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Working with lay midwives to improve the detection of neonatal complications in rural Guatemala
  1. Michel Juarez1,
  2. Yolanda Juarez1,
  3. Enma Coyote1,
  4. Tony Nguyen2,
  5. Corey Shaw2,
  6. Rachel Hall-Clifford3,
  7. Gari Clifford2,4,
  8. Peter Rohloff1,5
  1. 1Center for Research in Indigenous Health, Wuqu' Kawoq | Maya Health Alliance, Tecpán, Guatemala
  2. 2Department of Biomedical Informatics, Emory University, Atlanta, Georgia, USA
  3. 3Department of Sociology, Anthropology and Public Health, Agnes Scott College, Decatur, Georgia, USA
  4. 4Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia, USA
  5. 5Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
  1. Correspondence to Dr Peter Rohloff; peter{at}


Background Globally most neonatal deaths occur within the first week of life and in low-income and middle-income countries. Strengthening health system linkages for frontline providers—such as lay midwives providing home-based obstetrical care—may improve neonatal outcomes in these settings. Here, we conducted a quality improvement study to increase the detection of neonatal complications by lay midwives in rural Guatemala, thereby increasing referrals to a higher level of care.

Methods A quality improvement team in Guatemala reviewed drivers of neonatal health services provided by lay midwives. Improvement interventions included training on neonatal warning signs, optimised mobile health technology to standardise assessments and financial incentives for providers. The primary quality outcome was the rate of neonatal referral to a higher level of care.

Results From September 2017 to September 2018, participating midwives attended 869 home deliveries and referred 80 neonates to a higher level of care. A proportion control chart, using the preintervention period from January to September 2017 as the baseline, showed an increase in the referral rate of all births from 1.5% to 9.9%. Special cause was obtained in January 2018 and sustained except for May 2018. The proportion of neonates receiving assessments by midwives in the first week of life increased to >90%. A trend toward an increasing number of days between neonatal deaths did not attain special cause.

Conclusions Structured improvement interventions, including mobile health decision support and financial incentives, significantly increased the detection of neonatal complications and referral of neonates to higher levels of care by lay midwives operating in rural home-based settings in Guatemala. The results show the value of improving the integration of lay midwives and other first responders into neonatal systems of care in low-resource settings.

  • community health services
  • control charts/run charts
  • global health
  • infant mortality
  • mobile applications

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • Contributors MJ: coordinated and supervised the study, performed statistical analyses and drafted the initial manuscript. YJ and EC: coordinated and supervised the study and reviewed and revised the manuscript. TN and CS: programmed the app and provided support for data collection and engineering development. RH-C: provided design input to the mobile health technology and reviewed and revised the manuscript. GC: supervised the development of the mobile health technology and reviewed and revised the manuscript. PR: designed the study, performed statistical analyses, and reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

  • Funding All phases of this study were funded by the Charles Hood Foundation.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available in a public, open access repository at: