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Health Research Challenge for Impact (HRCI)

The aim of Health Research Challenge for Impact (HRCI) was to accelerate the development and introduction of new, feasible, culturally acceptable, low-cost, preventive and curative interventions for the main causes of maternal, newborn and child deaths. 

Pathways to Survival


Health Research Challenge for Impact (HRCI) was supported by USAID through a Leader with Associates (LWA) Cooperative Agreement to Johns Hopkins University.


Verbal and Social Autopsy Study (VASA):

 A Verbal/Social Autopsy Study to Improve Estimates of the Causes and Determinants of Neonatal and Child Mortality in Nigeria

Completed in late 2013, the 40,680 household 2013 Demographic and Health Survey (DHS) was supported by USAID and conducted by the National Population Commission (NPC) of Nigeria to plan and conduct the 2013 Demographic and Health Survey (DHS) that identified recent deaths of children under 5 years old from a full birth history of women age 15-49 years. With support from USAID and US Fund for UNICEF’s Child Health and Epidemiology Reference Group (CHERG) grant from the Bill and Melinda Gates Foundation, JHU faculty is working with the NPC to implement a national-level verbal autopsy-social autopsy (VASA) study on the platform of the DHS.  The VASA interviewers will return to households where a death was determined to have occurred in up to the prior 5 years to conduct the VASA interviews. Data on the biological causes or social and behavioral determinants of these deaths are vital to the Government of Nigeria’s efforts to develop effective interventions and which could meaningfully contribute to global mortality estimates.  The VASA study will directly measure neonatal and child mortality and its determinants in Nigeria, with the following three specific aims:

  • Estimate the cause distributions of death, separately for neonates (0-27 days old) and young children (1-59 months old), in Nigeria;
  • Estimate the proportions of deaths, by cause, of neonates and young children that occur in hospital in Nigeria; and
  • Estimate the prevalences of social factors contributing to deaths of neonates and young children in Nigeria.


Verbal autopsy is the most useful tool available to determine cause of death in settings with limited access to health care. A VA inquiry of a child’s death consists of interviewing the main caregiver about the fatal illness. The cause of death is determined from predefined combinations of the reported illness signs; by independent classification of the interview findings by one or more study physicians; or by statistical methods that examine the associations between particular signs and illnesses.


While knowledge of the biological causes of child death is important, effective delivery of child survival interventions depends on improved understanding of modifiable cultural, social and health system factors affecting health care access and utilization. The “Pathway to Survival” conceptual framework (figure), organizes the steps that families, communities and health systems must take to prevent illness and return sick children to health.


  • National Population Commission of Nigeria (NPC)
  • Akintola Williams Deloitte (AWD)


Development of Community Based Programs

A Learning Agenda for the Development of Community Based Programs in Tanzania: Towards the Development of a Community Health Worker (CHW) Cadre (Tanzania)

The evaluation project will support the Ministry of Health and Social Welfare’s (MOHSW) Community Health Worker (CHW) Task Force with the design and development of an integrated community health worker program, support the implementation partners with the proposed scale-up of integrated community-based programs and improve their effectiveness through implementation research, and assist implementation partners to help reduce dropouts from the continuum of care by improving retention and adherence to care.  Specifically, the evaluation team will provide technical assistance to generate policy and program-relevant evidence through landscaping, a learning agenda, and the monitoring, evaluation, and implementation research activities.  The goal of this project is to facilitate active learning that will take advantage of existing resources and planned policy changes.  The active learning cycles would help strengthen the quality and coverage of an effective and efficient package of services that can provide a full continuum of MNCH care in a sustainable and evolving delivery system.  In support of this goal, the JHU-MUHAS evaluation team will work collaboratively with MOHSW including the CHW Task Force and implementing partners to achieve the following objectives:

  • Support different sections of the MOHSW with the information and evidence required to develop an integrated community program, and make recommendations to the MOHSW through the CHW Task Force regarding a long-term approach for an integrated CHW that will serve the needs of pregnant women and children, both HIV-positive and negative.
  • Support the MOHSW (NACP) and PEPFAR partners in the collection and analysis of uniform data from the various regions/ districts to quantify the extent of and reasons for dropout and develop and test integrated facility-community implementation strategies to improve adherence and retention of HIV-positive mothers and testing and treatment of children.
  • Provide evaluation and implementation research support to MOHSW and other partners responsible for community programming to effectively scale up the community program. 


