EVERY PREEMIE—SCALE 
Scaling, Catalyzing, Advocating, Learning, Evidence-Driven 
END-OF-PROJECT EVALUATION REPORT
JULY 2019
COOPERATIVE AGREEMENT NO. AID-OAA-A-14-00049 Every 
Preemie—SCALE
External evaluation reviewer: 
Anne-Marie Bergh, University of Pretoria
___________________________________________________________________________
Table of Contents
Acronyms
Acknowledgements
Executive Summary i
Outcome 1: An applied learning approach ii
Outcome 2: The implementation of Family-Led Care in Malawi v
Outcome 3: Preparing countries to focus on preterm and low birth weight care vi
Propelling the global agenda ix
Achievements in cross-cutting priorities x
1 Background 1
1.1 Beneficiaries of Every Preemie—SCALE 3
2 Evaluation Approach and Methods 4
2.1 Definition of “catalyze” and “catalyst” 5
2.2 Tool development 6
2.3 Data collection 6
2.4 Data management and analysis 7
2.5 Structure of the report and presentation of findings 8
2.6 Limitations of the evaluation 10
3 Accomplishments of Every Preemie—SCALE: “large mandate”, “limited funding” and “high 
expectations” 11
3.1 The Every Preemie project – “as a team they are very respected” 11
3.1.1 Relationship with the donor – “wish list exceeded their bandwidth or budget …” 12
3.2 Outcome 1: Applied learning through implementation research in four demonstration 
countries – “brave” and “ambitious” 12
3.2.1 Different models: questions, designs, geographies, timelines, partners 13
3.2.2 Implementation research: country highlights 16
3.2.3 Flexibility and responsiveness as hallmarks of managing implementation research 25
3.2.4 Value of research participation for individuals, teams, institutions – “the whole 
research was a great benefit” 26
3.2.5 The legacy of Every Preemie’s implementation research 28
3.3 Outcome 2: Targeted technical assistance to implement Family-Led Care in Malawi – 
“cutting edge stuff” 29
3.3.1 The Family-Led Care model 29
3.3.2 Implementation of the Family-Led Care model 30
3.3.3 Family-Led Care implementation – did it work? 32
3.3.4 The way forward – “the whole concept of Family-Led Care is here to stay” 38
3.4 Outcome 3: Preparing countries to focus on preterm and low birth weight care – “a 
platform for action and for strategic planning” 39
3.4.1 Development of global documents – “a significant contribution” 39
3.4.2 Tracking global coverage of PTB/LBW and country profiles – “good for advocacy” 40
3.4.3 Continuum of Care for Prevention of Preterm Birth, Management of Preterm Labor 
and Delivery, and Care of the Preterm and Small Newborn 44
3.4.4 Multi-country antenatal corticosteroids landscape analysis 44
3.4.5 Joint statement on preterm birth 46
3.4.6 Multi-country situation analysis of inpatient care of newborns and young infants –
clinical care and “a snapshot of systems” Error! Bookmark not defined.
3.4.7 Survive and Thrive: Transforming care for every small and sick newborn 469
3.4.8 Evidence synthesis on nurturing care of the small and sick newborn 49
3.5 Moving forward with the global agenda on preterm birth – “foresight” and “leadership” 50
3.5.1 The PTB/LBW Technical Working Group – “very successful to bring top leaders 
together on technical subject matters” 50
3.5.2 Do No Harm Technical Brief Series – “a big piece” with “longstanding benefit” 52
3.5.3 Advocacy, media and meeting participation 54
3.5.4 The Legacy of Every Preemie’s global engagement 56
4 Achievements of Every Preemie in cross-cutting priorities 57
5 Every Preemie—SCALE “catalyzed this global effort” – “a great learning opportunity” 59
5.1 Recommendations 61
Annexures 63
A. Evaluation tools 63
B. Details of the implementation research studies 79
C. Answering the evaluation questions for Outcome 1 84
D. Answering the evaluation questions for Outcome 2 85
E. Organizations contributing to the development of the Do No Harm briefs 87
F. Blog posts and press releases 88
G. Answering the evaluation questions for Outcome 3 90
List of tables
Table 1. Overview of target audiences and data collection methods 6
Table 2. Breakdown of types of interview participants 8
Table 3. Country partnerships 14
Table 4. Perceived catalytic effect of the implementation of the Family-Led Care model 33
Table 5. Topics discussed at the Technical Working Group meetings 51
Table 6. Topics of the Do No Harm technical brief series 53
List of figures
Figure 1. Every Preemie Results Framework 2
Figure 2. Project life cycle and accomplishments 3
Figure 3. Different levels of engagement in the Every Preemie—SCALE project, by outcome 9
Figure 4. Study site maps 16
Figure 5. Basic components of the Family-Led Care model 30
Figure 6. Health facilities covered by Family-Led Care in Balaka district, Malawi 31
Figure 7. Perceived influence of the implementation of Family-Led Care in Balaka district 35
Figure 8. Map of USAID priority countries 41
Figure 9. Performance of the dashboard elements over time 43
List of boxes
Box 1. Implementation research highlights from Bangladesh 17
Box 2. Implementation research highlights from Ethiopia 19
Box 3. Implementation research highlights from India 21
Box 4. Implementation research highlights from Malawi 23
Acronyms
ACNM American College of Nurse-Midwives 
ACS Antenatal corticosteroids 
AG Abdominal girth 
ASSIST Applying Science to Strengthen and Improve Systems
CHW Community health worker
COINN Council of International Neonatal Nurses 
DRC Democratic Republic of Congo
ECEB Essential Care for Every Baby 
ECSB Essential Care for Small Babies (ECSB) 
ENAP Every Newborn Action Plan
FMOH Federal Ministry of Health 
GAPPS Global Alliance to Prevent Prematurity and Stillbirth 
GOI Government of India 
HSA Health surveillance assistant (Malawi)
ICN International Council of Nurses 
IRB Institutional Review Board
KMC Kangaroo mother care 
LBW Low birth weight 
MCH Maternal and child health
MCSP Maternal and Child Survival Program
MOH Ministry of Health
MOHFW Ministry of Health and Family Welfare
NGO Non-governmental organization
ONSE Organized Network of Services for Everyone’s Health Activity
PAG Project Advisory Group 
PCI Project Concern International 
PGIMER Postgraduate Institute of Medical Education and Research
PTB Preterm birth 
PTB TWG-ICS PTB/LBW Global Technical Working Group on Implementation Challenges and Solutions
QI Quality improvement 
SCALE Scaling, Catalyzing, Advocating, Learning, and Evidence-driven
SFH Symphysis fundal height 
SNL Saving Newborn Lives
TWG Technical Working Group (PTB TWG-ICS)
UN United Nations
UNCoLSC United Nations Commission on Life-Saving Commodities
UNICEF United Nations Children’s Fund 
US United States of America
USAID United States Agency for International Development
USAID/W USAID/Washington 
WHO World Health Organization 
Acknowledgements
A sincere thank you to all the informants who were willing to give their time for an interview and share 
their views. Irene Kamanga’s meticulous organization of the logistics for the evaluator’s visit to Malawi is 
much appreciated. Enormous appreciation goes to Mindy Hochgesang who worked closely with me to 
organize the evaluation scope of work, tools and processes and for her leadership in providing 
comments and input to draft documents. Thank you also to the Project Director, Judith Robb-McCord, 
and team leads, Jim Litch and Patrice White, for the intellectual sharing and to Rebecca Freeman and
Chelsea Dunning for assisting with all the administrative matters around this evaluation. The assistants 
and administrators at the Centre for Fetal, Maternal, Newborn and Child Health Care Strategies of the
University of Pretoria are also thanked for their contributions and support, especially Riaan Pretorius,
Lumbani Tshotsetsi and Cathy Bezuidenhout.
Declaration. The evaluator assisted the Malawi research teams with their Implementation Research 
protocol development, data analysis and report writing.
i
Executive Summary
Every Preemie—SCALE (henceforth called “Every Preemie”) is nearing the end of a five-year award from 
the USAID/Washington (USAID/W) Bureau for Global Health. The project was awarded September 1, 
2014 and ends August 31, 2019. A team of three organizations received the award: Project Concern 
International (PCI) (the prime partner); the Global Alliance to Prevent Prematurity and Stillbirth (GAPPS); 
and the American College of Nurse-Midwives (ACNM). 
The partners worked together collaboratively across the project while each led in specific areas: 
• PCI led overall project management, global partner engagement, implementation of Family-Led 
Care in Malawi and supported research, learning and global communications; 
• GAPPS led evidence, research and learning activities; and 
• ACNM led health provider capacity building and performance improvement activities in Malawi 
and supported the development of global tools and products.1
As designed, Every Preemie’s primary objective was to serve as a catalyst for change: accelerating and 
supporting innovative approaches for evidence-based preterm birth (PTB) and low birth weight (LBW) 
interventions in 24 USAID priority maternal and child health countries.2 Through its work, Every Preemie 
sought to expand the global conversation, stimulate country-specific adoption of these interventions, 
overcome obstacles to their delivery, and increase the coverage and utilization of services.”3
Did Every Preemie succeed as a catalyst for change?
There were multiple stakeholders with whom Every Preemie engaged and many who benefitted from 
the roll out of project initiatives. To gauge its success and determine the degree to which the project 
affected or catalyzed change, Every Preemie contracted the University of Pretoria to conduct a thorough
evaluation. Several tools were developed and used to collect data, including online surveys, 
questionnaires, e-mails, and interviews. Evaluation questions centered on the project’s three main 
outcomes: 
• Outcome 1: Improved translation of evidence into action
• Outcome 2: Increased capacity of local, national and global entities to scale-up and sustain the 
utilization of high impact interventions 
• Outcome 3: Increased prioritization of PTB and LBW with in-country decision-makers and other 
relevant stakeholders at global and national level
 1 https://www.everypreemie.org/
2 Afghanistan, Bangladesh, Democratic Republic of Congo, Ethiopia, Ghana, Haiti, India, Indonesia, Kenya, Liberia, 
Madagascar, Malawi, Mali, Mozambique, Myanmar, Nepal, Nigeria, Pakistan, Rwanda, Senegal, South Sudan, 
Tanzania, Uganda, Zambia
3 Work plan Year 1 
ii
This Executive Summary highlights major findings for each outcome. The full End-of-Project Evaluation 
Report illustrates the deeper details and uses
extensive quotes to form an authentic narrative
reflective of themes and findings.
Outcome 1: An applied learning 
approach
The Every Preemie team, in collaboration with 
USAID/W and USAID field missions, selected four 
demonstration countries to receive support for 
implementation research: Bangladesh, Ethiopia,
India, and Malawi. The goal was to learn more about 
specific preterm birth and low birth weight 
(PTB/LBW)-focused interventions, obtain evidence of 
what worked during implementation, and determine 
how this knowledge could be shared with and applied 
by stakeholders to replicate and scale successful 
models. The Every Preemie team designed its
implementation research agreements and 
partnerships with this in mind; and committed to 
strengthen the capacity of local research 
organizations and other partners through mentoring 
and technical support.
In alignment with the vision of Every Preemie, each 
country-specific study “was developed in 
collaboration with the government and local partners 
to address questions central to moving evidence to 
action in an effective and feasible way within their 
unique settings.”4 This directly linked their work to 
the applied learning approach promoted in Outcome 
1.
Country-specific implementation research models
Each country had a contextually appropriate model of 
implementation research and a focus that was negotiated with local partners: 
1. Bangladesh provided an opportunity to advance work on maternal gestational age assessment by an 
already existing project led by the Projahnmo Research Group.
2. The goal of the Ethiopian study was to “inform the development of recommendations to the Federal 
Ministry of Health (FMOH) on national programming to support the implementation, coverage and 
 4 Biannual Report, Year 5
SCALING—expanding the Family-Led Care 
model in Malawi to 16 new districts; with other 
countries showing interest in adapting the model.
CATALYZING—sparking global and national 
dialogue to bring attention to PTB and LBW and 
care of the small/sick newborn; using 
implementation research results to build the 
national response to PTB and LBW; developing 
products and tools to accelerate information￾sharing and action.
ADVOCACY—serving as the active global 
champion for essential newborn care and care of 
the vulnerable newborn; supporting national 
engagement in IR countries and in others to bring 
attention to PTB and LBW.
LEARNING—broadly disseminating findings 
from landscape analyses; supporting the 
development and dissemination of global 
products and publications; sharing 
implementation research findings to influence 
country level action.
EVIDENCE-DRIVEN—ensuring that global and 
national stakeholders had access to the most 
recent evidence on the safe and effective care of 
small and sick newborns; generating evidence for 
country programming.
BUILDING SCALE 
iii
quality of select interventions and services within the public health care system to improve 
outcomes for small and sick newborns in Ethiopia.”5
3. In India, the aim was to inform policy and operational guidelines to improve clinical practice, to 
revise the current Government of India (GOI) antenatal corticosteroids (ACS) operational guidelines 
and to assess the implementation of the revised ACS operational guidelines in two districts in 
Haryana State.6
4. In Malawi, Every Preemie assessed the implementation of its new model of care for early/small 
newborns – Family-Led Care – in Balaka District.
All four implementation studies occurred in specific geographic areas, as depicted in the study site maps
below.
Study site maps
 5 Ethiopia study protocol
6 India study protocol
iv
The value of participating in implementation research
Those interviewed for this End-of-Project Evaluation Report (informants) provided feedback on the 
value of participating in the research for individuals, institutions and ministries.
Individuals valued the entire research process and experience, particularly learning about the context of 
health facility-based research. Some saw benefits in making research efficient and more productive and 
collaborating with other partners and non-governmental organizations (NGOs). Those in group 
interviews mentioned being able to improve their own skills and perspectives through their involvement 
with Every Preemie. 
Institutions benefited from increased visibility and recognition that opened doors to future 
collaborations. One research team mentioned that the experience helped with other grant applications.
Ministries of health emphasized the importance of involving the government at national and sub￾national levels from the outset to facilitate a sense of ownership and greater adoption of 
recommendations. Involving Ministry of Health (MOH) officials was not without challenges, however, 
due to issues related to their availability.
Driving ambitious innovation
Every Preemie’s commitment to implementation research was considered both ambitious and
innovative. In each country, the research model evolved to leverage existing situations, priorities and 
resources. Each had its own history, including varying levels of engagement by principal investigators 
and study coordinators.
Yet all experienced great success against their individual agendas. With extensive involvement from 
U.S.-based colleagues and in-country stakeholders in Ethiopia, India and Malawi, all countries completed 
their research. As of this evaluation, all were positioned to share findings both globally and at the 
national level through various meetings and via peer-reviewed journal publications. 
Findings across the board are significant and relevant. 
• Bangladesh findings demonstrate that ultrasound technology remains the gold standard for 
gestational age estimates, even in low- and middle-resource settings. These findings will push 
the global community to continue to explore new ultrasound technologies for these settings. 
• The depth of analysis in the Ethiopia public health system for care of the early/small/sick 
newborn is noteworthy. Exploring different geographies and providing insights into obstacles, 
challenges and opportunities will strengthen the government’s commitment to building the 
public health system as they continue to work towards improvements in under-five and 
newborn outcomes. 
• Government representatives in India are engaged in a robust debate regarding the safe and 
effective use of ACS for women in imminent preterm labor as a result of Every Preemie–
Postgraduate Institute of Medical Education and Research (PGIMER) research. It is critically 
important that ACS is used appropriately as the results of unsafe use can lead to poor maternal 
and newborn outcomes including death. Identifying weaknesses in the previously launched ACS 
operational guidelines has enormous value as they advance their work in maternal and newborn 
health.
v
• In Malawi, the Family-Led Care model has been well received and is currently being scaled 
throughout the country. While there are areas for improvement, the model is the first of its kind 
in Malawi. In a resource-limited environment, it is crucial to identify innovative ways to engage 
families in the care of their early/small baby, build health care provider competence, and link 
community health workers (health surveillance assistants (HSAs), in this case) to households 
post-discharge. 
Outcome 2: The implementation of Family-Led Care in Malawi
With USAID/Malawi field support, Every Preemie worked with the Balaka District Health Management 
Team (DHMT) to design and implement an innovative and new model of care for early and small babies 
– Family-Led Care. The model is designed to improve the quality of care in facilities; empower families to 
participate in the care of their small babies in the facility and at home; and strengthen post-discharge 
follow-up care. Family-Led Care was implemented in nine health facilities in the district, including Balaka 
District Hospital.
The services pathway of the model focused on improving provider skills and quality of care in KMC units 
through clinical training and capacity strengthening, quality improvement (QI) processes and the 
procurement of essential supplies and equipment:
1. Capacity strengthening through training. From 2016 through 2018, 128 health care providers (nurse￾midwives, medical assistants and clinical officers) from the designated health facilities were trained 
in Essential Care for Every Baby (ECEB) and Essential Care for Small Babies (ECSB). These providers 
and 20 support staff (mainly hospital attendants) were trained in Family-Led Care. To strengthen the 
link from facility to home, 93 HSAs were also trained on Family-Led Care. 
2. Quality improvement. Every Preemie worked with MaiKhanda Trust, an NGO specializing in QI, to 
focus on PTB/LBW interventions in the target facilities and create stronger links between 
communities and facilities. Mentors from the district hospital were nominated to conduct monthly 
coaching visits to improve regular monitoring of and documentation (data quality) for preterm/LBW 
babies.
3. Infrastructure, equipment and supplies. Prior to the design and implementation of the model, two 
health facility assessments were conducted to identify clinical care needs for early/small babies in 
Balaka district. This was followed by infrastructure upgrades, the procurement of equipment (e.g. 
weighing scales) and supplies (e.g. feeding cups).
The practices pathway focused on families continuing care of their baby after returning home: 
1. Mothers and families were taught to care for their early/small newborn during their stay in the 
health facility, and upon discharge, received a reminder leaflet and monitoring form to help them 
continue caring for their baby and recognize danger signs that require immediate care from the 
facility; 
2. HSAs and Care Group Lead Mothers were introduced to Family-Led Care as part of their training in 
maternal health and essential newborn care; and 
3. Community sensitization continued through existing structures, such as meetings and special events.
vi
The link between facility and community is the referral system that ensures the mother and family 
continue caring for their small baby at home, are able to identify danger signs and seek immediate 
treatment, and regularly return to the facility for post-discharge follow-up of the baby.
To implement the model, a Family-Led Care package of materials and tools was developed. These 
included a flipbook with messages on the care of preterm/LBW newborns for providers to use at 
admission to KMC; a take-home leaflet with a summary of key messages; an easy-to-use newborn 
monitoring form for families to use in the facility and at home; and a feeding chart for clinical providers 
to use during inpatient care. These materials also formed the basis for a Global Family-Led Care Package 
which can be adapted for use in other countries.7
Measuring success
In addition to the implementation research study assessing the Family-Led care model in Malawi, data 
were collected from MOH facility records to measure the model’s effect. The model’s greatest influence 
and impact, supported by review of MOH data, is improved health outcomes for preterm/LBW 
newborns and higher survival rates. Specifically, there was a reduction of in-facility preterm/LBW
newborn deaths during the project period, from 11% in 2016 to 4% in 2018 (p=0.018). This is a 
significant finding.
There was little observed improvement in the percentage of KMC newborns with adequate weight gain 
at the first facility-based follow-up visit. However, data quality/completeness for this indicator 
(complete recording of follow-up date and weight) improved from 16% in 2016 to 69% at the end of 
2018. 
