Abstract
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. 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. 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). 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.
Highlights
In Ecuador, the institutional deliveries increased from 74% between 2000 and 2006 to 85% between 2007 and 2012
Since most indigenous Ecuadoreans reside in rural parishes, difficult access to care and cultural preferences resulted in them receiving maternal and newborn health care from traditional birth attendants (TBAs), traditional healers, and family members
This study evaluated changes in facilities participating in the essential obstetric and newborn care (EONC) network created by United States Agency for International Development (USAID)’s Cotopaxi Project in terms of access and quality indicators of EONC and compared to nonparticipating facilities
Summary
In Ecuador, the institutional deliveries increased from 74% between 2000 and 2006 to 85% between 2007 and 2012. A recent national maternal and child health survey showed that 37% of indigenous women did not receive four antenatal care (ANC) visits and only 30% had skilled delivery attendance in rural areas compared with 13 and 80% of Mestizo (non-indigenous) women, respectively. 15% compared with 38% received postpartum care, respectively [1] This disparity is partly attributable to a public health-care system that preferentially offered more skilled care to larger urban populations in provincial and county capitals. Since most indigenous Ecuadoreans reside in rural parishes, difficult access to care and cultural preferences resulted in them receiving maternal and newborn health care from traditional birth attendants (TBAs), traditional healers, and family members. We evaluated changes in participating facilities compared to non-participating controls
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