  • Muhimbili University of Health and Allied Sciences (MUHAS)
Evaluation of an Integrated Maternal and Newborn Health Care Program

Monitoring, documentation and evaluation of an Integrated Maternal and Newborn Health Care Program in Morogoro Region (Tanzania)

The goal of this project is to improve maternal, newborn and child health outcomes by identifying optimal strategies for implementation and sustained delivery of evidence-based, cost-effective, culturally acceptable, and integrated maternal newborn care interventions with attention to both HIV positive and negative mothers and infants. 

This is an external evaluation of the “Integrated Maternal and Newborn Health Care Program in Morogoro Region, Tanzania.”  The Integrated Program is a maternal, newborn, postpartum care, and HIV/AIDS program implemented by the Tanzania Ministry of Health and Social Welfare (MOHSW) with technical support from Jhpiego and other partners.  The main components of the Integrated Program include capacity building at health facilities and development of a Community Health Worker (CHW) program to provide behavior change communication (BCC).

Greenspan JA, McMahon SA, Chebet JJ, Mpunga M, Urassa DP, Winch PJ. Sources of community health worker motivation: a qualitative study in Morogoro Region, Tanzania.  Hum Resour Health. 2013 Oct 10;11:52. doi: 10.1186/1478-4491-11-52. Review.


  • Muhimbili University of Health and Allied Sciences (MUHAS)
Simplified Antibiotic Treatment (SAT)

Safety and Efficacy of Simplified Antibiotic Regimens for Outpatient Treatment (SAT) of Suspected Severe Infections in Neonates and Young Infants (Bangladesh)

The Simplified Antibiotic Treatment (a randomized controlled) Trial in Bangladesh provided evidence that simpler antibiotic regimens involving 2 days of injection followed by oral antibiotics for treatment of clinically severe infection in young infants are as efficacious as the standard regimen involving 7 days of injectable antibiotics, thus expanding treatment options for many more infants who live in resource poor settings where hospital care is not accessible.The treatment failure rates (9.8%, 8.3%, and 8.1%), death any time before day 15 follow-up (1.5% to 1.8%), and relapse rates (<2%) similar among all three treatment arms.



  • Child Health Research Foundation
  • Hospital for Sick Children
  • Shimantik
Pneumonia Etiology Research for Child Health (PERCH)

The Care and Treatment of Severe Pneumonia in HIV-exposed and Infected Children (Zambia)

Pneumonia is the leading infectious cause of death in children. HIV-exposed and infected children are particularly susceptible to pneumonia but little information exists on the likelihood of and risk factors for mortality among hospitalized children with pneumonia. To address the gaps in knowledge, this study, nested within the Pneumonia Etiology Research for Child Health (PERCH) project, is evaluating treatment outcomes for severe and very severe pneumonia among hospitalized children enrolled at the site in Lusaka, Zambia.

The PERCH project is a multi-center, case-control study conducted in seven countries to determine the etiology of severe and very severe pneumonia among hospitalized children younger than five years of age. The PERCH Zambia site is led by investigators at Boston University and University of Zambia Teaching Hospital (UTH). Preliminary data from the PERCH site in Zambia indicated that there was little standardization of care of pneumonia in hospitalized children. To standardize and improve the care and management of these children, this sub-study developed, implemented, and evaluated a clinical guidance tool based on the WHO recommendations, including best practices specific to HIV-infected and exposed children. The clinical guidance tool was well-accepted and easy to use. Despite improving and standardizing the care received, the clinical guidance tool did not significantly reduce mortality. The tool appeared to be more effective among HIV-exposed but uninfected children and children younger than 6 months of age. Simple tools like these are needed to ensure that children hospitalized with pneumonia receive the best possible care in accordance with recommended guidelines.

Testing Mental Health Treatment

Development and Testing of Evidence-based Mental Health Treatment for Affected Zambian Youth (Zambia)

Many children in sub-Saharan Africa experience traumatic events such as loss of family members, severe poverty, and chronic illness. These events frequently affect mental health and ability to function, including the ability to learn and engage in healthy practices and to avoid risky or negative behaviors.

This study is a community-based randomized controlled trial to explore the effectiveness of Trauma Focused Cognitive Behavioral Therapy (TF-CBT) in addressing psychological and behavioral problems of Zambian youth resulting from trauma.  TF-CBT is an evidence-based treatment for youth who have experienced trauma and/or grief, and includes eight treatment components for children ages 5-18 and their primary caregivers when available. Through a prior feasibility study and pilot project (2009-2010) TF-CBT was adapted for use in Zambia and found it to be feasible with lay practitioners. Preliminary data from our pilot study suggested that it reduced trauma and shame-related symptoms.