While Every Preemie’s work centered on facilities in Balaka district, the project built a strong network of 
stakeholders, including the national MOH Reproductive Health Directorate, implementing partners such 
as the National Safe Motherhood Working Group, and health care providers at the community level. This 
network coupled with the key inputs left in place by the project, will help to facilitate future 
implementations by the MOH and other USAID partners.
For all of these reasons, the End-of-Project Evaluation found many informants optimistic about the 
Family-Led Care model and the idea that it is “here to stay”.
Outcome 3: Preparing countries to focus on preterm and low birth weight care
To prepare countries to focus on preterm and low birth weight care, Every Preemie contributed to eight 
pivotal global activities. These include:
1. Tracking and monitoring country level indicators in 24 USAID priority countries; 
2. Developing a PTB/LBW Continuum of Care matrix;
3. Conducting a multi-country ACS landscape analysis; 
4. Leading efforts for a Joint Statement on Preterm Birth; 
 7 https://www.everypreemie.org/family-led-care-global/
vii
5. Collaborating as part of the team behind the WHO document Survive and Thrive: Transforming 
care for every small and sick newborn; 
6. Conducting a multi-country situation analysis of inpatient care for small and sick newborns; 
7. Developing the Global Family-Led Care package; and 
8. Synthesizing global evidence on nurturing care for small and sick newborns.
Tracking and monitoring country-level indicators
As part of the commitment to inspire action in the 24 USAID priority countries, Every Preemie compiled 
data on PTB and LBW and created individual country profiles. These provide a national-level report on 
the status of the prevention and care for preterm/LBW babies for each country and highlight related risk 
factors and coverage of important interventions. Profiles were launched in November 2015 at an Every 
Preemie-sponsored World Prematurity Day event on Capitol Hill in Washington, DC, as part of a global 
multi-partner call-to-action. Country profiles were updated in 2017, with a new profile added for 
Myanmar. Further updates are expected in 2019. According to the Every Preemie annual and biannual 
reports, the profiles were disseminated via USAID missions in these priority countries as well as at 
various events. 
In addition to profiles, a country-level tracking and monitoring system was developed, featuring a
dashboard indicator to track clinical standards and operating procedures based on the WHO 
Recommendations on interventions to improve preterm outcomes. 
A Continuum of Care matrix
Another early product designed and disseminated by Every Preemie was the PTB Continuum of Care 
matrix. It highlights “priority evidence-based interventions for the prevention of PTB, the management 
of preterm labor, and care of the preterm and small newborn”.8 The matrix serves as a roadmap for 
partners to design and plan activities related to preterm birth and LBW and is the first time this type of 
information and guidance has been organized and framed in this manner. The matrix was disseminated 
to USAID missions and country-level stakeholders, as well as during meetings in Washington, DC and 
around the world. However, the End-of-Project Evaluation found that awareness levels for the matrix 
could be higher.
Multi-country antenatal corticosteroids landscape analysis
One of the project’s more hands-on activities involved the Antenatal Corticosteroids for Women at Risk 
of Imminent Preterm Birth in the Democratic Republic of the Congo, Ethiopia, Malawi, Nigeria, Sierra
Leone, Tanzania and Uganda: A Policy and Implementation Landscape Analysis. It was conducted in 
seven of the eight Pathfinder countries of the UN Commission on Life-Saving Commodities (UNCoLSC) in 
sub-Saharan Africa on behalf of the UNCoLSC Newborn Health Technical Resource Team. Results were 
 8 Annual Report Year 1
viii
published in 2016 as an internal report and shared at a UNCoLSC ACS Technical Working Group meeting. 
In 2018 it was published in Global Health: Science and Practice.
9
Joint statement on preterm birth
Every Preemie was also involved in developing and reviewing three international joint statements 
disseminated in 2016/7 to demonstrate professional associations’ commitment to action and the imple￾mentation of key World Health Assembly resolutions such as the Every Newborn Action Plan (ENAP), the 
Global Strategy for Women’s, Children’s and Adolescents’ Health, and the 2015 WHO recommendations 
on interventions to improve preterm birth outcomes. Every Preemie led the development of the Joint 
Statement International WHO Recommendations on Interventions to Improve Preterm Birth Outcomes: A 
Commitment to Action from Professional Health Organizations. In addition, the Every Preemie team 
contributed significantly to the development of the statements on Kangaroo Mother Care (led by Saving 
Newborn Lives [SNL]) and Quality of Care (led by the USAID-funded ASSIST project).
The Joint Statement on Preterm Birth recognizes the important and collaborative role of national 
professional associations to assist countries to update policies and programs and support the safe and 
effective implementation of the WHO recommendations. Five relevant international professional 
associations reviewed and endorsed this joint statement, namely the Council of International Neonatal 
Nurses (COINN), the International Confederation of Midwives, the International Council of Nurses (ICN), 
the International Federation of Gynecology and Obstetrics, and the International Pediatric Association. 
The joint statements were distributed through Every Preemie’s networks, with the intention to also have 
them disseminated through the respective international professional association memberships. 
Collectively, according to Every Preemie, the three joint statements “represent a significant global move 
to catalyze action for improved maternal and newborn health in low resource settings”.10
Multi-country situation analysis
Midway through the project cycle, at the request of USAID/W, Every Preemie broadened its scope 
beyond PTB and LBW to include a focus on sick newborns and inpatient newborn care. 
There is a need to define, standardize, and mainstream inpatient care of small and sick newborns on the 
essential newborn care platform. Every Preemie’s expanded focus include the design of a multi-country 
situation analysis of inpatient care of newborns and young infants in order to gain greater
understanding of the service readiness landscape. Every Preemie led the development of the protocol 
and tools for this analysis in collaboration with other partners. The tools were tested in Malawi and 
Nepal; posted on the Every Preemie website;
11 and made available to low- or middle-income countries
wishing to assess service readiness and quality of care provided to inpatient small and sick newborns. As 
of the End-of-Project Evaluation, Ghana, Nepal, Rwanda, Tanzania and Uganda had completed or were 
 9 Greensides D, Robb-McCord J, Noriega A, Litch J. Antenatal Corticosteroids for Women at Risk of Imminent 
Preterm Birth in 7 sub-Saharan African Countries: A Policy and Implementation Landscape Analysis. Global Health: 
Science and Practice. 2018;6(4):644-656. 10 Annual Report Year 2 11 https://www.everypreemie.org/technical-materials/
ix
in the process of completing the situation analysis. The project plans to create a multi-country profile of 
key findings across Ghana, Nepal, Rwanda and Uganda.12
Survive and Thrive: Transforming care for every small and sick newborn
Every Preemie collaborated with WHO, UNICEF, USAID, the Bill & Melinda Gates Foundation, the London 
School for Hygiene and Tropical Medicine and others to design and develop a global document on 
inpatient care of the small and sick newborn, titled Survive and Thrive: Transforming care for every small 
and sick newborn. It targets country-level managers in ministries of health “with a goal to provide a 
programmatic framework for integrating this critical work into newborn inpatient care.”13 Every Preemie 
provided the project coordinator and the Senior Director, who was one of four managing editors and a 
lead author for the publication. The GAPPS Evidence and Learning Lead provided publication review. The 
Key Findings Report14 was launched on December 13, 2018 at the global Partnership for Maternal, 
Newborn and Child Health Partners Forum in New Delhi, India. The full document was launched at the 
World Health Assembly in May 2019; and a related panel discussion was held at the Vancouver Women 
Deliver conference in June 2019. 
Evidence synthesis on nurturing care
In Year 5, Every Preemie worked with WHO, UNICEF, USAID and the USAID-funded MCSP project to
design and conduct an evidence review around nurturing care for small and sick newborns. The evidence 
synthesis was designed based on the Nurturing Care for Early Childhood Development—A Framework 
for Helping Children Survive and Thrive to Transform Health and Human Potential. The report will 
include a summary of findings from peer-reviewed literature, country case studies (including country￾specific grey literature) and a gap analysis. It is expected to be finalized in July 2019. Findings will be 
used by WHO and UNICEF to develop guidelines for nurturing care to complement the clinical standards 
of care for small and sick newborns currently in development (with other partners including Every 
Preemie).
Propelling the global agenda
From 2015 through 2018, Every Preemie convened six meetings of the PTB/LBW Global Technical 
Working Group on Implementation Challenges and Solutions (PTB TWG-ICS), a group of more than 200 
thought-leaders representing a wide range of clinical and public health disciplines.15 The meetings 
provided a multidisciplinary forum for sharing “emerging evidence, relevant research and learning 
across the range of PTB and LBW interventions and implementation in low-income countries”.16 The 
TWG explored opportunities to address gaps in critical knowledge and identify priorities for future 
implementation research. This evaluation informants considered the TWG’s contribution necessary for 
maintaining momentum and moving the global preterm birth agenda forward.
 12 Tanzania data were not ready for inclusion in the multi-country document.
13 Annual Report Year 3 14 https://apps.who.int/iris/bitstream/handle/10665/276655/WHO-FWC-MCA-18.11-eng.pdf?ua=1 15 Annual Report Years 3 & 4 16 Annual Report Year 4
x
Do No Harm Technical Brief Series
A key spinoff of the TWG was the development of technical briefs on the safe and effective use of 
inpatient newborn care interventions in low-resource settings. The “Do No Harm” series provided
evidence-based guidance on how to avoid harm and improve newborn health outcomes and were 
grounded in WHO guidelines and recommendations. “The target audience for the briefs is a wide range 
of policymakers, program managers and clinicians with the intended outcome of guiding decision￾makers to integrate the WHO recommendations in their country in a safe and effective way.”17 These
briefs were shared at numerous meetings and conferences; and, more than 4,300 copies have been 
downloaded to date from the Every Preemie website. 
Advocacy, media and meeting participation
Most of Every Preemie’s activities included an advocacy component through sharing evidence for best 
practices and by promoting the implementation research conducted in the four demonstration 
countries. Major advocacy efforts involved creating and maintaining a website; supporting social media;
participating in international awareness days and campaigns; and using meetings and conferences to 
raise awareness for Every Preemie, its expertise, and its cause. The Every Preemie website launched in 
May 201518 and has since garnered more than 200,000 page views and 30,000 downloads.
Achievements in cross-cutting priorities
Every Preemie’s Results Framework features six cross-cutting priorities: (1) local capacity strengthening, 
(2) gender equity, (3) knowledge management, (4) action-oriented advocacy and awareness raising, (5) 
access to commodities and (6) sustainability.
• Local capacity strengthening19 was evident in all four demonstration countries vis-a-vis work 
with the local research partners. In Malawi, this extended to the improvement of knowledge 
and skills in the care of preterm/LBW newborns by health workers and professionals, support 
staff, HSAs and community volunteers. A key element of the Family-Led Care model was also 
building the capacity of families to actively engage in the care of their babies during inpatient 
KMC and at home.
• Gender equity appears to have received less attention and should benefit from more careful 
thought in future projects. In Balaka district in Malawi, however, there were anecdotal reports 
of male involvement in community awareness activities (e.g. fathers’ groups) and observations 
of fathers carrying their babies skin-to-skin. 
• Knowledge management and shared learning are central to Every Preemie and are linked to 
action-oriented advocacy and awareness raising. The project’s mandate to share evidence 
through a variety of means – including the implementation research, Joint statements, TWG, 
conference attendance, web and social media campaigns, and Do No Harm briefs – heightened 
awareness and influenced meaningful action. 
 17 Annual Report Year 3 18 www.everypreemie.org 19 We used a broad definition here of local capacity strengthening. 
xi
• Access to commodities was implicated in the implementation research in Ethiopia, India and 
Malawi. In Ethiopia, the research looked at the availability of basic commodities for newborn 
care; and, in India, research focused on the safe and effective use of ACS across levels of care. In 
Malawi, the Family-Led Care model implementation included procurement of essential items for 
the care of early/small newborns (e.g. weighing scales, feeding tubes and cups). The project also 
looked carefully at the use of ACS in seven countries via the landscape analysis and included 
commodities in the situation analysis for inpatient newborn care.
• Sustainability was addressed indirectly, as the Every Preemie project focused on inspiring action 
and preparing the landscape for future implementation of PTB/LBW interventions.
USAID/Washington’s investment in the Every Preemie—SCALE project ensured that a consistent 
spotlight was put on preterm birth, low birth weight and inpatient newborn care over the last five years. 
Every Preemie—SCALE was appreciated by global and national partners and was commended for its 
engagement in the global newborn health arena and for bringing attention to these critical topics. The 
global conversation is evolving and there is significant attention being paid to moving global evidence to 
action at the country level. Every Preemie has been engaged in and led key conversations and activities 
at the global level that will influence country-level commitment to PTB/LBW and inpatient newborn 
care. At the same time, there is great interest in learning from countries, and Every Preemie’s research 
findings in Bangladesh, Ethiopia, India and Malawi will contribute significantly to the global body of 
knowledge while also influencing national action. 
“Every Preemie—SCALE was quite successful in bringing a new perspective 
to topics that were not otherwise being discussed and will definitely last 
into the future.” (GP04)
1
1 Background
________________________________________________________
Every Preemie is nearing the end of a five-year award from the USAID/W Bureau for Global Health. The 
project was awarded September 1, 2014 and ends August 31, 2019. A Consortium of three organizations
received the award: PCI (the prime partner); (GAPPS); and the ACNM. Each Consortium partner played 
unique and specific roles in global and country engagements and in implementation research activities: 
“PCI leads overall project management, global and partner engagement, and supports research and 
learning; GAPPS leads evidence, research and learning activities; and ACNM leads health provider 
capacity building and performance improvement activities”.
20
The project was designed to accelerate and support innovative approaches to expand the uptake of 
evidence-informed PTB/LBW interventions in 24 USAID priority countries.21 SCALE is the acronym for 
Scaling, Catalyzing, Advocating, Learning, and Evidence-driven, which summarizes the project’s five-year 
strategic objective as “to catalyze global uptake of PTB and LBW interventions, overcome obstacles to 
the delivery of interventions and services, and increase coverage and utilization of services.”22
According to two informants in the end-of-project evaluation, the conceptualization of Every Preemie 
had similarities with that of the Prevention of Postpartum Hemorrhage Initiative in that both focused 
specifically on high-priority global public health issues. Given their singular focus, the projects were 
designed to highlight these issues – PTB and LBW, and postpartum hemorrhage, respectively – and build 
global and country-level attention and momentum for a concerted response.
Since its inception, Every Preemie has organized the project’s focus, resources and activities around the 
Results Framework depicted in Figure 1. A snapshot of project highlights and accomplishments over the 
project’s life cycle is provided in Figure 2 below.
 20 https://www.everypreemie.org/ 21 Afghanistan, Bangladesh, Democratic Republic of Congo, Ethiopia, Ghana, Haiti, India, Indonesia, Kenya, Liberia, 
Madagascar, Malawi, Mali, Mozambique, Myanmar, Nepal, Nigeria, Pakistan, Rwanda, Senegal, South Sudan, 
Tanzania, Uganda, Zambia
22 Work plan Year 1 
2
Figure 1. Every Preemie Results Framework
3
Figure 2. Project life cycle and accomplishments
1.1 Beneficiaries of Every Preemie—SCALE
There were five main groups of stakeholders that were engaged and/or benefited in some way from 
being engaged with Every Preemie: 
1. Partners who participated in Every Preemie activities such as attending the PTB TWG-ICS,
participating in the writing and reviewing of materials developed under the umbrella of or in 
collaboration with Every Preemie; and participating in the implementation of the situation analysis 
in different countries (See Sections 3.3 and 3.4.);
2. In-country researchers whose skills and experience in implementation research were developed 
(See Section 3.1.);
4
3. Health care providers who could use the materials developed for global use, those who have been 
involved in the implementation of Family-Led Care in Malawi and those benefitting from the pilot 
implementation of the revised ACS guidelines in India (See Sections 3.1 and 3.2.);
4. The health system stakeholders in the different countries who may use the findings from the 
implementation research to improve the quality of care for preterm and LBW babies; and 
5. The most important ‘stakeholders’ in the rollout of Every Preemie initiatives are the preterm and 
LBW newborns who directly and indirectly benefit from improved quality of care immediately or in 
the future. 
2 Evaluation Approach and Methods
________________________________________________________
The Year 4 Annual Report refers to the intention of Every Preemie to “undertake an end of project eval￾uation to document its key achievements and results at both national and global levels.”23 The terms of 
reference of the evaluation consultancy describe the purpose of the evaluation as follows:
“Given the specific focus of the project to catalyze action at the country and global level around 
PTB/LBW, the evaluation will focus on the ‘catalytic effect’ that the project has had over the life of 
the project. Specifically, the evaluation aims to document where the project has facilitated change 
or catalyzed acceleration or scale in the areas of PTB/LBW and inpatient care of the small and/or 
sick newborn. The evaluation will explore the types of changes the project has influenced and 
how.” 
The University of Pretoria was contracted to conduct the end-of-project evaluation from February to 
May 2019. The evaluation was designed and the tools developed at an evaluation-planning workshop 
between February 6 and 8, 2019 in Pretoria, South Africa. The planning meeting was attended by the 
external consultant, the Every Preemie Senior Director, PCI’s Director of Monitoring, Evaluation, 
Research, and Learning supporting the project, and the Every Preemie Technical Advisor based in 
Malawi. Over the period of data collection, the consultant gave regular feedback to the Director of 
Monitoring, Evaluation, Research, and Learning and a Senior Every Preemie Program Officer.
The evaluation questions are organized around the project’s three main outcomes: 
Outcome 1: Improved translation of evidence into action
b. How has the project’s IR agenda contributed to or influenced improved knowledge among key 
stakeholders/decision makers around PTB/LBW interventions and/or programming in 
demonstration countries?
c. How has the project’s IR agenda contributed to or catalyzed change/s in policy or action 
targeting PTB/LBW interventions and/or programming in Every Preemie demonstration and 
focus countries?
 23 Annual Report Year 4
5
d. How is the project perceived and valued among demonstration country partners, including 
stakeholder perceptions at the country level regarding Every Preemie’s contributions?
Outcome 2: Increased capacity of local, national and global entities to scale-up and sustain the 
utilization of high impact interventions 
b. What progress has been achieved in enhancing PTB/LBW interventions in Malawi (and other 
countries where relevant) and what has been the role of the project in these changes? 
c. How is the project perceived and valued among partners in Malawi, including stakeholder 
perceptions at the country level regarding Every Preemie’s contributions?
Outcome 3: Increased prioritization of PTB and LBW with in-country decision-makers and other 
relevant stakeholders at global and national level
a. What progress has been achieved in raising awareness about and action for PTB/LBW and 
inpatient care for the small and/or sick newborn at the global level during the project period 
and what role has the project played in this progress?
b. What are the pathways of change to raise awareness and catalyze action for PTB/LBW and what
role has the project played among global partners and stakeholders?
c. How is the project perceived and valued among global partners, including stakeholder 
perceptions of Every Preemie’s role and contributions?
2.1 Definition of “catalyze” and “catalyst”
One of the overarching objectives of this evaluation was to document stakeholder perspectives on the 
catalytic effect or influence that the project had over time. For a common understanding, the following 
dictionary definition of “catalytic” was used as point of departure: “If you describe a person or thing as 
having a catalytic effect, you mean that they cause things to happen or they increase the speed at which 
things happen” (our emphasis).24
Applied to the Every Preemie project’s strategic objective, this evaluation focused on partners at various 
levels (from country to global level) and their views regarding how Every Preemie, with its limited 
budget, was able to engage strategically and contribute to:
• the acceleration of global advocacy around PTB and LBW and action for change at the country 
level;
• the assessment of models of care for early/small babies and the identification of opportunities 
and challenges for improved service delivery via implementation research;
• the development of government-owned recommendations to improve services and increase 
coverage and service utilization for the small and/or sick newborn; and
• the adoption of a new model of care (Family-Led Care in Malawi) for improved outcomes among 
early/small babies.
