title: Evaluation of an Intervention to Improve Essential Obstetric and Newborn Care Access and Quality in Cotopaxi, Ecuador.
abstract: BACKGROUND
  Despite improvements in health-care utilization, disadvantages persist among rural, less educated, and indigenous populations in Ecuador. The United States Agency for International Development-funded Cotopaxi Project created a provincial-level network of health services, including community agents to improve access, quality, and coordination of essential obstetric and newborn care. We evaluated changes in participating facilities compared to non-participating controls.
  
  
  METHODS
  The 21 poorest parishes (third-level administrative unit) in Cotopaxi were targeted from 2010 to 2013 for a collaborative health system performance improvement. The intervention included service reorganization, integration of traditional birth attendants (TBAs) with formal supervision, community outreach and education, and health worker technical training. Baseline (n= 462) and end-line (n= 412) household surveys assessed access, quality and use of care, and women's knowledge and practices. TBAs' knowledge and skills were assessed from simulations. Chart audits were used to assess facility obstetric and newborn care quality. Provincial government data were used for change in neonatal mortality between intervention and non-intervention parishes using weighted linear regression.
  
  
  RESULTS
  The percentage of women receiving a postnatal visit within first 2 days of delivery increased from 53 to 81 in the intervention group and from 70 to 90 in the comparison group (p≤ 0.001). Postpartum/counseling on newborn care increased 18% in the intervention compared with 5% in the comparison group (p≤ 0.001). The project increased community and facility care quality and improved mothers' health knowledge. Intervention parishes experienced a nearly continual decline in newborn mortality between 2009 and 2012 compared with an increase in control parishes (p≤ 0.001).
  
  
  CONCLUSIONS
  The project established a comprehensive coordinated provincial-level network of health services and strengthened links between community, primary, and hospital health care. This improved access to, quality, use, and provision of essential obstetric and neonatal care and survival. Ecuador's Ministry of Health is scaling up the model nationally.
authors.affiliation: University Research Co., LLC, Bethesda, MD, USA; Johns Hopkins School of Public Health, Baltimore, MD, USA.
authors.forename: Edward
authors.initials: E
authors.lastname: Broughton
authors.affiliation: University Research Co., LLC , Bethesda, MD , USA.
authors.forename: Jorge
authors.initials: J
authors.lastname: Hermida
authors.affiliation: Jhpiego , Washington, DC , USA.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Hill
authors.affiliation: Independent Contractor , New York, NY , USA.
authors.forename: Nancy
authors.initials: N
authors.lastname: Sloan
authors.affiliation: Ministerio de Salud , Quito , Ecuador.
authors.forename: Mario
authors.initials: M
authors.lastname: Chavez
authors.affiliation: Ministerio de Cultura , Quito , Ecuador.
authors.forename: Daniel
authors.initials: D
authors.lastname: Gonzalez
authors.affiliation: Universidad San Francisco de Quito , Quito , Ecuador.
authors.forename: Juana Maria
authors.initials: JM
authors.lastname: Freire
authors.affiliation: University Research Co., LLC , Bethesda, MD , USA.
authors.forename: Ximena
authors.initials: X
authors.lastname: Gudino
keywords: Ecuador; essential obstetric and newborn care; neonatal mortality; quality of care