Table 1 Key findings of Papers 1–9

1 [11]

Introduction and project description

The components of CBIO+ (CBIO, Care Groups, and Community Birthing Centers) have a long history of effective implementation but have not been widely adopted. This is the first example we are aware of the three components having been implemented together and evaluated. The Project Area was a challenging one in terms of the mountainous terrain, the difficulty of geographic access, the traditional culture and language barriers, and the history of conflict during the Guatemala civil war (1960–1996)

2 [12]

Study site, design and methods

The implementation research consisted of multiple household surveys at baseline and endline in both Areas A and B, numerous in-depth individual and group interviews, focus group discussions, and the registration of vital events. Since interventions in Area B began midway through the implementation of the Project, it served as a quasi-control area

3[13]

Expansion of population coverage of key interventions

Statistically significant improvements were observed in the coverage in 21 of 24 evidence-based interventions in Area A and 19 of 24 evidence-based interventions in Area B. There was a three-fold (200%) increase for 7 of 24 indicators in Area A and for 5 of 24 indicators in Area B. There was no improvement for indicators of interventions that required support from the government’s Extension of Coverage (PEC) Program (immunizations, vitamin A, and family planning) as a result of the government's shutdown of its PEC Program during the Project implementation

4 [14]

Nutritional assessment

Levels of stunting in under-2 children in Area A declined from 74.5% to 39.5%, with endline levels considerably lower than for comparison areas outside of the Project Area. The endline level of stunting in Area B was lower than for comparison areas outside of the Project Area but higher than in Area A. Improvements in multiple output and outcome indicators associated with nutritional status were also observed in Areas A and B. These included infant and child feeding practices, routine growth monitoring and counseling, and household practices for the prevention and treatment of diarrhea. The results were stronger in Area A

5 [15]

Mortality assessment

The maternal mortality ratio declined from 632 in Years 1 and 2 to 257 per 100,000 live births in Years 3 and 4 in Area A (p=.006). There was no decline in the under-5 mortality rate (U5MR) in Area A (45 per 1,000 live births in Years 1 and 2 and 45 per 1,000 live births in Years 3 and 4). The 12-<60-month mortality rate declined from 9 deaths per 1,000 live births in the first three years of the Project to 2 in the final year. No declines in mortality were observed in Area B, where the Project operated for only 15 months in Years 3 and 4. Incomplete registration of deaths during the first two years of Project operations appears to have muted the mortality impact of the Project as measured by vital events registration. An indirect estimate of mortality declines using the Lives Saved Tool (based on changes in population coverage of evidence-based interventions) suggests a net decline, independent of ongoing secular changes, of 12% for maternal mortality and 22% for under-5 mortality

6 [16]

Management of pregnancy complications at Community Birthing Centers

15% of 1,378 women coming to a birthing center between 2009 and 2016 experienced a complication; 42% were managed successfully at the birthing center and 58% were referred to a higher-level facility. Only one maternal death occurred. Referrals were rejected initially by the patient or the family in approximately 15% of cases but eventually almost all accepted the recommendation. Birthing Center staff attributed their successful management of complications to intensive training, teamwork, and logistical support

7 [17]

The empowering effect of Care Groups

Participation in the Care Group process was an empowering process for women. Mothers reported increased respect accorded to them by the community, an increased willingness and ability to make health-related decisions, as well as the development of stronger bonds among Care Group members and with other community members and community leaders

8 [18]

Empowerment of women

Household surveys revealed statistically significant increases in women’s active participation in community meetings and in health-related decision-making. These findings corroborated qualitative findings from focus group discussions that the Project has accelerated progress in increasing women’s empowerment, though women still face major barriers in accessing needed health care services for themselves and their children

9 [19]

Key stakeholder perspectives on CBIO+ 

Project staff members and government health workers were enthusiastic supporters of CBIO+ , especially its approach to involving the community in program planning. There was a strong desire among government health workers for the Project to continue