25
 24 https://www.collinsdictionary.com/dictionary/english/catalytic 25 The expansion of the Family-Led Care model was underway in Malawi in Years 4 and 5; other models of care 
including changes to the India Operational Guidelines for ACS use were in review.
6
2.2 Tool development 
A number of evaluation tools were developed to cover the project’s three outcomes. The target audi￾ence for each tool was determined according to the role of individuals, institutions (including Ministries 
of Health) and organizations with regard to the realization of each outcome. There were two online sur￾veys administered with Qualtrics software, one for USAID health officers in USAID-supported countries 
prioritizing maternal and child health (MCH) and an anonymous questionnaire for global partners in￾volved in Every Preemie’s PTB TWG-ICS. An e-mail survey on ACS policy and use was conducted using 
individualized e-mails sent to seven individuals who were involved in the development of the multi￾country policy and landscape analysis on ACS use for women at risk of imminent preterm birth. The rest 
of the tools included six interview guides shaped around the interest, focus, tasks or responsibilities of 
the particular informants. Table 1 gives an overview of the target audiences and data collection 
methods. The tools are included in Annexure A.
Table 1. Overview of target audiences and data collection methods
Tool # Target audience Method
OUTCOME 1 (Implementation research)
1A Implementation research partners in the 4 demonstration 
countries Individual and group 
interviews
1B Implementation research partner stakeholders in Ethiopia 
and India* 
OUTCOME 2 (Targeted technical assistance – Malawi)
2A Participants in Family-Led Care 
Other stakeholders in Malawi Individual and group 
interviews
2B MaiKhanda Trust 
OUTCOME 3 (Global and national partners)
3A USAID health officers in USAID priority MCH countries Online questionnaire
3B Global partners involved in the PTB TWG-ICS Online questionnaire
3C USAID/W Newborn Health Team Individual and group 
interviews
3D Selected global partners Individual Interviews
3E People involved in the ACS landscape analysis Open-ended e-mail
* USAID missions and government officials
2.3 Data collection
Major documents obtained from the Every Preemie team and the official Every Preemie website were
reviewed for relevant information on different aspects of the project. The documents included annual 
7
and biannual reports and annexures, work plans, inventories, assessments, protocols and tools, presen￾tations, blogs, regular and ad hoc reports from the four demonstration countries, and the Midterm 
Review.
Invitations for participation in the end-of-project evaluation were issued by Lily Kak, USAID/W Newborn 
Health team, Judith Robb-McCord, Senior Director, Every Preemie, and the external consultant, depend￾ing on target audience. Data collection took place between February 25 and April 30, 2019 and included 
the following activities:
1. Visit to Malawi – 16 face-to-face interviews with 21 informants plus one Skype and one phone 
interview – priority informants: implementers of Family-Led Care in Balaka District; partners; MOH 
officials; and implementation research partners (Tools 2A, 2B). 
2. Telephone, mobile, Skype and other online interviews – informants: implementation research stake￾holders (Tools 1A, 1B); global partners (Tools 3C, 3D); and one Malawi informant (Tool 2A).
3. Online survey sent to USAID mission officials in 20 countries (excluding the four demonstration 
countries) (Tool 3A) – five countries responded. 
4. Online survey sent to 22 global-level partners (Tool 3B) – 17 potential informants started the survey, 
only 10 completed the full survey.
5. E-mail invitation to respond to questions regarding ACS policy and use (Tool 3E) – information was 
obtained from four of the seven sub-Saharan countries targeted. 
6. Conversations with five members of the Every Preemie core team to corroborate some of the infor￾mation provided by the other informants. 
7. Potential informants invited to participate in an interview or an online survey received one or two 
reminders if there had been no response to the first invitation. 
One global partner and one government official declined an interview because they felt others had 
already provided or would be in a better position to provide the necessary information. Interviews were 
only audio-recorded where informants gave oral permission. Three informants declined audio-recording
but were willing to be interviewed. During one interview, the audio-recorder malfunctioned. Detailed 
notes were taken during all interviews. Table 2 gives a breakdown of the interviews conducted with 
different groups. Although a maximum of 35 interviews was envisaged, we eventually conducted 44 
interviews with 55 informants. Six interviews were conducted with groups of 2-4 informants, while the 
rest were individual interviews. 
2.4 Data management and analysis 
Responses to the online questionnaires were received directly through the Qualtrics program and were 
exported to Excel. A few basic frequencies were calculated and responses to open-ended questions 
were used to add relevant information and perceptions to Sections 3.3 and 3.4 of this report. 
8
Table 2. Breakdown of types of interview participants
CATEGORY
Individual 
interviews
(n)
Group 
interviews*
(n)
Interviews 
completed
(n)
Total 
informants
(n)
Global partners 6 0 6 6
Implementation research partners and 
stakeholders**
10 2 12 16
Malawi 14 3 17 23
USAID newborn team 2 1 3 5
Every Preemie Consortium members 6 0 6 5
TOTAL 38 6 44 55
* 2-4 informants per interview ** Including Malawi research partners
Each interview recording was allocated a unique ID number. Audio-recordings were transcribed by a 
professional transcription company. Seven audio-recordings were of poor quality because of poor online 
connectivity or unavoidable background noises and were not submitted for full transcription. Because of 
the tight time frame and the late availability of some of the informants, a further six interviews could 
not be transcribed in full. However, the consultant listened to all these recordings again and transcribed 
important sections.
The interview transcripts, the notes of interviews not transcribed, and a selection of Every Preemie 
documents were uploaded to NVivo 9 for qualitative analysis. Documents were read several times to 
identify potential themes. Excerpts of the transcripts, notes and documents were then allocated to 
different nodes corresponding with the identified themes. Nodes also received a tag to distinguish 
between different data sources (documents and informant groups) to facilitate the review of text 
excerpts and the triangulation between sources when writing up the findings. The text of some of the 
nodes was exported to Microsoft Word® for further analysis and nodes with the same name but 
different tags were combined in one document where there was a need to analyze a particular theme 
from different perspectives. 
2.5 Structure of the report and presentation of findings
Figure 3 is an illustration of how different countries and stakeholders have been involved with the Every 
Preemie activities and how they were approached to participate in the evaluation. The two inner circles 
focus on the four demonstration countries (Bangladesh, Ethiopia, India and Malawi) targeted for imple￾mentation research (Outcome 1). The inner circle focuses on Malawi, the country that received targeted 
technical assistance with the implementation of the Family-Led Care model (Outcome 2). The two green 
circles reflect the project’s engagement at the global level, development of country profiles, global tech￾nical documents, technical working group, and includes both the 24 priority USAID-supported countries 
(light green) and global partners (dark green circle) (Outcome 3). An element of the catalytic nature of 
the project is the interaction between and among activities and stakeholders within these different 
9
levels. Evaluation findings are presented by outcome, according to the Project Results Framework 
(Figure 1) and the evaluation questions formulated for each outcome. 
Figure 3. Different levels of engagement in the Every Preemie—SCALE project, by outcome
The Every Preemie project is not conducive to a quantitative approach to measure the achievement of 
objectives and intended outcomes. This report is therefore a reconstruction of events and ensuing 
products and derivatives and the experiences of various stakeholder groups. Although it contains many 
verbatim quotes to provide an authentic narrative, they reflect primary themes and are not exhaustive. 
To ensure confidentiality of participant responses, this report does not contain a name list of inform￾ants. To protect the identity of participants that could be easily recognized in direct quotations, only 
four broad reference categories were created for these quotations, namely “IR” for all informants in the 
category of implementation research (including Malawi), “MW” for all other Malawi informants, “GP” 
for global partners and USAID/W informants, and “CO” for Consortium members. 
Other editorial styles include the following:
• Direct quotations from informants are presented in italics, whereas quotations from documents 
are not;
• It is presumed that when an informant uses the term “LBW” in a direct quotation, preterm
babies are included in this designation.
10
2.6 Limitations of the evaluation
As this evaluation was conducted before the closeout of the Every Preemie project, there are inherent 
challenges to evaluating this type of project within the program period. It is only post-project that one 
can fully see and document the level of change resulting from a project. Some of the findings in this 
report may reflect current perceptions of the status or achievements of the project but not reflect 
changes that may occur in the coming years.
This evaluation is mainly based on the self-reporting of information and experiences by evaluation 
participants. Most of the stakeholders were also identified as those who had been actively involved in 
one or more of the Every Preemie activities and who in general may have had a positive experience of 
their involvement. To enhance validity, the findings were triangulated from various data sources
wherever possible.
Although reminders were sent to follow up with potential participants in the two online surveys and in 
the ACS e-mail survey to improve response rates, responses remained low (USAID missions 5/20 = 25%; 
global-level partners 10/22 = 46%; ACS survey 4/7 = 57%). The reasons for this are not clear. One reason 
may be end-of-project ‘fatigue’ in some potential respondents or the fact that USAID missions had 
bigger projects that demanded attention and Every Preemie was funded centrally from Washington. A 
few e-mails from potential global informants indicated that they felt they had only participated in a 
limited number of activities during the initial stages of the project. Regarding the ACS survey, at least 
one potential informant had moved on to another position and a possible substitute did not respond to 
e-mails. Another one had retired, but it was possible to get more information from current government 
officials. 
Although this report is considered an “evaluation”, it is more a review of the achievements (“catalytic 
effect”) and accomplished or potential impact of the Every Preemie—SCALE project as described in 
documents and perceived by beneficiaries, stakeholders and partners from the global to the local level. 
The scope of the evaluation did not include other aspects often associated with a formal evaluation such 
as management and logistics of the project or the management of projects in the four demonstration 
countries. This report also does not include an assessment of the quality of the implementation research 
processes or the findings from the studies in the four demonstration countries. Management issues 
were only considered when they could have had a negative impact on the outcomes of the project or 
when there was a potential for future learning. 
11
3 Accomplishments of Every Preemie—SCALE: “large mandate”, 
“limited funding” and “high expectations”
________________________________________________________
The three Every Preemie—SCALE outcomes illustrate the project’s large mandate. The project was 
implemented under a central funding mechanism managed by USAID/W and received $7.2 million US 
dollar over the life-of-project.26
“If I were being asked this question with regard to the donor I would say that they (Every 
Preemie) were limited by their funding envelope and had a lot expected of them with a limited 
funding envelope and that was a little bit of a handicap I think.” (GP04)
This section is divided into five subsections; the first addresses cross-cutting accomplishments, with the 
subsequent four corresponding to the explanation in Section 2.5 and Figure 3, and shown below:
Subsection heading Outcome
3.2 Applied learning through implementation research in four demonstration countries 1
3.3 Family-Led Care in Malawi 2
3.4 Preparing countries to focus on preterm and low birth weight care 3
3.5 Moving the global agenda forward 3
3.1 The Every Preemie project – “as a team they are very respected” 
Overall informants had tremendous appreciation for the passion, leadership, management skills and 
responsiveness of all Every Preemie team members including the three team leads. Team members 
were described with phrases like “a tremendous advocate for the newborn, a huge wealth of knowledge 
and very respected in the field.” (GP08-1), “great as a technical leader” (GP07), “an excellent systems 
thinker” (GP08-2), “a great manager and good partner” (GP07) and “superior quality technical 
assistance” (Midterm Review).
There was particular mention of how the different competencies and experiences of the three consor￾tium partners and the project leads complemented each other to bring “a clinical perspective” (GP08-1), 
“a health-systems and on-the-job perspective” (GP08-1) and a training perspective for “understanding 
the Family-Led Care model” (IR01-1).
“They got some of the right people involved in the project and they picked the right application. 
Because they could [capture] all that momentum [of the technical knowhow] of GAPPS, while they 
could use the strength on community engagement, mother care groups and on-the-ground presence 
of PCI and the capacity building of ACNM. … So everybody contributed differently in very important 
ways.” (CO5)
 26 The established ceiling for the Every Preemie award was $8,999,296. 
12
3.1.1 Relationship with the donor – “wish list exceeded their bandwidth or budget …”
The Every Preemie team had good relationships with the donor – “there was a mutual respect” (GP08-1)
and “quick responses and quick support when that was requested” (GP08-3). This is how a USAID/W staff 
member commented in the Midterm Review:
“I value their responsiveness. I value their flexibility. Every time I come up with a hairbrained idea, 
they are willing to listen and debate. If they don’t like the idea, they’ll say so. And that’s fine with 
me. I feel like we have a very professional, collegial, trusting relationship and I feel we have good 
partners that I can rely on, and I feel that they are implementing one of USAID’s highest priority 
technical areas so I view them to be very important – an important part of the newborn portfolio so 
I treat them very seriously … I think they do very high-quality work. They are top notch. So, I value 
all of that.” (p. 23) 
“Overall I think the project has been very responsive to all USAID requests and not just responsive 
because USAID as a donor is asking them to do something, but also because I think they believe that 
we are working on this together as partners and that they believe that all the requests that USAID is 
making is truly of global relevance and importance. So I believe we have really worked as partners, I 
have enjoyed working with [the Every Preemie advisors], they are colleagues and partners, we have 
good discussions on: is this an important issue – and if we agree mutually that yes it is important, 
then we figure it out how do we implement it. So I feel like we are really good partners, I have been 
really grateful for that.” (GP07)
Mention was also made about the trade-offs that had to be made in terms of being “very clear about 
what can and cannot be done” (GP08-2). 
“I also really appreciated that at times when our wish list exceeded their bandwidth or budget that 
[the project director] would very directly and forthrightly state that so that we weren’t – she wasn’t 
making promises for the project that were just infeasible. That was appropriate and it’s important 
for us to sort of then step back and say, ‘Okay, well what are we going to give up in order to get this 
done?’ Or whether we want to continue and scale back.” (GP08-1)
3.2 Outcome 1: Applied learning through implementation research in four 
demonstration countries – “brave” and “ambitious”
The Every Preemie team, in collaboration with USAID/W and USAID field missions, selected four coun￾tries as demonstration countries to receive support for undertaking implementation research. 
Although the initial plan was to identify two countries in the first year of the project, high interest from 
field missions, and a unique research opportunity in Bangladesh, led to the selection of four countries: 
Bangladesh, Ethiopia, India, and Malawi. The work in these four countries links very closely to the 
applied learning approach promoted in Outcome 1. The aim was to learn more about the 
implementation of specific PTB/LBW-focused interventions and obtain evidence of what worked and 
how this knowledge could inform local stakeholders on how to translate it into action through 
replicating and moving successful models to scale. The Every Preemie team designed “the 
implementation research agreements and partnerships as a chance to develop in-country capacity to do 
[implementation research]” (CO1). Every Preemie therefore committed to advance the leadership and 
13
strengthen the capacity of local research organizations and other partners, where requested, by means 
of ongoing mentoring and technical support.
The Every Preemie team “had to balance the project’s unique mandate with available resources and 
country expectations and priorities.”27 Activities included identifying in-country research partners, de￾veloping a learning agenda and research questions, designing the studies, and getting the necessary 
approvals from ministries and Institutional Review Boards (IRBs). Each country also had its unique 
challenges in dealing with delays at various points of the study. According to Every Preemie, establishing 
implementation research projects required “significant effort and extensive coordination with local 
partners to write concept notes, engage local stakeholders, and finalize corresponding budgets and 
contracts.”28
The implementation studies in Ethiopia, India and Malawi each had to align their work with the vision of 
Every Preemie. To do so, they generated research questions that “are central to moving evidence to 
action for preterm birth and LBW by supporting governments and their partners to identify 
interventions and models of care that are effective and feasible within their setting, while informing 
global learning.”29
“The idea was that we would set priorities with countries for critical questions that would be acted 
on locally, but would have global importance and that that priority would be set in partnership with 
the governments, in the individual governments and then we would identify local partners and work 
together.” (CO1)
A consortium of partners led by Brigham and Women’s Hospital designed the implementation research 
in Bangladesh and Every Preemie primarily provided resources to work already underway.
3.2.1 Different models: questions, designs, geographies, timelines, partners
Each country’s research process and highlights are described in separate boxes in Subsection 3.2.2 
below. Annexure B contains two tables that give an overview of the study titles, aims and objectives,
and a description of the annual accomplishments. Each country had a unique, contextually appropriate 
model of implementation research and a focus that was negotiated with the in-country partners.
“The thing that was kind of interesting about it is that [Every Preemie] really had very disparate foci 
in these different countries. … So in the way that the program evolved it just so happened that 
Malawi was the one that really required a lot of kind of onsite, face-based technical support. Where￾as in India it was more policy, it had to do with auxiliary nurse-midwives in India being enabled to 
provide first dose of antenatal corticosteroids. And in Ethiopia it was really just working with a 
whole-systems approach in terms of how prematures were dealt with. … The way that the program 
was structured in-country, was based to a large to extent on how the country shaped, what they felt 
they needed in terms of programming and understanding of premature birth.” (CO7) 
 27 Annual Report, Year 1 28 Annual Report, Year 3 29 Annual Report, Year 2
14
“If each country played out differently in terms of the priorities, we will talk about the priorities, but 
they also somewhat varied on the kind of relationship we had with the investigator team in-coun￾try.” (CO1) 
Implementation research in the four countries included: 
5. Bangladesh provided an opportunity to advance work on maternal gestational age assessment by an 
already existing project led by the Projahnmo Research Group.
6. The goal of the Ethiopian study was to “inform the development of recommendations to the FMOH 
on national programming to support the implementation, coverage and quality of select 
interventions and services within the public health care system to improve outcomes for small and 
sick newborns in Ethiopia.”30
7. In India, the aim was to inform policy and operational guidelines to improve clinical practice, to 
revise the current GOI ACS operational guidelines and to assess the implementation of the revised 
ACS operational guidelines in two districts in Haryana State.
31
8. In Malawi, Every Preemie provided targeted technical assistance in Balaka District for the 
implementation of a new model of care for early/small newborns – Family-Led Care. The aim of the 
implementation research in Malawi was to assess caregivers’ and health care providers’ experience 
with Family-Led Care.
All four demonstration countries had multiple partners and collaborators whose representatives 
attended in-country stakeholder meetings or provided specific support for the rollout of the research. 
Deliberations at these meetings informed the subsequent course of the in-country projects and models. 
Table 3 provides a list of country stakeholders.32
Table 3. Country partnerships 
Bangladesh Ethiopia India Malawi
• Ministry of Health and Family 
Welfare (MOHFW)
• USAID/Bangladesh
• Centre for Diarrhoeal Disease 
Research, Bangladesh
• Shimantik (NGO) 
• Child Health Research 
Foundation
• Brigham & Women’s 
Hospital/Harvard Medical 
School
• Johns Hopkins Bloomberg 
School of Public Health
• FMOH
• USAID/Ethiopia
• Ethiopian Pediatric 
Society
• Ethiopian Society for 
Obstetrics and 
Gynecology
• St. Paul’s Hospital 
Millennium Medical 
College
• Ethiopian Public 
Health Institute
• MOHFW, Government 
of India
• USAID/India
• Department of Health 
and Family Welfare, 
Government of Haryana
• All India Institute for 
Medical Sciences 
(AIIMS)
• National Neonatology
Forum of India (NNFI)
• Ministry of Health RH 
Directorate
• Balaka District Health 
Management Team
(DHMT)
• USAID/Malawi
• National Safe Mother￾hood Technical Work￾ing Group 
• PCI Njira Project
• Save the Children
• University of Malawi, 
College of Medicine, 
School of Public Health 
and Family Medicine
 30 Ethiopia study protocol 31 India study protocol 32 Annual Report, Year 1
15
Bangladesh Ethiopia India Malawi
• MaiKhanda Trust
In the implementation research, it was important to find “the right partners who are credible” (IR07). 
