”, which means health workers tend to consider them unpleasant as the investigations can lead to legal consequences for them.

About the project
This project was created to introduce a confidential auditing system of both positive aspects and missed opportunities of maternity care at the National Research Center of Maternity and Childhood in Astana and the Maternity Hospital and Perinatal Center in Almaty. The project team examined the “near-miss” postpartum hemorrhage cases, which were less controversial than the cases where the woman or newborn had died. The “near-miss” cases were situations where the medical staff had actually saved the woman’s life, which made them suitable for the introduction of the confidential auditing system. Once the staff trust the system, the project team plan to expand it to include all cases related to maternal care, like pre-eclampsia, eclampsia and sepsis.

Results
Since the project launch in April 2008, the confidential auditing system of cases of maternal “near misses” has been implemented in both Astana and Almaty. After initial problems with suspicious leaders as well as health workers, the project team have been appointed to form a national commission to spread their working method of confidential auditing on maternal mortality and “near misses”. Midwives were included in this national commission, which is an important step as it is the first time that has happened in Kazakhstan. This method is now being scaled up to all (24) perinatal centres in the country.

Year: 2008