Faculty from the Applied Mental Health Research Group at Johns Hopkins University (AMHR) trained the local staff of service providers in both assessment and treatment of children, using the assessment tools and TF-CBT manuals developed and validated during aforementioned pilot study. These assessment tools were used by staff to screen children in populations being served by our partner organizations in Lusaka, Zambia. Triage into the study was done on the basis of symptom and function scores, and those who agreed to be in the study were allocated at random either to receive TF-CBT immediately or to a treatment as usual (TAU) control group.

Results of the study indicated that TF-CBT was a powerful intervention for treating trauma-related symptoms among youth. Children in the study receiving TF-CBT had a clinically and statistically significantly greater reduction in both trauma symptoms and functional impairment as compared to children receiving treatment as usual. The full primary study results were published in JAMA Pediatrics in 2015. Overall, given the effectiveness of TF-CBT, we recommend that it be scaled up and integrated into services. Zambia would benefit from future evaluations on implementation variables such as who are the providers best served to deliver TF-CBT, what infrastructures could integrate TF-CBT, and the sustainability within different delivery systems.  


  • Serenity Harm Reduction Programme Zambia (SHARPZ)
  • Zambia Ministry of Health
Sanitation Hygiene Infant Nutrition Efficacy (SHINE)

Sub-study with the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial Characterizing Pregnancy Exposure to Multiple Mycotoxins and its Relation to Birth Outcomes (Zimbabwe)

The SHINE Trial, funded by the Bill & Melinda Gates Foundation, is a community-based trial in rural Zimbabwe recruiting women during the first trimester of pregnancy to investigate the independent and combined effects of improved water, sanitation and hygiene and/or improved infant feeding on child stunting and anemia at 18 months of age.  Birth outcomes such as miscarriage, stillbirth, prematurity, small-for-gestational age and stunted-for-gestational age are being measured, and there is strong evidence that mycotoxin exposures are prevalent and significant in this study population. Mycotoxins (including AF, FUM and DON) pose a threat to the safety of the global food supply, and may adversely affect the health of mothers and the health and development of their children. HRCI is supporting a sub-study within the larger SHINE trial to characterize pregnancy exposure to multiple mycotoxins and its relation to birth outcomes in SHINE. The over-arching hypothesis is that AF exposure, alone or in combination with FUM and DON, is an important cause of adverse birth outcomes globally. 


  • To describe the prevalence and severity of multiple mycotoxin exposures in a large representative sample of pregnant women in rural Zimbabwe.
  • To characterize the relationship between maternal serum aflatoxin-albumin  concentration during pregnancy and adverse birth outcomes preterm birth, low birth weight (LBW), small-for-gestational age (SGA) and short-for-gestational age in HIV-negative mothers. Pregnancy loss will also be explored as an outcome variable, but with less robust statistical power.
  • To explore the joint exposures of FUM, DON and AF in relation to risk of preterm birth.

This sub-study will generate novel knowledge about the burden of multiple mycotoxins (AF, FUM, DON) during pregnancy and the potential contribution of mycotoxin exposure to adverse birth outcomes. Our long-term goal is to understand the effect of mycotoxin exposure on maternal and child health in Zimbabwe and by doing so, to inform the development of more effective child health interventions and food safety policy globally. Preliminary results show that AFM1 was detected in 30% of pregnant women (median of exposed, 162.5 pg AFM1/mg creatinine; range 30-6046 pg AFM1/mg). Lab analysis and data analysis are ongoing.


  • Zvitambo
Reproductive Age Mortality Study (RAMOS II)

Repeat Reproductive Age Mortality Study (RAMOS II) (Afghanistan)

In 2011, a reproductive age mortality study (RAMOS) was implemented in three districts to measure changes in maternal and child mortality, maternal causes of death, and risk factors. It was designed to replicate the methods used in RAMOS I conducted in 2002 by the MoPH, the US Centers for Disease Control and Prevention and UNICEF. This 2002 study found that all indicators of mortality risk were among the highest recorded globally, increasing substantially with remoteness. These study findings initiated a strong response from the Afghan MoPH and the international humanitarian aid community. Enhancement of maternal and child health services became a major priority area and the focus of nearly a decade of health strategies and policies

In an effort to identify changes in mortality rates in the same geographic areas over time the MoPH and stakeholders approved a repeat of the RAMOS I study using the same two-stage survey methodology, as well as qualitative data collection to assess contextual influences affecting maternal mortality decline. The survey was completed among 27,000 households in Kabul City and Ragh district in Badakshan province – a sample size calculated to measure a decline of up to 25% in maternal mortality. Kabul and Ragh represent extremes of urban and rural contexts. . 