One of the challenges in forging in-country partnerships was to get everyone on the same page 
regarding their understanding of what implementation research was: 
“… on who should actually do IR [implementation research] and how it contributes to and comple￾ments clinical trials; that it’s quite a different type of science and has not been appreciated and 
utilized much in the maternal and newborn health space to date. … The trialists just could not appre￾ciate it … but in every case, the local researchers and I think the government really appreciated it 
and took it deeply and was very committed to do this kind of work. … People were appreciating it as 
the way to find critical information and evidence efficiently.” (CO1) 
In India and Ethiopia, current government policies and interventions were taken as a point of departure 
to phrase the research questions. India had an in-country Project Advisory Group (PAG) that included 
government officials, donor and in-country partners. The research team worked closely with the PAG 
and government, donor, and in-country partners were all included as investigators. An informant from 
Ethiopia reflected that it would have been good for the study to have had some form of advisory group. 
“A … point I would have changed is I would establish some kind of ad hoc group that would look at 
the progress by inviting the Federal Ministry of Health, USAID, PCI. … Although the follow-up was 
not loose, it would have been good to kind of get guidance from a team that comprises of the 
funding agencies, the implementers and the technical support providers. … When you have under￾takings which engage a lot of people, I feel like it’s really important to make sure you have repre￾sentatives [advisory board] and those that are involved in making decisions, because there will not 
be any surprises in the process.” (IR03)
All four implementation studies occurred in specific geographic spaces. In the case of Bangladesh, the 
space was determined by a pre-existing study in Sylhet. The Ethiopian study was conducted in three
different regions representing different geographies and demographics. In India, two districts in Haryana 
state were identified as study sites and in Malawi, the study took place in Balaka district. Figure 4 
contains maps of the four countries’ study sites.
16
Figure 4. Study site maps
3.2.2 Implementation research: country highlights
Highlights of the implementation research in each country are presented in Boxes 1-4. 
17
Box 1. Implementation research highlights from Bangladesh
BANGLADESH 
“We were able to start pretty quickly”
Study title:
Maternal anthropometrics and statistical modeling to improve prediction of gestational age 
before birth in low-income settings
__________________________________________________________________________
The Bangladesh implementation research project had a shorter and easier inception than the 
other three countries. Every Preemie’s Evidence and Learning Lead’s ongoing relationship and 
interactions with researchers at Brigham & Women’s Hospital facilitated the identification of an 
excellent opportunity to advance work in the critical area of gestational age assessment. 
The Sylhet study site in Bangladesh is managed by the Projahnmo Research Group (now a Foun￾dation) and the local NGO Shimantik. They have an international partnership with Johns Hop￾kins University and a relationship with the Brigham & Women’s Hospital. These connections 
enabled the development of a research proposal that could complement existing National 
Institutes of Health-supported trials aimed at improving “pregnancy-related screening and the 
treatment of infections in pregnancies to try to prevent preterm birth” (IR08). The Midterm 
Review quotes the Bangladesh study director as saying that “the major challenge affecting 
preterm birth is either lack of gestational age dating or the inaccuracy of gestational age dating 
in these [low-income] settings” (p. 29). Work on better ways for community health workers 
(CHWs) to identify premature infants at birth was already ongoing through a USAID Saving Lives 
at Birth award in the same study area, which “created a nice platform to build on that platform 
to add a few more additional questions” (GP07) and to include “a new measurement as part of 
this study” (IR08). 
“We were lucky because we already had the infrastructure in place in the trial phase; we 
had all of our staff, our health workers, the cohort that was doing an ultrasound screen for 
gestational age; that was already happening. So we just kind of added on this intensive 
module for training of health workers for the physical anthropometrics at the start. …
It was an opportune moment …we just needed that infusion of funding to be able to devote 
staffing, to devote the training material, the physicians that could oversee everything, do 
the quality control.“ (IR08) 
As envisioned, the Bangladesh study could complement other studies in low- and middle￾income countries to address the need for an affordable, simplified and appropriate method for 
pre-birth gestational age assessment. The Every Preemie project focused on the development 
and validation of methods for measuring maternal abdominal girth (AG) and symphysis fundal 
height (SFH) to improve prediction of gestational age before birth. The aim of the study was to 
determine the accuracy, reliability and feasibility of maternal anthropometric measurements 
(e.g. SFH and AG) in the third trimester of pregnancy to estimate gestational age compared 
18
with the gold standard of ultrasound dating in early pregnancy (<20 weeks). Standardized
methods for CHWs to measure SFH and AG in pregnancy were tested. Procedures were also 
developed and tested to improve the reliability of SFH and AG measurement by different levels 
of health workers (CHWs, nurses, and physicians) to assess the programmatic feasibility of 
implementing these procedures in low-resource settings. If this method could be shown to be 
effective for determining pre-birth gestational age, it had the potential for rapidly improving 
life-saving clinical care such as the use of ACS and antibiotics, kangaroo mother care (KMC), the 
management of obstetric complications, and addressing referral needs in resource-limited 
settings.
“They were important findings, but they were disappointing”
The results were disappointing – “not the findings that we had hoped for” (GP07). Findings
showed that the tested method was not successful at estimating gestational age to an 
acceptable level of precision to guide clinical management. Nevertheless, these findings 
provided significant learning for the global community and confirmed the continued 
importance of ultrasound for accurate gestational age estimation. The learning points to the 
need for global advocacy and research prioritization in making ultrasound technology more 
readily available and user-friendly in low-resource settings.
“The clear message is that ultrasonography needs to be scaled up. … I think it’s more evi￾dent that there needs to be more resources towards [expanded use of] ultrasound, both for 
dating but also for general pregnancy care. There needs to be that within the health 
system. It helps to provide that information that without the resources it may not shift the 
needle that much … it’s to get the message out there and hopefully it will really help to kind 
of move the needle and make people think more.” (IR08)
Data analysis was completed in Year 3 of the Every Preemie project and further advanced sta￾tistical modelling were undertaken in Year 4. Results were shared at multiple conferences and 
technical meetings. At the time of the evaluation, manuscripts based on this research were still 
being submitted and reviewed for publication. 
“I think that hopefully once the reviewers review it and we respond to everything that it will be 
in a kind of polished version where all the results will be final. And then we would disseminate it 
both to our local partners, the ministry, as well as EP SCALE or whatever ...” (IR08)
19
Box 2. Implementation research highlights from Ethiopia
ETHIOPIA
“A whole-systems approach”
Study title:
Assessment of the scope and implementation of services for small and sick newborns within the 
Ethiopian public health care system: a health systems implementation study
_________________________________________________________________________________
Activities in Ethiopia in the first year of the Every Preemie project revolved around the develop￾ment of a learning agenda though extensive dialogue with various partners and the approval of a 
concept note. The design of the implementation research started in Year 2 in collaboration with 
the FMOH and USAID/Ethiopia. They identified St. Paul’s Hospital Millennium Medical College (St. 
Paul’s) as the research partner. In Year 2, two protocol writing and instrument development 
workshops were conducted.
The study’s goal was to describe the implementation of newborn interventions and services for 
small and sick newborns in the Ethiopian public health care system in three regions representing 
three different geographic settings: 
• K’obo Woreda (district), North Wello Zone, Amhara Region (settled agrarian)
• Dolo-Mena Woreda, Bale Zone, Oromia Region (semi-pastoral agrarian)
• Kirkos and Yeka Sub-cities, Addis Ababa Region (urban)
A further aim was the identification of key challenges to and opportunities for improving preterm, 
LBW and sick newborn services nationwide, specifically health-system structural factors and essen￾tial service-delivery processes. It was envisaged that the learning and evidence emanating from 
this study would inform recommendations to the FMOH on an effective essential package of 
PTB/LBW interventions for national scale-up, based on current capabilities, practices, experiences, 
and strengths and weaknesses of the newborn care system. The findings could potentially 
contribute to the strengthening the FMOH’s promotion of equitable access to health care services 
for the Ethiopian population.
The study included multiple data collection activities and designs (mixed methods, prospective, 
cross-sectional). It focused on the evaluation of the structures, processes and outcomes of a set of 
priority interventions essential to small and sick newborns and the assessment of current delivery 
and readiness to deliver such services within levels of care and by setting. The following were main 
focus areas of the research: 
• Facility readiness 
• Health systems readiness 
• Referral and transfer system
• Experience of care /quality of care 
20
• Post-discharge care utilization and mortality 
In each region study populations included clinical leaders in the health facilities, administrators in 
obstetric and newborn health, medical professionals and staff providing obstetric and/or newborn 
care, health extension workers and various groups of mothers whose newborns had been admitted 
and not admitted to newborns units in tertiary and secondary hospitals.
The choice of study sites and the development of the protocol posed some challenges. Originally, 
an urban setting was not included. A contribution of USD100,000 by USAID/Ethiopia as part of their 
field support made this addition possible. Some of the initially selected sites had to change 
because of persistent drought and security concerns. A similar study working with the same 
patient population at St. Paul’s Hospital also necessitated a change of sites for the post-discharge 
care study in the urban area. 
“The original belief we had … was that there are a lot of babies who are being discharged from 
the NICUs [neonatal intensive care units] … meanwhile the study enrolment rate was low. That 
resulted in a significant delay in completing our cohort, which called for making changes to the 
protocol, asking for additional funding.“ (IR03)
At the time of the end-of-project evaluation, the analysis of qualitative and cross-sectional data 
and data collection for the post-discharge care study had been completed. There was planning 
underway for in-county dissemination and two draft manuscripts on quality of care and health￾system readiness were in process. 
“We didn’t actually have a new model that we designed through our project, but what we 
did was really document how different partners have come together and implemented a 
program for preterm babies and small low birthweight babies. … It was just looking at 
what's happening in the country, what are different partners doing and how does it all 
come together, and how is it being implemented. So it has become an interesting study, I 
still have to wait and see how useful it will be for the country to roll out as a model of care 
and can we use that model globally.” (GP07)
21
Box 3. Implementation research highlights from India
INDIA
“There was a global burning need to find out whether antenatal 
corticosteroids was feasible administering at a lower level of 
the health system”
Study title:
Assessment of use of antenatal corticosteroids and national operational guidelines
in Haryana state, India
_________________________________________________________________________________
In 2014 the GOI published policy and operational guidelines for the use of antenatal corticosteroids 
(ACS) in preterm labor that included support for auxiliary nurse-midwives to administer a pre￾referral dose to pregnant women in preterm labor at public health facilities. This policy, together 
with the publication of the Indian Newborn Action Plan, provided an opportunity for Every Preemie 
to work with the MOHFW of the GOI to evaluate the implementation of the ACS policy in two 
districts in Haryana State (Hisar and Ambala). The local research partner was the PGIMER in 
Chandigarh. Year 2 was devoted to protocol writing and instrument development and the final IRB 
approvals were obtained in Year 3. 
The aim of this mixed-methods study was to assess the utilization and practice of ACS administra￾tion for women in imminent preterm labor in selected childbirth care facilities in Haryana State.
There was a particular focus on the safe provision of pre-referral dose by auxiliary nurse midwives.
It was anticipated that the findings from this study would provide important lessons for the safe 
and effective rollout of ACS in low-income settings. 
The three main study objectives corresponded with the three phases of engagement in Years 4 and 
5: 
• Phase 1 assessed the current ACS availability and utilization practices and compliance with the 
MOFWH operational guidelines and identified critical pre-conditions for the safe administration 
of the pre-referral first dose ACS within the primary health care unit setting. 
• Phase 2 was informed by the findings from Phase 1. The focus was to review current practices 
and to revise and update the GOI operational guidelines/policy for the use of ACS. Job aids and 
training materials to accompany the three-month pilot of the implementation of the revised 
guidelines were also developed. The table below shows how the findings were translated to 
revisions in the guidelines:33
IR Findings Revisions to Guidelines
Standard protocols/job aids, training and 
supervision not available for health workers 
Job aids and guidelines developed to support 
training, performance standards and super￾vision
Mismatch between health worker confidence Guidelines and job aids designed to address 
 33 Annual Report, Year 4
22
in providing ACS, attitude on safety of ACS, and 
knowledge on proper use of ACS 
knowledge and competencies
Use of ACS by health workers not standardized 
(timing, dose, medication choice, indications) 
Job aids, ACS indication checklist, and require￾ments for documentation in the case record 
provided 
Clarification on roles of providers lacking Roles and responsibilities for each level of 
cadre specifically outlined
Authorization of level of facility for providing 
ACS lacking 
Roles and responsibilities for each level of 
facility providing services specifically outlined
Typical referral time to reach a facility with 
adequate care for threatened preterm 
labor/PTB: 2-3 hours 
Full-course ACS use limited to facilities with 
adequate care for threatened preterm 
labor/PTB
Key indicators for monitoring ACS use not 
reported 
Appropriate, measurable indicators with clear 
definitions
• In Phase 3, the implementation of standard practice of the revised operational guidelines and 
algorithm for ACS administration was evaluated in facilities that met the health-system precon￾ditions in the same sites within Haryana State. These findings would further inform the revision
of the national ACS operational guidelines and the scale-up of such guidelines. A staff member 
of the USAID/W’s newborn health team commented in the Midterm Review that “the study 
was designed to be very, very catalytic” (p. 13).
A PAG established in collaboration with the GOI oversaw the research and the dissemination of 
findings with a view to make recommendations for revision of the final ACS guidelines. When this 
end-of-project evaluation was conducted, the first two study phases had been completed and
findings disseminated. For the third phase, implementation and data collection had been 
completed and planning with the GOI for the final dissemination of findings in India and beyond 
was underway. The research team had also completed two manuscripts reporting on findings. 
23
Box 4. Implementation research highlights from Malawi
MALAWI
“An ideal and very unique situation”
Study titles:
Knowledge, perceptions and practices of families who have experienced Family-Led Care 
in Balaka district, Malawi
AND
Health care providers’ experience of implementing Family-Led Care for preterm and low 
birthweight newborns in Balaka district, Malawi
_________________________________________________________________________________
The aim of the implementation research in Balaka district, Malawi was to assess caregivers’ and 
health care providers’ experience with Family-Led Care, a new model of care for the early/small 
newborn. Implementation research was complemented by data collection on key health facility 
indicators over time using MOH facility registers. The latter is further discussed in Section 3.2.3.
Two research partners in Malawi were contracted to conduct two studies, a provider study and a
caregiver study, to assess the implementation of the Family-Led Care model. Both studies have 
been concluded and the findings are reported in three separate reports. Meetings for the 
dissemination of findings to stakeholders are forthcoming.
MaiKhanda Trust conducted the caregiver study on families’ knowledge, perceptions, practices and 
experiences of Family-Led Care in Balaka district. The specific study objectives were to assess:
1. Family perceptions of their inpatient care experience in relation to the implementation of 
the Family-Led Care model;
2. Family perceptions of whether Family-Led Care prepared them to confidently assume care 
for their newborn at home; 
3. Family readiness/knowledge to continue care provision of their early/small newborn at 
home post discharge; 
4. Family knowledge on the management of kangaroo mother care prior to discharge; and
5. Actual home-based care practices post discharge.
The caregiver study consisted of two consecutive data collection phases. A cross-sectional, 
quantitative, descriptive survey was conducted between February and November 2018. A number 
of qualitative individual and group interviews were conducted in two study sites in November and 
December 2018 to gain a deeper understanding of caregiver experiences of Family-Led Care. The 
first phase had 222 participants; the second phase had 25.
The Centre for Reproductive Health of the University of Malawi’s College of Medicine was 
responsible for the study on health care providers’ experience of implementing Family-Led Care in 
Balaka district. The study had the following specific objectives:
24
1. Assess provider ability (including HSAs) to accurately identify preterm/LBW newborns for 
admission, referral and discharge (knowledge);
2. Assess provider adherence to the clinical care standards set out in the Family-Led Care 
model (adherence); 
3. Assess provider competency in providing care (inpatient and follow-up care) for early/small 
newborns (competence); 
4. Explore staff and HSA attitudes towards the Family-Led Care model, the Quality Improve￾ment intervention and the donations of material/equipment to implement the model 
(attitudes); and
5. Explore staff and HSA perceptions of how mothers/families reacted to the Family-Led Care 
model (perceptions).
The provider study used a mixed-methods approach targeting health care providers and support 
staff practicing or having been exposed to the Family-Led Care model in five health facilities. An in￾depth understanding of providers’ perceptions of and attitudes towards Family-Led Care was 
sought through qualitative methods like focus group and in-depth interviews. Quantitative 
methods (e.g. record review, questionnaires and clinical observations) were used to gathered data 
about providers’ knowledge of, adherence to, and competency in providing Family-Led Care. Data 
were collected at two points during the implementation of Family-Led Care with the same set of 
data collection tools – midway through the implementation (February-March 2018) and towards 
the end of the project (November-December 2018). Two different groups of health care providers 
were targeted for the two data collection events, respectively – those who had initially been 
trained in Family-Led Care in 2017 and those who had been trained in the course of 2018. Sixty-two 
staff took part in the first round and 61 in the second round.
Data from the Malawi implementation research have been presented within Malawi and in various 
international meetings including the 2018 12th International Conference on KMC; 2018 Priorities in 
Perinatal Care Conference (poster session); the 2018 COINN Africa Conference; and the 2019 
International Pediatrics Association meeting. 
25
3.2.3 Flexibility and responsiveness as hallmarks of managing implementation research
Global and country informants all commented positively on the responsiveness and flexibility of the 
Every Preemie team in searching for mutually acceptable solutions to problems. The research partners 
were appreciative of the support – “very supportive and very easy to work with and obviously under￾standing of the kind of real field challenges, the timelines and things like that” (IR08). Another point of 
appreciation was budget flexibility – “that was a huge lesson for us, because many funding agencies are 
not very flexible” (IR04-2).
“I have to appreciate PCI in this process because they have been very practical and very responsive 
to the reality on the ground and we have had actually a good amount of flexibility from their side. 
One of which is the timelines and the second one is the associated budget.” (IR03) 
Some of the research partners also referred to the quality research guidance they received.
“We obtained first-hand experience in implementation research with [the Every Preemie technical 
advisor]. We at the same time learnt a lot … a practical exercise which we were privileged to have ...
[the Every Preemie technical advisor], every time he was approachable and available whenever we 
had some issues and he was always there to guide, like how it should be approached and what 
should be the better way to [do something].” (IR04-3) The Every Preemie team faced some 
challenges in advancing the implementation research: “it was very difficult to manage research 
from a distance with local research organizations” (CO4). One informant considered the country￾level implementation as the major challenge of the project. 
“It was hard for them in some ways because they didn’t have an on-the-ground presence for the 
most part and had to work through partners. And I think that there was a long process of trying to 
get some of that started and decide on what were going to be the priorities…those challenges were 
not inconsequential and … maybe the results of those endeavors were not as impactful as were the 
other outputs ... It’s hard to go into the country and really get people on board unless you bring a lot 
of money to the program support. … Basically I think those are sort of inherent in what they were 
handed, more so than they were sort of mistakes that were made in terms of the EP SCALE team.”
