Improving the continuum of care for neonates born in rural settings in low- and middle-income countries is a pressing public health concern. The central hypothesis of this project is that lay midwives in Guatemala can serve as an efficient means for rapid evaluation of medical referral of neonates when indicated, if they are provided with decision support and formal linkages to the medical referral chain.  In this project, we will accomplish this by designing a novel phone-based mHealth application which provides midwives with real-time decision support and access to on-call clinicians to guide them through the examination and triage of neonates in the first week of life. The mHealth implementation will be embedded within a larger quality improvement framework designed, in partnership with a local primary health care organization in Guatemala, to reduce barriers to neonatal referrals. The project has two Specific Aims:

Specific Aim 1: To develop a smart-phone based decision support system for early neonatal evaluation by lay midwives.

Specific Aim 2: To use a QI framework to evaluate the impact of the use of the decision support application by a cohort of lay midwives on improving the neonatal referral rates.

The primary outcome will be an increase in the proportion of neonates referred to a higher level of care. Secondary outcomes include the proportion of neonates receiving timely evaluation by midwives and the incidence of neonatal death/adverse events. After an iterative, adaptive design process to optimize the mHealth application, a quality improvement team will oversee the mHealth implementation over 12 months. Statistical process control methodology (control charts) will be used to track improvements in then neonatal continuum of care throughout the implementation and to document achievement of the primary and secondary outcomes.