The results have shown significant improvements in maternal and newborn mortality risk, but also evidence of great disparity between urban and rural settings. Results have been submitted to the Lancet Global Health, and are being used by the MoPH and international partners to guide further action to save mothers lives. 

Maternal, Neonatal and Child Health, Family Planning and Nutrition Programs

Best practices, capacity-building and leadership for Maternal, Neonatal and Child Health, Family Planning and Nutrition Programs (Bangladesh)

This activity is a result of an expressed need from the Bangladesh Mission for specific activities.  The activity falls into three main program components: 1) documentation and dissemination of best practices, 2) capacity building of national institutions to provide strategic leadership training, 3) provide support for Improved Functioning of the Project Management and Monitoring Unit (PMMU), MOHFW, Bangladesh.  In February 2014, the following two workshops were held:

Strategic Leadership and Management Training Program for District Managers in Health and Family Planning (SLMTP) - the goal of this course was to motivate managers to lead with enthusiasm and to become proactive, ready to make small changes within their existing constraints, to the best of their abilities and to the betterment of their districts.  Topics that were discussed, and which are being addressed in the SLMTP curriculum, include:

  • Daily activities and responsibilities of health and family planning managers
  • Examples of leadership roles of health and family planning managers
  • Challenges that managers contend with in the field that test their leadership
  • Examples of triumphs in leadership
  • Examples of gaps in leadership that SLMTP could fill
  • How can managers be supported and motivated so they can exercise their abilities fully?

Documenting Best Practices in Maternal, Neonatal, and Child Health, Family Planning and Nutrition – the aim of to share “lessons learned” through the profiling of best practices, which will help development partners, government, professional bodies and NGOs to better understand how these practices are implanted, which could potentially lead to their scale-up across the country.  The participants discussed a wide variety of innovations in service delivery, such as reaching underserved communities and the use of community health workers and informal service providers, and prioritized a set of topics and specific best practices for further investigation and profiling.


  • Save the Children
  • Bangabandhu Sheikh Mujib Medical University (BSMMU)
Non-communicable Disease and Injuries

Non-communicable Disease and Injuries: Development of a Computer Modeling Program (global)

Preventive interventions can be used to reduce the burden of chronic conditions and injuries. However, countries are often reluctant to invest in prevention because such activities are often perceived to be costly and their gains are not always immediately valued. In addition such activities can carry high uncertainty on their actual effectiveness. The challenge is to identify the preventive strategies that will be most cost effective in specific countries.  A range of constraints will impact the specific choice of preventive services. The same constraints affect secondary and tertiary prevention as well as treatment models.

This activity aims to develop the first-stage of an analytical model to capture the burden of non-communicable diseases and injuries (NCDI) and how the burden is affected by selected interventions in four low- and middle-income countries (Guatemala, Bangladesh, Cambodia, and Kenya). The analytical model will be established in an Excel format to allow easy manipulation and transparency and it will focus on the three key objectives of the WHO Global Monitoring Framework: Surveillance and Monitoring, Prevention and Management, based on the outcome, exposure and health systems targets agreed upon.  The proposed model will provide evidence of reduction in mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases. We will be able to compare the reduction suggested from the modeling exercise to the NCD targets suggested from WHO targets.


Examining the existing global diseases estimates and computer platforms to identify areas of improvement given country specific data and modeling specification has been completed. 


Identification of 4-5 interventions and estimation of their range of impact and cost to ameliorate the burden of NCDI has been completed, and faculty at JHU are currently working on building the Excel-based analytical model to assess the impact of the identified interventions.