(GP04)
It was difficult for in-country partners to understand that all their wishes could not be included in the 
available time or funding envelope; this challenge was also mentioned in the Midterm Review (p. 27). A 
few informants referred to perceived missed opportunities in terms of the research projects being too 
limited in terms of geographic or population coverage, methodological approaches and the use of tools.
This is in contrast with project thinking that “maybe just limiting the scope so that they could be more 
productive with the implementation research, maybe more focused with that as well would have been 
useful” (CO7). It all comes down to what “can be done realistically” (CO3) – “it’s hard to go into the 
country and really get people on board unless you bring a lot of money to the program support” (CO7).
“I think the process of trying to do country-level implementation research is a big undertaking if you 
don’t have an on-the-ground presence … it’s probably more difficult than they realized it would be to 
really move that along. I think it moved slowly at times and again I am not clear on the impact of 
that.” (CO7)
26
3.2.4 Value of research participation for individuals, teams, institutions, and ministries of 
health – “the whole research was a great benefit”
Informants participating in the country implementation research commented on what participation in 
the research meant for them individually, as a research team and for their institutions.
Individuals valued the experience of the whole research process – “For me like seeing through the whole 
process from protocol involvement, data collection, analysis, it’s been a wonderful opportunity to do it”
(IR01-2). A number of informants “gained extensive research skills” (IR08). Specific skills mentioned 
included “preparing protocols”, “analysis of the training data sets”, “qualitative research” and “manu￾script writing”. Learning about the context of health facility-based research was also appreciated – “first￾hand information about … [the] adoption to new interventions” (IR01-3).
Project management, learning about making research efficient and more productive and collaborating 
with other partners like NGOs were perceived benefits for some informants, especially those for whom 
it was a first experience as manager. 
“From my side as the program manager this project was a huge learning for me, like starting from 
the development of the protocol and drafting ... and with stakeholders, it was a great learning, but 
the main lesson for me was that ... I came to know … the ground realities. We came to know the 
actual realities and then it gives us the idea like – before implementing you should pilot, we should 
make like guidelines or any job which should be customized to look at the context. … So those were 
the areas which we think we often neglect when we just introduce new guidelines. … It really built 
up capacity in the implementation research, so in future whenever we have a project it could be a 
great lesson and experience for us to carry out the implementation research processes.” (IR04-3)
Collaboration and teamwork were valuable experience gained through the implementation research –
“it kind of strengthened our research collaborations at every level” (IR04-2).
“We have this good amount of skill to collaborate with multiple institutions. … We have gotten the 
chance to know each other within the organization. You know if you don’t get the chance to work 
together it’s usually difficult to know who can do what when and this collaboration has given us the 
chance to learn more about each other.” (IR03)
Informants participating in one of the group interviews mentioned the benefit of talking about the value 
added to their own skills and perspectives through their involvement in Every Preemie. 
“It’s nice to sit down and think about how you have benefited from a particular project, because 
that’s something that you don’t normally do. You are just working, you are looking to catch dead￾lines, but you don’t sit down to reflect on how the project as a whole has benefited you.” (IR01-3)
Institutions benefited from the implementation research, especially with regard to institutional visibility 
and recognition that also opened doors for future collaborations – “When people are looking for 
research collaborators, then there will be those who say, ‘Okay, they have done research on this before 
and we can work with them’” (IR01-1). One research team mentioned that the research experience 
assisted them with other grant applications – “We have cited our involvement in Every Preemie … in the 
other grants we applied for it” (IR01-1). Some institutions also benefited on the administrative side –
27
“our administration learnt a great lesson because we now know about the fact that somebody should be 
assigned to handle the admin aspects” (IR03).
Ministries of Health were included in designing, conducting and/or overseeing the implementation 
research in India and Ethiopia. One informant emphasized the importance of involving the government 
at national and sub-national levels from the outset so that there is “complete ownership of the govern￾ment” (IR07). Another referred to the challenge of accommodating implementation research projects in 
the public health system, “how to work with the public health system” (IR06). One informant referred to 
individual research capacity building, implementation research as “a new bridging mechanism to close 
the [very huge] gap between the academia and the health managers” (IR05), and the facilitation of the 
adoption of recommendations emanating from the research.
“Because someone is part of this process and when the recommendations are believable it will be 
easier to advocate, or it would be easier to disseminate this information, as opposed to an idle 
person who is not engaged in this process and we give him or her the article and they may not take 
it seriously. So it will really strengthen our staff in these kind of studies so that we can easily be able 
to disseminate, or we can be able to advocate for this particular case for premature babies. So it will 
really make someone be realistic with this recommendation that will come out ...
So then, I have learnt … a lot about the challenge of working in the system. It was a good lens 
to show me where the gaps really exist when it comes to the care of preterm and premature babies. 
So I think it was highly informative … it clearly shows how the country has a lot to go to address 
premature-related diseases.” (IR05)
Another informant described his experience of being on the receiving end of research capacity building: 
“Personally … [I was] engaged in this sort of deep dive and in fact evidence research activities, so it 
is an eye opener or it is a form of capacitating the health system staff like myself. … I had to sit and 
do the write-up, a portion of this one article and I had to read lots of references with my colleagues 
and other obstetricians from another university. … So it really capacitates the ministry’s staff on 
research writing and write-up … the analysis part … how to do simple research methodologies, how 
to critically read journals and how to critically write your research. So personally it is one of capacity 
building.” (IR05)
Involving ministry officials in the research process also brought challenges, especially in terms of time –
“we have lots of activities to attend to, we run here and there and it is really difficult to get focused on 
one or two or three research [projects]” (IR05).
“The results of the implementation research study I think would all be of global 
relevance and going forward … I would like to find ways of taking those lessons 
forward through other projects and through global policies, through bilateral 
projects and so on.” (GP07)
28
3.2.5 The legacy of Every Preemie’s implementation research
Including implementation research in the Every Preemie project was considered innovative – “we chose 
to be ambitious” (CO1) and “it’s very ambitious research, which is not a reason it shouldn’t be done”
(GP08-2). In each country, the implementation research evolved into a unique model to leverage the 
existing situation, priorities and resources available. Each project also had its own ‘history’ that included 
different levels of engagement of the principal investigators and study coordinators across the whole 
period of each study.
The successful implementation of the project’s country level research agenda cannot be overstated. 
With extensive involvement from U.S.-based colleagues with in-country stakeholders in Ethiopia, India 
and Malawi all countries completed their research and as of this evaluation, were positioning to share 
findings both globally and at the national level through various meetings and via peer-reviewed journal 
publications. Stakeholder engagement in all four countries is exemplary and there is evidence that 
country-level research partners found the engagement to be hugely beneficial to their institutions, 
themselves as individuals and to the country. Findings across the board are significant and relevant. 
• Bangladesh findings demonstrate that ultrasound technology remains the gold standard for 
gestational age estimates, even in middle- and low-resource settings. These findings will push 
the global community to continue to explore new ultrasound technologies for these resource 
settings. 
• The depth of analysis in the Ethiopia public health system for care of the early/small/sick 
newborn is noteworthy. Exploring different geographies and providing insights into obstacles, 
challenges and opportunities there will strengthen the government’s commitment to further 
building the public health system as they continue to work towards improvements in under-five 
and newborn outcomes. 
• Government representatives in India are engaged in a robust debate regarding the safe and 
effective use of ACS for women in imminent preterm labor as a result of Every Preemie-PGIMER 
research. It is critically important that ACS is used appropriately as the results of unsafe use can 
lead to poor maternal and newborn outcomes including death. Identifying weaknesses in the 
previously launched ACS operational guidelines as per their implementation is enormous value 
add to the country as they advance their work in maternal and newborn health. The updated 
Operational Guidelines are currently under debate elevating this important intervention to the 
senior most levels of the MOHFW. 
• In Malawi, the Family-Led Care model has been well received and is currently being scaled 
throughout the country. While there are areas for improvement, the model is the first of its kind 
in Malawi. In a very resource-limited environment, such as Malawi, identifying innovative ways 
to engage families in the care of their early/small baby, build health care provider competence 
and link community health workers (health surveillance assistants, in this case) to households 
post-discharge is deeply important. 
See Annexure C for a table of evaluation questions and findings for Outcome 1.
29
3.3 Outcome 2: Targeted technical assistance to implement Family-Led Care 
in Malawi – “cutting edge stuff” 
Malawi was the demonstration country selected for targeted technical assistance in conjunction with 
implementation research. The activities in Malawi reflect the pursuance of Outcome 2 of the Every 
Preemie project in that Balaka district became the demonstration site for the implementation of the 
Family-Led Care model. Balaka district was selected because of the linkage of Every Preemie with PCI’s 
Njira Project, a five-year USAID/Malawi Development Food Assistance Program deployed in a number of 
traditional authority areas in Balaka district. The community-based health promotion activities within 
Njira had the potential to be harnessed as a platform to promote and extend quality home-based care 
for preterm and LBW babies.
This subsection describes the basics of the Family-Led Care model and its implementation in Balaka 
district, as well as the perceptions of implementers and other stakeholders on the achievements and 
challenges of implementing the model in Balaka district and the way forward. A more detailed report, 
“Telling the Story” of Family-Led Care will be produced as a separate document.
3.3.1 The Family-Led Care model
The model depicted in Figure 5 is a theoretical model of the components of Family-Led Care and how it 
should be implemented. “The Family-Led Care model is designed to improve the quality of KMC pro￾vided to inpatient preterm and LBW newborns; strengthen post-discharge follow-up care; and extend 
care of the preterm/LBW newborn to the community and household levels.”34 The care of the small 
newborn starts with a services pathway (clinical care) in the health facility with maternity and newborn 
services (including a KMC space or room) that aims to improve the quality of KMC provided to inpatient 
preterm and LBW newborns. This component is described in the left-hand column of the figure and 
focuses on improving provider skills and quality of care in KMC units and on empowering families to 
participate in the care of their preterm/LBW babies. It also includes clinical training and capacity 
strengthening, QI processes and the procurement of essential supplies and equipment.
The right-hand column of the figure describes the practices pathway (community engagement), which 
represents an extension of the care of preterm/LBW newborns to the household level and active links to 
the health system. This component includes care groups and HSAs who provide home-based follow up 
visits and encourage families to go for facility-based follow-up care, to give guidance on basic care for 
preterm and LBW babies, to provide them with the basic family monitoring form on which to track the 
well-being of the baby and to promote male involvement. The linkage between facility and community is 
the referral system that should ensure that the mother and family continue caring for the small baby at 
home, are able to identify danger signs and seek immediate treatment, and regularly return to the 
facility for post-discharge follow-up of the baby.
 34 Annual Report Year 4
30
Figure 5. Basic components of the Family-Led Care model
To implement the model, a Family-Led Care package of materials and tools was developed. These 
included an orientation flipbook with messages on the care of preterm/LBW newborns for providers to 
use at admission to KMC, a take-home leaflet with a summary of key messages from the flipchart, an 
easy-to-use newborn monitoring form for families to use in the facility and at home, and a feeding chart 
for clinical providers to use during inpatient care. The tools are available on the Every Preemie 
website.35 During the time of the Every Preemie project in Malawi, the resource materials already had 
wider use – “the materials that they have produced, we are actually using them in other programs”
(MW12). Furthermore, the materials formed the basis of the development of the Global Family-Led Care 
Package with a variety of resources that can be adapted for introduction and scale up of the model in 
new countries. These will be available in June 2019.36
3.3.2 Implementation of the Family-Led Care model
The Balaka District Hospital and eight health centers where most births occurred were identified as the 
health facilities to receive targeted technical assistance to pilot the implementation of the Family-Led 
Care model in the district (see map in Figure 6). Five health centers and the hospital had the ability to 
provide inpatient Family-Led Care and three health centers with no maternity services could provide 
Family-Led Care-based follow-up. 
 35 https://www.everypreemie.org/ 36 https://www.everypreemie.org/family-led-care-global/
31
Figure 6. Health facilities covered by Family-Led Care in Balaka district, Malawi
(a) The services pathway in the health facility
The services pathway had three components:
1. Capacity strengthening through training. From 2016 through 2018, 128 health care providers (nurse￾midwives, medical assistants and clinical officers) and 20 support staff (mainly hospital attendants) 
from the designated health facilities were trained in Essential Care for Every Baby (ECEB), Essential 
Care for Small Babies (ECSB) and Family-Led Care. To strengthen linkages from the facility to the 
household post-discharge, 93 HSAs were also trained on Family-Led Care. 
2. Infrastructure, equipment and supplies. Prior to the design and implementation of the model, two 
health facility assessments were conducted to identify clinical care needs for early/small babies in 
Balaka district. This was followed by infrastructure upgrades, the procurement of equipment (e.g. 
accurate weighing scales) and supplies (e.g. feeding cups).
3. Quality improvement. Every Preemie worked with MaiKhanda Trust, an NGO specializing in QI, to 
focus on PTB/LBW interventions in the target facilities and work on creating stronger linkages 
between communities and facilities. These activities were harmonized with the rollout of the Family￾Led Care model. Mentors from the district hospital were nominated to conduct monthly coaching 
visits to each of the target health facilities. They focused on improving regular monitoring of and 
documentation for all the preterm/LBW babies and data quality and completeness. Further activities 
include monthly mentors’ meetings to share lessons and challenges and five collaborative learning 
sessions. 
32
The overall aim of activities and inpatient care at the health facility was for health care providers to use 
their new skills to improve the quality of care in the KMC unit and to facilitate the empowerment of 
families to participate directly in the care of their early/small newborns during their stay in the facility 
and at home post discharge. 
“The clinical support, the technical support we provided, it really was couched within the concept of 
Family-Led Care, given the human resources shortage in the hospitals, then the concept was to 
involve not only the mothers but the families to a significant extent to actually look at what was 
needed clinically for the baby.” (CO7) 
(b) The practices pathway in the community and at home
The practices pathway also had three components:
1. Mothers and families were taught to take care of their early/small newborn during their stay in the 
health facility and what to do after discharge. They received a take-home leaflet with key messages 
and were to continue completing a Basic Family Monitoring Form twice a day;
2. Health surveillance assistants (n=142) and care group leaders (number unknown) were oriented in 
Family-Led Care as part of their training in essential newborn care and had a support role; and
3. There was ongoing community sensitization through existing structures like community meetings.
3.3.3 Family-Led Care implementation – did it work?
As part of the evaluation, 16 informants who were involved in implementing Family-Led Care in Balaka 
district and 8 informants working at the national level, in either government or partner organizations or 
projects, were interviewed.
As part of overall efforts to measure the effect of the implementation of the Family-Led Care model in 
Malawi, data were collected from MOH facility records to measure key indicators of KMC initiation and 
related service delivery results over time; these indicators 
were included in the project’s performance-monitoring 
plan. While there were significant recorded improvements 
in KMC admissions and reductions in newborn mortality 
(see text box), there was little observed improvement in
percentage of KMC newborns with adequate weight gain at 
the first facility-based follow-up visit. However, data 
quality/completeness for this indicator (complete recording 
of follow-up date and weight) improved from 16% in 2016 
to 69% at the end of 2018 in the recording of follow-up date and weight (p=<0.0001). Collected data 
helped to track key MOH indicators as well as data quality during the period of project support; 
however, due to the documented issues with data quality in MOH records, lack of counterfactual (lack of 
data collected from other sites not receiving project support) and in recognition of the various external 
factors that might influence results, caution is warranted in (positively or negatively) attributing results 
to the project.
Data collected from MOH facility-based 
records indicate a high enrollment rate of 
eligible preterm/LBW newborns (<2500 g) 
initiated on KMC throughout the project 
period as well as a significant reduction in 
in-facility preterm/LBW newborn deaths 
during the project period, from 11% in 
2016 and 4% in 2018 (p=0.018).
33
Table 4 gives a summary of the perceptions of the catalytic achievements of Family-Led Care in terms of 
facility-based care (the services pathway) and community-based engagement (the practices pathway) 
for preterm/LBW newborns. 
Table 4. Perceived catalytic effect of the implementation of the Family-Led Care model
Services pathway (clinical care)
• As a direct result of 
Every Preemie 
engagement in Balaka 
district around Family￾Led Care and KMC, the 
District Health Officer 
appointed a KMC 
coordinator at Balaka 
District Hospital (a 
“champion”)
“Before [appointing a KMC coordinator] the program wasn’t that kicking.” (MW04)
• Staff dedicated to the 
care of preterm/LBW 
newborns
“Before Family-Led Care started ... the staff is the same staff which was in postnatal 
taking care for these babies. … During the night it’s only two nurses, so you can imagine 
nurses should care for the cesarean section patients, care for antenatal patients and the 
same nurse should care for the sick babies and the same nurse can care for KMC – it was 
not easy. And these [LBW] babies [in KMC were] left out. … It was really a fight for KMC … 
to be a standalone model [with its own staff]. As for me, I still stand to say, ‘Wow, … we 
are able to care… for these babies like special’! They are now special, rather than to be 
combined with the postnatal mothers. … But the good thing is they left some people [who 
were not rotated to other wards].” (MW05)
• Staff capacity building 
improved knowledge, 
skills, quality of care
“Even the knowledge and the skills of the staff looking after preterm or low birthweight 
infants had actually improved.” (MW12)
• Focused quality 
improvement and 
transferability of the 
approach 
“If people are able to see the challenges, this is where we went wrong, and then develop 
action points, how can we improve this. It helps a lot in terms of improving the out￾comes.” (M06)
“The approach that this project also took, it was like a linear approach. MNH is too broad, 
so this project was just focusing on premature babies. … And then we were also advising 
… the QI mentors … they should use the same QI concept maybe to the MNH, to the other 
side within the MNH category. So that kind of a thing was also good to us.” (MW13)
• Improved monitoring of 
preterm/LBW 
newborns
“This time around we are able to identify babies who need KMC. … All those babies are 
being monitored effectively.” (MW05)
• Resource mobilization 
and enhancement of 
the KMC unit
“In the KMC ward we received the mattresses and the beds, the feeding cups, tubes and 
then the drips and the knowledge how the babies would be draped in front of their 
mothers.” (MW01)
“At first of course the room that we were in we had that one only, so they tried to advo￾cate for another room. … The space was a challenge, so we negotiated for a space … 
another room to keep the mothers.” (MW13) 
34
• Counting every baby –
improved 
documentation, data 
management, tracking, 
and reporting
“We have seen a tremendous increase in admission of our babies.” (MW01)
“At facility level … I have noted … the issue of data … improved … documentation of KMC 
registers. … When you go to a facility, you can … see data for the low birthweight baby … 
and you go into the KMC [space], you actually see that this baby was initiated on KMC. … 
When you go even to the other reporting elements, you actually see that this data [can] 
be traced … you can actually have a picture to say, ‘Yes, low birthweight babies are being 
taken care of’.” (MW06)
“Before Family-Led Care babies were not admitted, they were not having forms, so we 
were not able to see if the mother absconded. … Because of this Family-Led Care, we are 
now able to identify that the mother has absconded.” (MW05)
Practices pathway (community engagement)
• Empowerment of 
mothers and guardians 
to take care of 
preterm/LBW babies 
“Parents are much more involved than they were at the beginning [of the Every Preemie 
project]. … The parents are going home with some understanding of what to do other 
than going home totally confused about what is going on. And the parents are coming 
back more often.” (CO2)
• Continuity of care: 
increased follow-up of 
babies
“The big achievements with the Family-Led Care project is this that we are able to retain –
we have been able to retain a lot of babies and we are able to follow them up to their 
communities.” (MW01)
• Community awareness 
and acceptance of the 
LBW/preterm baby
“The other achievement that I have seen is on the involvement of the caregivers. It has 
helped a lot in terms of even the attitude of the community towards the low birthweight 
babies. I think by now where the Family-Led Care was, communities have been sensitized 
and they know that a low birthweight baby or a preterm baby is a baby and if given a 
chance this baby can also live and grow just like any other baby.” (MW06)
• Community 
participation in 
management of LBW 
babies – local support 
for mothers
“It’s easier for them [cluster/care group leaders] to do home visits and follow-up.”
(MW08)
“[The] community group is readily available for the family and is able to support the 
family.” (MW02)
• Good collaboration 
between community, 
mothers and health 
care workers 
“There's linkages between nurses and midwives and health workers in the community like 
the health surveillance assistants in the community, as well as those women, the care￾takers in the community, they are being linked in.” (MW02)
• Peer motivator –
champion mothers who 
encourage others in the 
community
“We have champion mothers, we have admitted say 900 grams; the baby has been 
coming for follow-up. It’s now a big baby. These mothers are able to talk to their friends in 
the villages, like, ‘You see, this is my baby. You can also practice, you can also do it; your 
baby will survive.’ So it’s champion mothers who are encouraging their friends in the 
community.” (MW05)
The major impacts of Family-Led Care mentioned by informants were improved health outcomes for the 
preterm and LBW newborn and a higher survival rate. This is a significant finding and is supported by 
review of MOH data. Figure 7 is a causal graph depiction of the influences mentioned.
35
Figure 7. Perceived catalytic influence of the implementation of Family-Led Care in Balaka district
Informants at the national level provided more distal descriptions of perceived benefits of implementing 
Family-Led Care and focused much more on the facility-community linkage of the model. One informant 
commented on Every Preemie’s achievements as follows:
“I know uptake for kangaroo mother care has gone up, the number of babies being put on kangaroo 
mother care, that number has gone up. I need to look at the mortality figures at hospital level, but 
the last time I listened to their presentation there was an impact, KMC uptake, KMC practices and 
even the knowledge and the skills of the staff looking after preterm or low birthweight infants had 
actually improved. There was also improvement in the quality of care, so things around feeding for 
these preterm low birthweight babies which is a big thing, had actually improved.” (MW12)
The following is a view from a global informant on how Family-Led Care brought together multiple issues 
in preterm and LBW care because the model was established in a holistic systems approach: 
We weren’t completely off base to think that parents have the capacity to really provide some very 
robust clinical care and to help them understand what is needed in a way that’s accessible and feasi￾ble for them. I loved the project … it was something that addressed so many gaps in terms of clinical 
care, in terms of systems care, in terms of human resources, in terms of psychosocial cultural 
aspects. And we looked at it from a systems perspective … I feel like we are getting a better and 
better understanding what the system perspective needs to be, rather than these isolated, discon￾nected things that [we did] 20 years ago …” (CO7)
36
(a) Challenges with implementation
Three main challenges to the implementation of Family-Led Care were mentioned: (1) as a pilot, Family￾Led Care was not implemented in the whole district; (2) there were concerns about the sustainability of 
the provision and completion of Family-Led Care forms and charts (particularly post-project); and (3) 
there were expressed concerns about the care of preterm/LBW newborns post-discharge including 
follow up provided by HSAs (and Care Groups) at the household level. 
Some informants referred to the limitation of piloting the model in a selected number of health 
facilities only. This exposed a further weakness in the reinforcement of the community component, 
especially regarding the facility-based follow-up of the preterm/LBW newborns. Not all babies initiated 
on KMC (especially in Balaka Hospital) were followed up at the same health facility – “at the centers who 
do not practice Family-Led Care … we are having challenges in case of follow-up of the babies” (MW05-
1). The health care providers from these centers were not familiar with the special community care 
provisions for preterm/LBW babies, as they did not participate in the training and rollout of Family-Led 
Care. They also did not have the counselling materials to guide and reinforce the key messages. One 
informant suggested, “instead of having implemented in selected sites, it should be all sites” (MW06).
There were also remarks about the sustainable provision of the forms and charts adapted and 
developed as part of the Family-Led Care package and the motivation for continuing to complete all the 
forms once the project ended. It is important to highlight that prior to Every Preemie’s engagement in 
Balaka district, health care providers were not consistently or adequately capturing key elements of care 
and outcomes related to provision of KMC and newborn outcomes. Newborn charts were largely 
incomplete; feeds and weight gain were not monitored, and babies were discharged with little 
information about their growth during KMC or their stability upon discharge. In response, Every Preemie 
worked with the DHMT and introduced a feeding/growth chart and a family monitoring form and 
through the QI work strengthened the completion of existing MOH maternal and newborn registers.
One informant viewed the Family-Led Care forms and charts as “the complementary way of 
documenting the project” (MW14). 
As time goes I am sure some of the forms would be lost, people will stop filling the forms – because 
… they may not have the forms and because some health workers will not be willing to fill the forms. 
So I am afraid as time goes they might lose the forms.” (MW14)
Facility-based providers commented on the number of forms, documents and registers that had to be 
completed (beyond the feeding form and family monitoring form introduced by Every Preemie). They
suggested merging documents for the MOH. 
“In terms of the monitoring forms I think there are many. It’s like we have the feeding charts, we 
have the vital signs, the one which we record vital signs and we have the admissions. I think if it can 
be possible to maybe combine to one form.” (MW05-1)
There were high expectations for the mobilization of the community towards the implementation of 
the Family-Led Care: “I think the work in Malawi was really very much at the grassroots level … So that 
might be one aspect that again was unique” (GP08-2). However, multiple informants indicated that the 
HSAs were a weak link in the implementation of the model for many reasons. These include overload 
with many different tasks, lack of knowledge of or training in preterm/LBW newborn care and Family-
37
Led Care, inadequate supervision, expectation of remuneration to attend meetings, mobility and 
transport issues, and living far from their catchment area.
The three Family-Led Care health centers without maternity services did undertake QI projects to 
improve the follow-up of preterm/LBW babies by communicating with the district hospital and using 
community health advisory committees and HSAs to sensitize communities.37 It appears that the HSAs in 
the district were not always included in the district health activities related to Family-Led Care and the 
follow-up of preterm/LBW newborns in the community. This is how a member of the DHMT explained 
the situation:
“The biggest challenges … we noted very late that not everybody was involved in the Family-Led 
Care … For instance the HSAs, the health surveillance assistants who are right in the communities, 
they weren’t involved in the review meetings ... But now we wanted them to be implementing the 
programs, whereas we haven’t trained them, or they were trained but now we wouldn’t take them 
on board during the review meetings to see what problems we were having and so on. … So it … was 
the key problem … a shortfall. … We would like the HSAs to be following up … Now we were not 
taking those HSAs on board to give us feedback of what they are finding in those – we just told them 
that you have to be following them up in the communities as well, but we are not receiving feedback 
from them … when we were having the review meetings it was just [the District Health Manage￾ment Team] and the facilities. … We were not getting a voice from them, so maybe that’s how you 
take it as a challenge.” (MW01)
Informants highlighted issues around the scale up of Family-Led Care in Malawi under USAID/Malawi’s 
bilateral project — Organized Network of Services for Everyone’s Health (ONSE). In FY18, Every Preemie 
was informed by USAID/Malawi and USAID/Washington that future implementation of the model would 
be managed by ONSE. Training-of-trainer sessions in Family-Led Care took place for 16 ONSE-supported 
districts, as well as the rest of the districts in Malawi in FY18 with support from Every Preemie. There 
was no further training in Balaka district in the last year of the project and ONSE did not manage to 
conduct the additional training needed to get more health centers on board or to do refresher training 
for health facilities already providing Family-Led Care. 
Some informants indicated that PTB and LBW may not get the same focused attention under ONSE that 
it had received under Every Preemie, because ONSE structures were different, for example quality 
improvement was a separate department – “we have QI as a component, but we haven’t incorporated it 
yet” (MW06). ONSE technical support is mandated to include other activities (FP/RH, MNCH, malaria, 
WASH) and cannot be organized in a vertical fashion for PTB/LBW or inpatient care for small and sick 
newborns only. 
“ONSE said that the system will change, it cannot continue supporting as the PCI was doing just be￾cause it has a lot of things to support. So, it’s like we will see many changes like the QI team and in 
terms of supervision, supervisory review meetings they will be adjusting it.” (MW05-1)
Managing this transition and changes to the in-depth implementation of the model are beyond the 
scope of Every Preemie. 
 37 MaiKhanda. Every Preemie - Scale narrative programme report for deliverable number eight (August-November 
2018)
38
3.3.4 The way forward – “the whole concept of Family-Led Care is here to stay”
Every Preemie’s work focused on nine health facilities in Balaka district; however, the project built a 
strong network of stakeholders from the national MOH Reproductive Health Directorate to the Balaka 
DHMT; among implementing partners operating in Malawi including the National Safe Motherhood 
Working Group; and among health care providers both within facilities and at the community level. At 
the completion of implementation, the project had left key inputs in place38 that, if taken up adequately 
by the MOH and USAID implementing partners, will ensure a smooth transition to future 
implementation. 
When probed about the legacy of the Family-Led Care project in Balaka district, many implementers felt 
that Family-Led Care was there to stay – “Family-Led Care will continue, that we should assure you”
(MW05-1). Some of the reasons for the optimism was the approach to embed Family-Led Care in the 
district health system and the visibility of the Family-Led Care model in national newborn structures. 
“Some of the activities that we have done, I believe they will still be there [in three years’ time]. I will 
give an example in terms of following up the babies in the community. Since the structures are still 
there and then there is nothing new that they have actually brought in, like parallel structures. We 
have used the same structures that were there in the community and then my hope is that we will 
continue.” (MW03) 
“Every Preemie was part of the Safe Motherhood Technical Working Group, for example, in Malawi 
and so their level of influence would be that they were working with ministry in the districts and 
they were doing the implementation research and feeding back to government. I think that that’s a 
good thing, that’s what we want to see happening. And so that contributes towards moving to￾wards scale, rather than just kind of coming in and doing your project and not necessarily feeding 
back.” (GP01) 
One informant provided advice to other districts wishing to implement Family-Led Care:
“I would advise the guys that this is the programme and this programme is here to stay. We have 
tried it in Balaka and then we have seen a lot of good results, a lot fruits.” (MW01) 
Despite the confidence of informants in the effectiveness of the Family-Led Care model and in continu￾ing to provide quality support for preterm and LBW newborns, they acknowledged that Family-Led Care 
was still in its infancy – “a toddler just starting to crawl” [CO2]. The need for more advocacy and 
strengthening the community component of the model was specifically mentioned.
“I wouldn’t say [the sand] has shifted as in fully shifted. We are still in the process … to get their [the 
sceptics’] fuller buy-in to say yes of course, we are able to track each and every person who has been 
discharged from the facility who is under KMC and now has been discharged in the community … So 
we are still in that process of getting to know. I wouldn’t say that we have reached the final stage 
and say okay now we are doing fine.” (MW01)
 38 The project has trained master trainers in Malawi; updated the Family-Led Care orientation package for 
providers; given templates of forms to the MOH (and ONSE) for their use; and strengthened provider capacity 
through training and the QI work.
39
See Annexure D for evaluation questions and achievements by Outcome 2. 
3.4 Outcome 3: Preparing countries to focus on preterm and low birth weight 
care – “a platform for action and for strategic planning”
3.4.1 Development of global documents – “a significant contribution”
This section reports on global activities including (1) tracking and monitoring country level indicators in 
24 USAID priority countries, including (a) the publication of country profiles highlighting country-specific 
information on PTB and LBW for each USAID priority country and (b) a dashboard indicator; (2) a 
PTB/LBW Continuum of Care matrix; (3) a multi-country antenatal corticosteroids landscape analysis; (4) 
a Joint Statement on Preterm Birth; (5) a multi-country situation analysis of inpatient care for small and 
sick newborns; (6) the WHO document Survive and Thrive: Transforming care for every small and sick 
newborn; (7) the development of the Global Family-Led Care package that can be adapted by individual 
countries, has already been mentioned in the discussion of the Malawi experience in Section 3.2.1; and 
(8) a global evidence synthesis on nurturing care for small and sick newborns.
“We’re leaving behind some staff who understand how to do QI. We have greatly 
strengthened documentation. I think overall we’ve built some capacity to deliver 
KMC.“ (CO2)
“If we have our heads together Balaka should actually be a shining example to the 
other districts. … Then Balaka would easily be a model district where you get people 
from other districts, go and learn from Balaka. … So I know that once Every Preemie 
and the Family-Led Care is shared, it cascades in the other districts. … Because we 
have got evidence of the best practice, the other districts will not be starting from 
scratch. … That will be a best practice that can actually be shared even with other 
countries.” (MW16)
40
3.4.2 Tracking global coverage of PTB/LBW and country profiles – “good for advocacy”
(A) Country Profiles
As part of the commitment to catalyze action in the 24 countries prioritized by USAID for MCH (see map 
in Figure 8), data on PTB and LBW for each country were compiled. From this, individual country profiles 
and a summary profile were created. The aim was to provide a national-level report on the status of the 
prevention and care for preterm and LBW babies for each country and to highlight related risk factors 
and the coverage of important reproductive, maternal and newborn health care interventions. “For 
most countries these profiles represent the first compilation of data focused on PTB/LBW”39. National￾level information related to PTB and LBW was extracted (e.g. from UN estimates for population and 
mortality rates); other primary data sources were consulted (e.g. available population-based surveys); 
and secondary data such as basic demographic information related to PTB/LBW were compiled (e.g. 
neonatal mortality rate, preterm birth rate, babies born <2500 grams and babies born <28 weeks of 
gestation). PTB/LBW interventions that occur across the continuum of care (pre-pregnancy to the 
postnatal period) and at various levels of the health system (household to hospital) were also inter￾rogated (e.g. adolescent birth rate, short stature of women and obesity in women of childbearing age). 
Interviews with key country informants provided insights “into the health system as related to PTB/LBW 
including health policy, pre-service and in-service provider training from the community to hospital level 
and data on PTB/LBW generated by the national Health Management Information System (HMIS).”40
The country profiles were launched in November 2015 at an Every Preemie-sponsored World 
Prematurity Day event on Capitol Hill in Washington, DC. This was part of a multi-partner global-level 
call for action for improved maternal and newborn health through partnerships and innovations.
 39 Annual Report Year 1 40 https://www.everypreemie.org/country-profiles/
41
Figure 8. Map of USAID priority countries 
The country profiles were updated in 2017 and a new profile was created for Myanmar, a new addition 
to USAID’s priority countries. A further update is expected before the end of the Every Preemie project 
in 2019. There are also French translations of the profiles for the Democratic Republic of Congo (DRC), 
Haiti, Madagascar, Mali, and Senegal and a Portuguese translation for Mozambique. In 2016, a profile 
for Sierra Leone was added to the set of country profiles given the project’s inclusion of Sierra Leone in 
the multi-country analysis of ACS use (see Section 3.3.2).
According to the Every Preemie annual and biannual reports, the profiles were disseminated to all 
USAID priority countries via USAID missions in these countries. Hard copies were also distributed 
throughout the project’s life cycle at various other events where Every Preemie had a presence. 
Project annual reports anticipated that the country profiles would “be used to catalyze dialogue and ac￾tion”41 and “energy”42 around PTB/LBW across the priority countries. By the time this evaluation report 
was compiled, the country profiles had been downloaded from the website over 26,000 times. 
Downloads, distribution and dissemination do not equal actual use, which is impossible to 
measure. 
Informants operating at the global level who were interviewed were mostly positive about the 
development of the country profiles – “we made use of them and they were very valuable” (GP04). One 
 41 Annual Report Year 1 42 Annual Reports Year 3
42
referred to the profiles as “fantastic” (GP02). Two referred to them as “good for advocacy” (GP04/06). 
Another informant described the available information as follows:
“The thing is that you want to see information about countries and those profiles are brought 
together with what was available in the public sector. Then there isn’t much new to offer and the 
gaps in the information remained. I don’t say that it was the fault of the profile. Profiles can be like 
the ones highlighting that there isn’t actually a lot of information.” (GP03)
Of the representatives of the six countries that responded to the online survey, only three were familiar 
with their country’s profile and two indicated that they had used it and had shared it with their 
ministries. Three of the 10 global-level respondents to the survey had used the country profiles. They 
were not asked how they had used it. Anecdotally, Every Preemie team members report hearing other 
partners including Born On Time, Saving Newborn Lives and the Maternal & Child Survival Project using 
the profiles. 
(B) Dashboard Indicator
A country-level tracking and monitoring system was developed that included a dashboard indicator to 
track clinical standards and operating procedures for the care of preterm and LBW newborns at the 
hospital level in each of the USAID priority countries based on the WHO Recommendations on 
interventions to improve preterm outcomes. The WHO Recommendations include ten critical elements 
for preterm care: 
1. Antenatal corticosteroids 
2. Tocolytics 
3. Magnesium sulphate 
4. Antibiotics for preterm premature rupture of membranes 
5. No antibiotics with intact membranes 
6. Vaginal birth preference 
7. Kangaroo mother care
8. Continuous positive airway pressure (CPAP) for respiratory distress syndrome 
9. Safe oxygen use 
10. Surfactant 
This is how one partner described the development of this dashboard indicator:
“And so going back to the indicator that I thought was pretty clever, was that around the time we 
were struggling to find one indicator to track as global coverage. We couldn’t find any indicator, so 
they said that why don’t we look at the 10 recommendations that WHO had made for addressing 
preterm birth complications … the preterm guideline, its 10 recommendations. So we said okay let’s 
look at countries, do they have policies in place for these 10 recommendations. And do they have 
drugs in place, like antenatal corticosteroids was one of their recommendations. Do countries have 
policies on antenatal corticosteroids, or do they have antenatal corticosteroids the commodity itself 
in the country. So that's how they combined these 10 different recommendations and came up with 
like one consolidated indicator.
It’s not easy, but they are tracking that now. If you look at the country profiles, they have one 
indicator I think under health systems or something like that, tracking the global coverage of these 
43
recommendations. So they did that once at the beginning of the project and we are doing that again 
at the end of the project and see if any changes occurred over time.” (GP07)
A blog post describing the development of this indicator and the scores for the different countries on 
this indicator was also posted on the website in 2016.43 Figure 9 gives an overview of the performance 
progress on the 10 elements of the dashboard indicator by country from 2015 to 2019. The elements 
that were included in more than 15 national clinical standards in 2015 were magnesium sulphate and 
KMC. For all the elements, except for no antibiotics with intact membranes, the number of countries 
having these elements in their standards increased from 2015 to 2019, with five elements in more than 
15 countries’ standards, namely ACS, tocolytics, magnesium sulphate, antibiotics for preterm premature 
rupture of membranes and KMC. The guideline for CPAP increased from no country in 2015 to five
countries in 2019. The mean score for this dashboard indicator increased from 3.9 in 2015 to 4.7 in 
2019, which means an average increase of slightly less than one element per country.