  • Tobacco control programs
  • Salt intake
  • Pills for hypertension and cholesterol
  • Seat belt use
USAID Meeting on Child Injury

On May 21 – 22, 2014, the United States Agency for International Development (USAID), the Johns Hopkins International Injury Research Unit (JH-IIRU) and the Institute of International Programs (IIP) jointly organized a workshop on “Child injuries in low and middle income countries” in Baltimore, MD, USA. The meeting was sponsored under the Health Research Challenge for Impact (HRCI) agreement between USAID and the Johns Hopkins Bloomberg School of Public Health. The overall goal of the workshop was to identify knowledge gaps in unintentional childhood injuries for five major injury mechanisms – road traffic injuries, drowning, burns, falls and poisoning – and to explore opportunities for addressing this burden. More than 40 child injury and child health experts from diverse disciplines, sectors and LMICs attended this workshop. 

International Health professor and director of IIP, Bob Black opened the meeting. JH-IIRU director, and Associate Chair of International Health, Professor Adnan Hyder discussed the prospects and challenges of child injuries at the global level. Dr. Olakunle Alonge, JH-IIRU faculty member who is leading the Unit’s work on Saving of Lives from Drowning in Bangladesh (SoLiD) project, discussed effective interventions for child injury and quality of data sources, as well as provided a summary and next steps for the meeting. Also participating from JH-IIRU was Dr. Ricardo Pérez-Núñez, who was a postdoctoral fellow with the Unit.

Five major themes emerged from the workshop: 1) that interdisciplinary and inter-sectoral engagement are important for child injuries; 2) more information with higher quality on epidemiology and risk factors of child injuries in LMICs is still needed; 3) there is a need to define and engage in opportunities for conducting new studies on child injury prevention interventions in LMICs; 4) there is a need to start the process of defining and implementing a “package” of child injury interventions for LMICs; and 5) a “political map” for child injury prevention is needed.

Some of the recommendations that emerged from this meeting include steps to: promote engagement between child health and child injury groups so that they can learn from each other; develop new data sources to support the burden of diseases and the epidemiology of child injuries in LMICs; update the 2008 WHO/UNICEF World Report on Child Injuries Prevention; conduct a systematic review on child injury and intervention effectiveness from LMICs; develop and test a “package of interventions” for child injury; and conduct a global review of policies and plans for child injury prevention.

The workshop was successful in highlighting both the lack of knowledge and potential pathways for short- and long-term investments in addressing the burden of child unintentional injuries in LMICs.

Implementation Research and Delivery Science (IRDS)

This work involved active participation in “The Collaboration for Implementation Research and Delivery Science” consisting of USAID, WHO’s Alliance for Health Policy and Systems Research (AHPSR), the World Bank, the TRACTION Project, and other stakeholders to support the development of IRDS. The JHU team has actively participated with the administrative team in a number of areas, including: 1) Jointly convening and facilitating meetings to build consensus about defining the field and key steps to be taken; 2) Supporting work on developing a Lancet Series, including authoring two of the papers; 3) Supporting the development of case studies and materials for promoting IRDS.

  • Implementation Research and Delivery Science Field Building. The convening activities included a set of structured and consultative international meetings which aimed to bring together different IRDS players to identify problems and opportunities related to IRDS, build consensus in describing the field, showcase useful examples and develop priorities for action. This series of meetings include: Developing and finalizing the Guide “Implementation Research in Health: A Practical Guide (Geneva, 2012); consultations on the priorities for statement on IRDS (Washington, April 2014 & Accra, July 2014); launch of the “Statement on Advancing Implementation Research and Delivery Science” at the Health Systems Global Conference (Cape Town, October 2014); and two Lancet series writing workshops (Washington, November, 2015 and Montreux April, 2016).
  • Lancet Series on IRDS. JHU led the conceptualization and negotiations to obtain a Lancet series on IRDS, and collaborated on facilitating the preparation meetings, paper development, including leading on some of the papers.  
  • Systematic Review of IRDS papers in LMICs. A systematic review of SCOPUS database was conducted to identify peer-reviewed literature on implementation research and delivery science (IRDS) in low- and middle-income countries (LMICs). The review covered the period of 1998-2014 and identified 7,066 records. Title and abstract screening were conducted to identify publications that were research or evaluations conducted in health or public health in an LMIC addressing an implementation issue.  This screening reduced the number of records to 1,596, which were then abstracted for a number of relevant fields.  Descriptive analyses were conducted along with an in-depth qualitative review of 17 articles identified as potential exemplars of IRDS publications.  These findings have formed the basis for a paper being written for the upcoming Lancet series on IRDS.
  • Supporting the development of Case Studies and Materials for IRDS. This work was done through participation on the ad hoc inter-agency committee supporting IRDS, and by supporting a graduate student to work at WHO Alliance for Health Policy and Systems Research (AHPSR) to help prepare case studies materials and protocols. Summary materials on IRDS have been produced through WHO, as well as case studies protocols, a call for case studies, and draft case studies on the application of IRDS. These will be curated at the WHO AHPSR website, and with presentations at the Vancouver Global Health Systems Symposium.  
Child Injury in Ethiopia