Figure 9. Performance of the dashboard elements over time
 43 http://www.everypreemie.org/are-preterm-and-low-birth-weight-babies-treated-as-a-priority/
0% 20% 40% 60% 80% 100%
Vaginal birth preference
Tocolytics
Surfactant
Safe oxygen
No antibiotics with intact membranes
MgSO4
KMC
CPAP for RDS
Antibiotics for pPROM
Antenatal Corticosteroids
2015 2019
Mean score:
2015 – 3.9
2019 – 4.7
Percentage of countries
44
3.4.3 Continuum of Care for Prevention of Preterm Birth, Management of Preterm Labor 
and Delivery, and Care of the Preterm and Small Newborn
An early product designed and disseminated by Every Preemie was a matrix on the Continuum of Care 
for the Prevention of Preterm Birth, Management of Preterm Labor and Delivery, and Care of the Pre￾term and Small Newborn, known as the PTB Continuum of Care matrix. The matrix highlights “priority 
evidence-based interventions for the prevention of PTB, the management of preterm labor, and care of 
the preterm and small newborn”.44 It was designed to provide a road map for partners who are involved 
in designing and planning activities related to preterm birth and LBW and is the first time this 
information was organized and framed in this manner. The matrix was disseminated to USAID missions,
country-level stakeholders and in meetings in Washington, DC and globally. Although it seems as if this 
matrix did not attract enough attention, individuals reported using it for strategic planning. 
One informant described it as “a great tool to look strategically at what are the gaps” (GP09).
A few individuals reported on how they had used the matrix, especially for strategic planning. Pakistan 
provided a more detailed description in the online survey: 
“The continuum of care matrix was an integral part and basis of our Maternal, Newborn and Child 
Health (MNCH) award that was implemented at a larger scale in 16 districts of Sindh. Interventions 
were designed and implemented based on the components of the matrix both in the community and 
at the facility level. The Activity was implemented in close coordination with Sindh Government and 
all the materials produced in relation with various components of continuum of care were shared 
with care providers and government officials.” 
It seems as if the Continuum of Care matrix “did not attract enough attention” (CO3) and not many of 
the informants remembered seeing it – “I am not sure if I am familiar with that one” (GP05). Of the six 
USAID priority countries responding to the online survey three were familiar with the document and 
used it for planning interventions for implementation. Three of the 10 global partners who completed 
the full online survey had used the matrix. 
One partner acknowledged the value and usefulness of the matrix – “there is more detail for the sick 
newborn” (GP06) – but was concerned that duplication and overlap with other similar attempts might 
be confusing to ministries of health. 
3.4.4 Multi-country antenatal corticosteroids landscape analysis
One of the more ‘hands-on’, country-level activities of Every Preemie was the Antenatal Corticosteroids 
for Women at Risk of Imminent Preterm Birth in the Democratic Republic of the Congo, Ethiopia, Malawi, 
Nigeria, Sierra Leone, Tanzania and Uganda: A Policy and Implementation Landscape Analysis. This 
analysis was conducted in seven of the eight Pathfinder countries of the UN Commission on Life-Saving 
Commodities (UNCoLSC) in sub-Saharan Africa on behalf of the UNCoLSC Newborn Health Technical 
Resource Team. MOH representatives were interviewed in each country and government documents 
were reviewed for ACS-specific content. 
 44 Annual Report Year 1
45
The results of this survey were published in 2016 as an internal report and shared at a UNCoLSC ACS 
Technical Working Group meeting. In 2018 it was published in a journal article format in Global Health: 
Science and Practice.
45 For each country, information is provided on the following: use of ACS at 
different levels of care; providers authorized to prescribe and/or administer ACS; critical maternal and 
newborn health care services available for safe and effective use of ACS; and tracking methods for ACS 
use. This is the short summary that appeared in the journal article:
“Countries have put in place some elements necessary for safe and effective ACS use, but 
significant challenges remain including: ensuring accurate gestational age determination, 
establishing clear treatment guidelines, strengthening provider capacity, incorporating obstetric 
indications for ACS use in national essential medicines lists, and collecting and using ACS-related 
data in the HMIS [Health Management Information System]. Most importantly, the quality of 
maternal and newborn care, including specialized newborn care, needs improvement to ensure a 
strong foundation for the safe and effective use of ACS.”
As part of the end-of-project evaluation, representatives in the seven countries that featured in the 
landscape analysis were contacted by email to inquire about any further developments with regard to 
national ACS policies and practice. Responses were received from four of the seven countries. This 
exercise yielded little information on specifically if/how the analysis had been used to influence policy or 
practice at the country level. No country could provide examples of anecdotal data on the use of ACS in 
the respective countries, though two countries indicated that there had been an increase in the use of 
ACS in a number of pilot sites. Ethiopia reported that there had been “no bold policy change regarding 
ACS” but that it was expected that “some of the ACS policy issues” would get attention in the Basic 
Emergency Obstetric and Neonatal Care guidelines that were under revision. This is what the 
respondent from Uganda said:
“ACS were included in our guidelines just before the embargo following a pilot in Uganda supported 
by the UN Life Saving Commodities commission and USAID/URC [University Research Company]. 
When the embargo came on we waited for further guidance from WHO. We are implementing the 
revised policy but it is not extensively disseminated. That is where we need to put more strength.”
One informant referred to ongoing challenges to updating national ACS guidance, including the need to 
harmonize different guideline documents that were in existence. Another informant referred to a 
problem with stock-outs of ACS. ACS had previously been procured from a trust fund but ongoing 
procurement was taken over by the Central Medical Stores. 
In the Year 2 Annual Report mention was made of the “valuable relationships” established that could 
“provide valuable inroads with ministries of health in these countries and can be tapped in the future as 
the project continues to advocate for action at the country level”.46 At the UNCoLSC ACS Working Group 
feedback meeting, country representatives “emphasized that ACS use is fairly new and that countries 
 45 Greensides D, Robb-McCord J, Noriega A, Litch J. Antenatal Corticosteroids for Women at Risk of Imminent 
Preterm Birth in 7 sub-Saharan African Countries: A Policy and Implementation Landscape Analysis. Global Health: 
Science and Practice. 2018;6(4):644-656. 46 Annual Report Year 2
46
need support to institutionalize WHO recommendations for improved maternal and newborn health”.47
It appears as if Every Preemie could not maintain these relationships, inter alia because of the limited 
budget and the small team.
3.4.5 Joint statement on preterm birth
Every Preemie was involved in the development and review of three international joint statements 
disseminated in 2016/7 to demonstrate professional associations’ commitment to action and the imple￾mentation of key World Health Assembly resolutions such as the ENAP, the Global Strategy for 
Women’s, Children’s and Adolescents’ Health, and the 2015 WHO recommendations on interventions to 
improve preterm birth outcomes. Every Preemie led the development of the Joint Statement 
International WHO Recommendations on Interventions to Improve Preterm Birth Outcomes: A 
Commitment to Action from Professional Health Organizations. The Every Preemie team also 
contributed significantly to the development of the statements on Kangaroo Mother Care (led by SNL) 
and Quality of Care (led by the USAID-funded ASSIST project).
The Joint Statement on Preterm Birth recognizes the important and collaborative role of national 
professional associations to assist countries in updating policies and programs and supporting the safe 
and effective implementation of the WHO recommendations. Five relevant international professional 
associations reviewed and endorsed this joint statement, namely COINN, ICN, the International 
Confederation of Midwives, the International Federation of Gynecology and Obstetrics, and the 
International Pediatric Association. 
The joint statements were distributed through the Every Preemie networks, but the intention was to
have them disseminated through the membership of the respective international professional 
associations as well. None of the respondents from the USAID countries who completed the online 
survey was familiar with the Joint Statement on Preterm Birth, whereas five of the ten global-level 
respondents had used it. The global informants interviewed were not very familiar with the Joint 
Statement either. One gave a more general view on the purpose of joint statements, which resonates 
with the Every Preemie view that the three joint statements “represent a significant global move to 
catalyze action for improved maternal and newborn health in low resource settings”.48
3.4.6 Multi-country situation analysis of inpatient care of newborns and young infants –
clinical care and “a snapshot of systems” 
Midway through the project cycle the “goal posts changed” (CO2) and, at the request of USAID/W, Every 
Preemie broadened its scope beyond LBW and PTB to include a focus on sick newborns and inpatient 
newborn care. A USAID staff member described the rationale for this emerging priority in the Midterm 
Review report as follows: 
“I’m really happy with the focus on the slightly broadening of the target population to look at sick 
newborns. So, it was an idea that became – it’s a huge priority for USAID now – focusing on sick 
 47 https://www.healthynewbornnetwork.org/blog/every-preemie-scale-launches-multi-country-report-antenatal￾corticosteroid-policy-implementation/ 48 Annual Report Year 2
47
newborns. And so, I’m happy with the way the Every Preemie team has been responsible to that. It 
doesn’t take them away – too far away from what they were originally designed to do … because 
the large majority of sick babies anyway are preterm and low birth weight.” (p. 30)
There is a need to define, standardize, and mainstream inpatient care of small and sick newborns on the 
essential newborn care platform. This expanded focus enabled the conceptualization of a multi-country 
situation analysis of inpatient care of newborns and young infants in order to get a better understanding 
of the country service readiness landscape. Every Preemie led the development of the protocol and 
tools for this analysis in collaboration with other global partners. The tools were tested in Malawi and 
Nepal. The protocol and tools are posted on the Every Preemie website49 and are available for global use 
by any low- or middle-income country wishing to assess service readiness and quality of care of 
inpatient small and sick newborns in public and/or private health facilities. The analysis “gives a 
snapshot of systems and procedures at multiple service delivery points” (GP09). It investigates health 
system structures, facility processes, national policies and clinical standards and parent/ caregiver 
experience of this care with a view to identify structural and procedural enablers, as well as challenges 
and gaps that hinder the quality of inpatient care of newborns and young infants. 
The protocol and situation analysis tools were highly commended by informants from global partner 
groupings. One informant felt that “although it may not be perfect”, there would be refinements as 
more countries conduct the analysis and the WHO standards of care for small and sick newborns 
become available – “I think we are now much, much better shaped to have a more consolidated situation 
assessment tool” (GP03).
“I think that was a very big critical piece of work that Every Preemie led. They led the whole dis￾cussion; they brought UNICEF, WHO and Saving Newborn Lives, USAID of course, to develop these 
tools that have been now used in several countries for conducting the assessment of small and sick 
newborns. … That was a really good piece of work and I appreciated working with Every Preemie on 
that. … We appreciated it when they brought in their consultants to help us understand the tools 
further and they shared all of the analysis framework, the protocols, helped us in any way that we 
needed whenever we went to the countries. … I feel it was a very good leadership on the part of 
Every Preemie; they have been very happy to be able to take all of that that they would have loved 
to implement it at the country level.” (GP02)
The assessment was conducted in Bangladesh, Ghana, Nepal, Pakistan, Rwanda, Tanzania and Uganda.
These countries self-selected based on the interest of the USAID mission, UNICEF or WHO country office, 
and the presence of an implementing partner interested in conducting the assessment. Every Preemie 
provided additional support to the African countries according to needs (e.g. for data analysis in Ghana 
and Tanzania), and supported a consultant to provide guidance with the implementation process 
throughout Years 4 and 5 – “so it has been used by different partners, but a prominent protocol was 
developed by Every Preemie” (GP07).
Despite an ambitious goal, different forms of delays were experienced, especially around IRB approvals 
and changes in government. By the time of this evaluation, Ghana and Uganda had produced a final 
 49 https://www.everypreemie.org/technical-materials/
48
report and data collection was completed in four more countries. Two informants referred to this as 
follows: 
“I felt [it] was extremely ambitious … but I did feel that through the review process that we were 
able to focus it down more which was really needed, but … it’s not entirely clear to me how that has 
panned out.” (GP04)
“So even the situational analysis I think we had hoped to have results from that to be available on 
World Prematurity Day last November and in fact I think we had one situational analysis report 
completed by that time.” (GP08-2)
Informants discussed the future use of the situation analysis tools and the results from the current 
situation analyses, all commenting on the importance of initiating an exercise that will “give fruit for a 
long time on what needs to be done just strengthen newborn and young infant care … [and] will have
lasting implications” (GP-08-1). 
“But now, if one can do the country situation assessment for every country … now that we have the 
situation assessment tool, if one has to redo the [country] profiles it would be really very good.”
(GP03)
“The situational analysis … we undertook … not just to get a read on a situation, but to provide a 
platform for action and for strategic planning and quality improvement of individual country ser￾vices, but also to look at them as an aggregate to say, ‘Here are different stages of this process and 
we have learnt from this overview what might be a larger goal progression and some common 
barriers and perhaps common solutions that can be found’. So I again hope that there's some mech￾anism to use this data when it all comes together and to keep it alive and really realize its value.”
(GP08-2)
Because of the limited time available for completing implementation, data analysis and report develop￾ment, it will not be possible to produce a combined report of all the country analyses. Every Preemie 
committed to develop a multi-country infographic and organize a webinar to share highlights (with 
available country data):
“Every Preemie will develop a brief to share an overview of the assessment, and if country reports 
are available by early June 2019 will include a synthesis of key findings from each implementing 
country, as well as a 2-page brief for in-country use. The project will organize a webinar to dissemi￾nate the full implementation package and country highlights. Representatives in each country will 
be invited to present their key findings.”50
Use of the data at the country level is beyond the mandate of the Every Preemie—SCALE project. 
Anecdotally, in-country stakeholders are reviewing the findings and are using them to establish action 
plans and prioritize resources for future investment. 
 50 Biannual report Year 5
49
3.4.7 Survive and Thrive: Transforming care for every small and sick newborn
Every Preemie collaborated with WHO, UNICEF, USAID, the 
Bill & Melinda Gates Foundation, the London School for 
Hygiene and Tropical Medicine and others to design and 
develop a global document on inpatient care of the small 
and sick newborn, titled Survive and Thrive: Transforming 
care for every small and sick newborn. It targets country￾level managers in ministries of health “with a goal to 
provide a programmatic framework for integrating this 
critical work into newborn inpatient care.”51 Every Preemie 
provided the project coordinator and the Senior Director, who was one of four managing editors and a 
lead author for the publication. The GAPPS Evidence and Learning Lead provided publication review. The 
Key Findings Report52 was launched on December 13, 2018 at the global Partnership for Maternal, 
Newborn and Child Health Partners Forum in New Delhi, India. The full document was launched at the 
World Health Assembly in May 2019. Every Preemie also co-hosted a panel with WHO at the Vancouver 
Women Deliver conference in June 2019.
3.4.8 Evidence synthesis on nurturing care of the small and sick newborn 
In Year 5, the project carried forward activities initiated in prior years in response to the global priority 
around inpatient care of small and sick newborns. Every Preemie worked with USAID, UNICEF, WHO and 
the USAID-funded MCSP to design and conduct an evidence review around nurturing care for small and 
sick newborns – “a very exciting piece of work working on evidence synthesis and case studies on 
nurturing care for small and sick newborns” (GP02). The aim of this report is to build on the Nurturing 
Care for Early Childhood Development—A Framework for Helping Children Survive and Thrive to 
Transform Health and Human Potential launched at the 71st World Health Assembly by providing 
guidance with a summary of evidence and best practice on approaches to nurturing care for small and 
sick newborns. The report will include a summary of findings from peer-reviewed literature, country 
case studies (including country-specific grey literature) and a gap analysis. It is expected to be finalized 
in July 2019. Findings will be used by WHO and UNICEF to develop guidelines for nurturing care to 
complement the clinical standards of care for small and sick newborns currently in development (with 
other partners including Every Preemie).
“I think the work that we are going to be doing on the nurturing care aspect will have longer term 
repercussions and will influence many changes in the coming times when … the [current] projects 
are gone.” (GP02)
 51 Annual Report Year 3 52 https://apps.who.int/iris/bitstream/handle/10665/276655/WHO-FWC-MCA-18.11-eng.pdf?ua=1
This document is a major contribution to 
global advocacy for care of the small and 
sick newborn and is setting the stage for 
other significant WHO publications
including standards of care for inpatient 
newborns and guidelines for nurturing care 
of small and sick newborns.
50
3.5 Moving forward with the global agenda on preterm birth – “foresight” 
and “leadership”
The achievements of Every Preemie at the global level are tightly linked to Outcome 3 of the project and 
will be discussed in terms of two of the top accomplishments emerging from the evaluation, namely
Every Preemie’s leadership in the PTB TWG-ICS and the corresponding Do No Harm technical brief 
series. Over the life of the project, members of the Every Preemie team participated in numerous events
focusing on PTB/LBW and small and sick newborns. 
3.5.1 The PTB/LBW Technical Working Group – “very successful to bring top leaders 
together on technical subject matters” 
From 2015 through 2018, Every Preemie convened six meetings of the PTB TWG-ICS, a group of more 
than 200 thought-leaders representing a wide range of clinical and public health disciplines.53 The 
meetings were framed to provide a multidisciplinary learning forum sharing “emerging evidence, 
relevant research and learning across the range of PTB and LBW interventions and implementation in 
low-income countries”.54 The TWG explored “potential opportunities to address gaps in critical 
knowledge that will help to overcome bottlenecks to implementation, and significantly increase 
coverage and quality of PTB and LBW evidence-based interventions.”55 These meetings were meant to 
inform “priorities for future IR [implementation research] investments, and to provide focus and 
technical insight into the development of PTB and LBW interventions and implementation 
approaches.”56 Table 5 lists the topics and the meetings that included a virtual component to maximize 
partner participation across the globe. Presentations, materials, and more information on these 
meetings are available on Every Preemie’s official website.57
 53 Annual Report Years 3 & 4 54 Annual Report Year 4 55 https://www.everypreemie.org/global-technical-working-group/ 56 Annual Report Year 1 57 https://www.everypreemie.org/global-technical-working-group/
51
Table 5. Topics discussed at the Technical Working Group meetings
Date Topic Venue
1 May 2015 Gestational age estimation in low-income countries Washington, DC
Plus web conference
16 May 2016 Preventing PTB/LBW through Lifestyle, Infection, 
Nutrition, Contraception (LINC) factors plus maternal 
complications* 
Copenhagen 
16 November 2016 Safe and effective use of preterm birth 
interventions**
Washington, DC
26 September 2017 Respectful newborn care Washington, DC
13 June 2018 Family member engagement during inpatient newborn 
care
Washington, DC
7 November 2018 Management of newborn infections and use of 
antibiotics during inpatient newborn care
Washington, DC
* Co-hosted with Ending Eclampsia
** Oxygen use, thermal stability, and lactation support
Informants considered the contribution of the PTB TWG-ICS meetings to the discourse needed for 
moving the global preterm birth agenda forward as very informative and useful because of the expertise 
that could be gathered. One referred to an important vacuum that the TWG filled with its coordinating 
role to keep momentum and accelerate the preterm and LBW agenda when other partners were moving 
on to other foci and scaling down on global meetings. 
“[The TWG] would pick a topic and they would focus on that topic on that day, they would bring in 
experts and there were these speeches or kind of presentations. And then they would have a 
broader discussion about the topic. So it was a learning opportunity for international global partners 
working in preterm birth. And I think that was a really great – that indicated to me that there was 
value in Every Preemie SCALE and keeping the momentum going through those technical working 
group meetings. … I found it extremely enriching, it was a fantastic opportunity to network with 
partners, specifically on … preterm birth and newborn health…. I was especially impressed that they 
brought in a number of country colleagues to the meeting as well, to present and to learn. … It was 
a kind of a link in the chain that they were helping to keep the momentum going. … We were no 
longer kind of like catalyzing something to start momentum, we had this journey and we are going 
on this journey and it’s a matter of keeping that momentum and continuing to build that network, 
and I think they contributed through those meetings very, very clearly.” (GP01)
The expertise that was brought together through the TWG elevated the discussion – “having those 
experts engaged has been very helpful in terms of helping prioritization of preterm birth” (GP01). The 
video-conferencing facilities for the meetings probably enabled “broad geographic representation”58. 