A large proportion of injury deaths in Ethiopia occur among children. It is estimated that of the 68,948 total injury deaths in 2012, 13,002 deaths were among children under 5 years and 9,267 among children 5-14 years old. It is therefore important for stakeholders to pay attention and take immediate actions to address the burden of injuries among children in Ethiopia.

The Johns Hopkins International Injury Research Unit (JH-IIRU) is committed to reducing the burden of child injuries around the world. In June 2015, JH-IIRU launched the Child Injury Project in Ethiopia funded through HRCI by USAID. The main objective of this project is to gain a better understanding of the burden of injuries and the underlying risk factors, as well as to propose immediate actions to confront the burden.

Initial literature reviews were conducted and draft reports on the burden of child injury and a policy analysis on child injuries were drafted. In December 2015, JH-IIRU team members including assistant scientists Qingfeng Li and, Kunle Alonge, along with USAID senior research advisor, Collene Lawhorn, traveled to Addis Ababa, Ethiopia to conduct site visits and attend collaborators’ meetings.

While there, meetings and interviews were conducted with: the child health team at the USAID mission in Addis Ababa, administrators from St. Paul Hospital, representatives from the Ethiopian Pediatrics Society, academics at Addis Ababa University, members of the Central Agency of Statistics and representatives from the Ministry of Health. During the meetings, the team revised two reports: The burden of child injuries report and a policy situation report. The researchers plan to develop these reports into two journal articles. In addition, they identified a network of potential stakeholders for advancing child injury work and developed a concept note for the upcoming stakeholders’ meeting. JH-IIRU is coordinating with USAID HQ/Addis mission and a network of stakeholders to co-convene a consultative meeting of in-country stakeholders and other leading international and local institutions working on injuries with relevant partners.

Members from the JH-IIRU and USAID will be returning to Addis Ababa to facilitate the child injury partners meeting, present the situation studies on the burden of child injuries, build a consensus with the Ministry of Health on the outcomes/deliverables of the meeting and prepare for a large-scale stakeholders’ meeting.

In collaboration with the government of Ethiopia, USAID, NGOs, international and local academic institutions and other in-country stakeholders and partners, JH-IIRU will develop a proposal for the implementation of a child injury prevention package in Ethiopia. 

Care Seeking for Newborn and/or Maternal Complications

Systematic Documentation of Community-oriented Approaches to Improve Recognition of and Appropriate Care Seeking for Newborn and/or Maternal Complications in Sarlahi District, Nepal  

Skilled and timely care before, during and after childbirth can save the lives of women and newborn babies from preventable and treatable causes. There are many real and perceived barriers to accessing care, particularly for women in rural areas of low-income countries. Delays in receiving appropriate care can be important for many conditions, but delays of even a few hours in addressing an obstetrical emergency around the time of birth or the onset of sepsis in a neonate can be significant. In rural Nepal, reasons for low usage of free maternal and newborn health facilities remains unclear, despite health policy and programs that have aimed to remove financial and access- to- care barriers to services at primary health care facilities. Understanding the care seeking practice and what drives decisions (both facilitators and barriers) at family and at community levels for maternal and newborn complications is crucial.

This study aims to assess how women and caretakers identify maternal/newborn complications and the factors behind decision-making to seek care, along with an assessment of the quality of maternal and newborn care received at birthing centers and its influence on care seeking behavior and practices in rural Nepal. This is a mix-methods study currently being conducted in Sarlahi District, located in the southern plains of Nepal where the JHSPH affiliated Nepal Nutrition Intervention Project-Sarlahi (NNIPS) research site is located and is nested within an ongoing large community randomized trial. Quantitative and qualitative data on illness recognition, decision making and care seeking behavior are collected through surveys with pregnant women and in-depth interviews and group interviews respectively. In addition, the quality of care of all the birthing centers in the study district is assessed through health facility audit to determine the availability of trained staff, equipment and supplies and through health worker interviews to assess health worker knowledge and training.