“I would really single out what I think the Every Preemie team did to pull together experts for the 
technical working group. Every Preemie really did a great job in getting people from very different 
perspectives, cutting-edge perspectives and bringing them together at those meetings. So I think 
they were revelatory and as a clinician I really appreciated the currency and some of the controversy
 58 Biannual Report Year 5
52
that Every Preemie was willing to pull, because that's where we need to [be] operating now, not just 
focusing on the problems and the difficulties, but how are we going to solve these things.” (GP08-2)
3.5.2 Do No Harm Technical Brief Series – “a big piece” with “longstanding benefit”
One of the spinoffs of the Technical Working Group activities was the development of a series of 
technical briefs on the safe and effective use of inpatient newborn care interventions in low-resource 
settings. 
“We found a lot of harmful practices in [five] countries and we came back saying we really must 
have some way of addressing these harmful practices. … We all felt this was important and there 
was some … sort of a felt need that we had to address harmful practices. So that's how we came up 
with the idea of having a series of technical briefs to address a series of harmful practices.” (GP07) 
The guiding principle of this series was “Do No Harm”, i.e. providing evidence-based guidance on how to 
avoid harm and improve newborn health outcomes, and were grounded in WHO recommendations and 
guidelines – “quality of care and especially for the preemies that’s also important that we are not doing 
damage” (GP03). “The target audience for the briefs is a wide range of policymakers, program managers 
and clinicians with the intended outcome of guiding decision-makers to integrate the WHO 
recommendations in their country in a safe and effective way.”59
“When you want to strengthen your program for small and sick newborn care, we would like you to 
integrate the standards recommended by WHO, but even before that, make sure that that there are 
no harmful practices. That is like job number one – ensure that you are addressing harmful practices 
before you do anything, that’s like the most basic thing for strengthening care of small and sick 
newborns, addressing harmful practices first, it’s job number one.” (GP07)
The topics of the series, as well as the languages in which they were published, are listed in Table 6. The 
brief on human milk feeding is currently being updated. The subgroup of content experts who wrote and 
reviewed the briefs were drawn from numerous United States (US) and international organizations, in￾stitutions and programs (see Annexure E).
The “enormously popular” (CO3) briefs that “stand on their own” (GP08-2) were shared at numerous 
meetings and conferences in presentations and through distributed copies. Other international 
associations, donor organizations, and NGOs were also targeted for global dissemination, whereas 
ministries of health and other stakeholders were recipients at the country level. Some global partners 
acknowledged that they were not in a position to gauge how the briefs were being used – “I informed 
the country offices or regional offices about the existence of those materials, but I cannot state whether 
they have listened to my advice and are using it or not” (GP05). At the time of this evaluation, more than 
4,300 copies of the briefs had been downloaded from the Every Preemie website. 
 59 Annual Report Year 3
53
Table 6. Topics of the Do No Harm technical brief series60
Topic English French Spanish
Safe and Effective Oxygen Use for Inpatient Care of Newborns
Safe and Effective Infection Prevention for Inpatient Newborn Care
Safe and Effective Thermal Protection for Inpatient Care of Newborns
Safe and Effective Human Milk Feeding for Inpatient Care of Newborns
Prevention and Screening of Retinopathy of Prematurity (ROP)
Family Participation in the Care of the Inpatient Newborn
Management of Newborn Infections and Safe Use of Antibiotics
Information on the geographical distribution of material is not available. Five of the 10 global partners 
who responded to the online survey indicated that they had used the Do No Harm technical briefs. 
Three of the six USAID priority countries responding to their survey were familiar with this series and 
used them “in providing inputs in national newborn health strategy documents” and “as a guide to 
provide technical direction to our implementing partners”. Rwanda reported:
“The materials reinforce our interventions in newborn care. They were shared with the national 
technical working group for MCH and the newborn subgroup. Our implementing Partner was able to 
use the content to improve patient care. The materials drew special attention to oxygen use and 
thermal care.”
With regard to the contribution and usefulness of the Do No Harm series – “very well thought through 
intellectual property” (GP02) – informants thought that “amongst global partners and the global sphere 
[the briefs] definitely had an important role to help ensure the continued kind of elevation of preterm 
birth amongst a very long priority list” (GP01). Two informants described the contribution of the briefs 
as follows: 
“The advantage of much of what we did both from a technical level and from a policy and advocacy 
statement point is that it was groundbreaking, it just hadn’t been done before. So that’s where I 
appreciated [the] foresight … and leadership around it in the sense that they [Every Preemie] felt like 
it was a priority. … I do appreciate them highlighting the issue.” (CO7)
“I think that what they produced was really sound evidence-based and frankly with the Do No Harm 
series it’s a unique approach to kind of evaluating interventions and risk and benefit. … So seldom
do we consider risks and risk of harm and trying to minimize or mitigate against harmful practice. So 
I felt that they offered a very unique perspective and one that we in the development community 
were not – many of us were worried about overuse of oxygen and things like that, but it had not 
been formally put forward, even by WHO or anything like that.” (GP04)
One informant felt the briefs were packaged in a way that health professionals and policy makers
needed to pay attention. They were “catchy and short” (GP01), “well reviewed by leading thought 
 60 https://www.everypreemie.org/donoharmbriefs/
54
leaders” (CO2) and “the whole effort was worthwhile” (GP03). UNICEF included the technical briefs in 
their KMC training package, because “the technical content was good” (GP03). In the Midterm Review,
an informant also referred to the importance of the basics: 
“I think it’s a very important part of sick newborn care – that you’re not only doing high tech stuff, 
but you’re beginning first by making sure that you’re not doing harm – inflicting harm on those 
babies in those sick newborn care units – making sure that they’re getting the basics of warmth and 
feeding – that they’re getting breastmilk, even if they’re not able to suckle, and that they are 
getting safe oxygen. These are so basic.” (p. 15)
Informants were of the view that the Do No Harm briefs would outlast the Every Preemie project. While 
the Do No Harm briefs will need to be updated as new evidence emerges, they “…will continue to be 
useful for a while and used in countries as a guideline” (CO6). 
"And if our [USAID] bilateral project doesn’t take it up or the governments don’t think it’s very im￾portant then it remains at a global level. … going forward we really must have a way of dissemi￾nating it at a national level and really make sure that they are integrated into national programs. … 
I feel like we can integrate the use of these Do No Harm series as WHO rolls out the new standards 
of care for small and sick newborn care. So even though we may not see countries using the Do No 
Harm series right now, I am hopeful that going forward once the standards are recommended … 
that we will be able to integrate all these different pieces together.” (GP07)
“I think Every Preemie—SCALE was quite successful in bringing a new 
perspective to topics that were not otherwise being discussed and I 
think that will definitely last into the future and it really is sort of a 
new perspective that had previously not been there.” (GP04)
3.5.3 Advocacy, media and meeting participation
Most of the Every Preemie activities, especially at the global and country level, included an advocacy 
component through sharing and producing evidence for best practices and by means of advocating for 
implementation research in the four demonstration countries. One informant also referred to how
USAID advanced Every Preemie’s agenda: “I think they were beyond kind of just the normal 
dissemination channels, there was also this kind of big advocacy push for the contents from USAID which 
helped as well.” (GP01)
Two major advocacy activities were the creation and maintenance of a website and associated 
contributions through social media, and participation in international awareness days and campaigns 
linked to PTB/LBW. At a more technical level advocacy was promoted by attending meetings and 
conferences that increased the visibility of the expertise associated with Every Preemie, but that also 
advocated for the cause of PTB and LBW.
(a) Website and social media
55
The Every Preemie website was launched in May 2015.61 It served to build the project’s visibility as a 
viable partner and technical resource. The website is organized under the following tabs: About Every 
Preemie—SCALE; Demonstration Countries; Global Technical Working Group; Country Profiles; News 
and Blogs; Resources; Contact. It acts as a repository for existing Every Preemie resources and provides 
links to partner websites and external partners. Every Preemie also tracked the number of users and the 
number of downloads of country profiles and the Do No Harm technical briefs. At the time of this 
evaluation, the website had more than 200,000 page views and 30,000 downloads of materials.
Every Preemie was particularly active in advocacy activities during several international awareness days 
and campaigns linked to PTB/LBW. The blogs and press releases on the Every Preemie website are listed 
in Annexure F. Social media engagement was ongoing throughout the year, but focused especially on
important international days and weeks like World Prematurity Day, International KMC Awareness Day,
International Breastfeeding Week, Father’s Day, the International Day of the Midwife, and World Pre￾eclampsia Day. 
Every Preemie also played an active role in coordinating some of the World Prematurity Day activities 
and materials. In 2017 and 2018 Every Preemie led message design and the development of the 
advocacy toolkits with the themes ‘Let them thrive!’ and ‘Working together: Partnering with families in 
the care of small and sick newborns’, respectively. One global partner described the role of Every 
Preemie in coordinating advocacy activities:
“They stepped in to engage from 2016, ’17 and ’18 as they were extremely pivotal. They took over … 
the messaging department which is obviously very critical towards the whole planning process for 
World Prematurity Day … the kind of ground work of putting together all of the different messages. 
… It essentially … needs people to do the work and its resources, but a lot of organizations don’t 
have that capacity to donate time of their staff to do these types of things, so it was really useful.”
(GP01)
(b) Global engagement: technical meetings, working groups and other events
In addition to the organization of the PTB/LBW TWG meetings, members of the Every Preemie team 
attended global conferences, meetings, workshops, webinars and other types of events as part of 
providing visibility to preterm and LBW issues in maternal, newborn and child health. The meetings were 
either led or co-led by Every Preemie, or its team members played a leadership (e.g. planning, 
facilitation) or technical role (e.g. oral and/or poster presentation). Meetings in the four demonstration 
countries are referred to elsewhere. Respondents in the online survey for global partners were asked 
about their engagement or participation in Every Preemie activities. Seven of these respondents 
indicated that they had attended “meetings” or “webinars” organized by Every Preemie, although 
respondents provided no specificity.
According to the annual reports on meetings attended by Every Preemie team members, the group had 
a fair-to-strong presence in the following activities at certain times:
• UNCoLSC working groups (chlorhexidine, ACS and neonatal resuscitation);
• ENAP (management team, partners, country implementation, metrics);
 61 www.everypreemie.org
56
• KMC Acceleration Partnership and the associated Community of Practice group; 
• Respectful Maternity Care Newborn Technical Working Group (working on an updated charter 
for respectful maternal and newborn care);
• Public Private Partnership for the Prevention of Preterm Birth, Global Steering Committee; and 
• CORE Group (Global Health Practitioners).
Individual team members and Every Preemie consultants were also involved as experts or promoters of 
Family-Led Care in meetings and working groups on themes around KMC and the care of small and sick 
newborns including the following: 
• Prevention of preterm birth (general, eclampsia/pre-eclampsia);
• KMC;
• World Breastfeeding Week;
• Standards of care for the small and sick newborn;
• Integration of maternal and newborn health;
• Midwifery and neonatal nursing, including Women Deliver conferences;
• Pediatrics;
• Discussion of global documents and action plans;
• Research; and
• Metrics.
3.5.4 The Legacy of Every Preemie’s global engagement
Over its five years, Every Preemie worked closely with partners to raise awareness and visibility around 
preterm birth and low birth weight, and inpatient care of the small and sick newborn through a variety 
of mechanisms. Work in this arena is central to the project’s mandate and strategic objective. Project 
team members were vocal advocates for preterm birth and LBW across the maternal and newborn 
health continuum of care. Global engagement and the design and development of products was highly 
interactive, and the project consistently promoted evidence-based interventions. Informants cited Every 
Preemie’s leadership on the development of key global products (listed above), and the availability of 
materials and products for future work in this realm (e.g. the protocol and tools for the inpatient 
newborn care situation analysis) as valuable. Informants placed emphasis on the Do No Harm Technical 
Brief series. These briefs are recognized as significant “value add” to the global and country level 
landscape and can be promoted and used in the future as countries move to upgrade their inpatient 
newborn care systems and services. 
From its variety of products and the activities Every Preemie was engaged in, including support for 
advocacy efforts such as World Prematurity Day, it can be concluded that the project has done “a good 
job responding to the global agenda” (CO3). It honored its acronym SCALE62 and its strategic objective of 
“the increased global utilization of prioritized evidence-based and underutilized PTB/LBW 
 62 Scaling, Catalyzing, Advocating, Learning, and Evidence-driven
57
interventions”63 through advocacy and learning with a view to the future scale-up of interventions – “as 
a catalytic project … it wasn’t about reaching scale” (CO5).
“The work of Every Preemie is focused on the preterm baby – [it] 
clearly kind of catalyzed this global effort, this global focus on small 
and sick newborn care which is sort of now the next phase of newborn 
programming. … I think that this focus on the preterm baby was a key 
way that sort of sparked a number of conversations and streams of 
work on small and sick newborn care. So I think that is an important 
legacy for them and their leadership.” (GP08-1)
“It just simply became a topic of conversations in a way that – it had 
never been a topic of conversation. I mean people were so focused 
and it makes perfect sense on just providing kind of basic fundamental 
care to both a mother and a newborn infant that the preterm infant or 
the infant with special needs has just not been a discussion topic in the 
global arena. So this suddenly became a topic of conversation and 
what kind of moral responsibility do we have and what can we do 
given the situation that exists in many of these countries, what can we 
do to help this dilemma.” (CO7)
See Annexure G for questions and achievements related to Outcome 3. 
4 Achievements of Every Preemie in cross-cutting priorities
At the basis of Every Preemie’s Results Framework (Figure 1), there are six cross-cutting priorities. They 
are: (1) local capacity strengthening, (2) gender equity, (3) knowledge management, (4) action-oriented 
advocacy and awareness raising, (5) access to commodities and (6) sustainability. Although informants 
did not comment on these priorities directly, we can deduce how these were achieved through Every 
Preemie. 
• Local capacity strengthening64 was evident in all four demonstration countries vis-a-vis work 
with the local research partners (see Section 3.2.4). In Malawi, capacity strengthening also 
extended to health workers’ improvement of knowledge and skills in the care of preterm and 
LBW newborns, ranging from professionals, support staff, HSAs and community volunteers such 
 63 Midterm Review, p. 5 64 We used a broad definition here of local capacity strengthening. 
58
as Care Group Lead Mothers. A key element of the Family-Led Care model was building the 
capacity of families to actively engage in the care of their babies during inpatient KMC and at 
home post-discharge. Families were taught how to monitor their babies and to identify danger 
signs and were given easy-to-use monitoring forms both at the facility and when they were 
discharged. 
• Gender equity appears to have received less focused attention and should receive more careful 
thought in future projects. It could be argued that the Family-Led Care model has a built-in
equity principle in that the care of early/small newborns is meant to extend beyond traditional 
reliance on mothers and female relatives to include fathers. In Balaka district in Malawi, there 
were anecdotal reports of male involvement in community awareness activities (e.g. fathers’ 
groups) and observations of fathers carrying their baby skin-to-skin. 
• Knowledge management and shared learning is a central feature of Every Preemie and links 
directly to action-oriented advocacy and awareness raising. The project’s knowledge 
management mandate was centered around sharing evidence, heightening awareness and 
influencing action for preterm birth and LBW. The project initiated and led the PTB TWG,
bringing experts together to share evidence and information on priority issues. The subsequent
development and broad dissemination of the Do No Harm technical briefs provides a strong 
example of sharing global evidence to improve care of small and sick newborns at the country 
level. The project participated in global conferences, workshops and other meetings to build 
global and country action around PTB and LBW; and, in addition to the technical briefs, the 
project created products that were used to inform stakeholders and build advocacy and action. 
This includes the PTB Joint Statement and the country profiles. Other project initiatives like the 
ACS Landscape Analysis and the situation analysis of inpatient care prompted unique learning 
opportunities for participating countries. Ideally, information gleaned from this work will be 
used to transform care of small and sick newborns. It is also important to highlight the 
implementation research and the project’s efforts to share early findings with in-country 
stakeholders (and globally as in the case of Malawi). As of this evaluation, in-country research 
partners were preparing to share final implementation research findings with country 
stakeholders before the close of the project. It is expected that the findings will be used to 
inform country action. 
• Access to commodities was implicated in the research in Ethiopia, India and Malawi. In Ethiopia, 
the implementation research looked at the availability of basic commodities for newborn care; 
and, in India, the study focused on the safe and effective use of ACS across levels of care. The 
multi-country ACS landscape analysis looked critically at ACS use in seven UNCoLSC priority 
countries. The project also designed a new Terms of Reference for a newborn commodities 
group that would replace the UNCoLSC and related working groups; however, that effort was 
not pursued by funding partners. At the country level, implementation of the Family-Led Care 
model in Malawi included the procurement of essential commodities for the care of early/small 
newborns (e.g. weighing scales, feeding tubes and cups). The project also included commodities 
in the situation analysis for inpatient newborn care.
• Sustainability was addressed more indirectly, as the Every Preemie project focused on
catalyzing action and preparing the landscape for others to take forward the implementation 
and scale-up of PTB/LBW interventions. Issues of sustainability in Malawi and the succession 
59
plan for ONSE to take forward the scaling up of Family-Led Care have been described under 
Outcome 2 (Section 3.3).
5 Every Preemie—SCALE “catalyzed this global effort” – “a great 
learning opportunity”
____________________________________________________
This evaluation was a review of Every Preemie activities and products over the project life cycle. It
provided insights and reflections from various 
project stakeholders on the catalytics processes 
that pushed both the global and national preterm 
and LBW agenda. Despite the core Every Preemie 
team being thinly spread and operating on a 
small funding envelope, the project provided an 
excellent platform for evidence generation and 
sharing; advocacy and awareness raising; and 
partnership engagement. Every Preemie fulfilled 
its mandate to affect change and acted as an 
important link in global-country advocacy and
action around essential newborn care and the 
care of vulnerable newborns.
Several informants commented on the “high 
visibility” and “influence” of Every Preemie – “we 
were at the table of every major initiative” (CO3) 
and partners were receptive to the information. 
“Well, I think it had high visibility. That was 
actually the way that the project was 
designed … to call attention to this particular 
aspect of newborn care and I appreciate
that...” (CO7)
One informant felt that Every Preemie filled a 
specific vacuum: “Once the Born Too Soon report 
[was] released, globally there wasn’t any other 
visible commitment from global partners” (GP05). 
Another had the view that Every Preemie came 
along at a particular point on a continuum, 
although not all new activities by other role 
players in the small and sick newborn movement 
could be attributed to Every Preemie, they all had 
“a touch point with Every Preemie” (CO5). There 
SCALING—expanding the Family-Led Care 
model in Malawi to 16 new districts; with other 
countries showing interest in adapting the model.
CATALYZING—sparking global and national 
dialogue to bring attention to PTB and LBW and 
care of the small/sick newborn; using 
implementation research results to build the 
national response to PTB and LBW; developing 
products and tools to accelerate information￾sharing and action.
ADVOCACY—serving as the active global 
champion for essential newborn care and care of 
the vulnerable newborn; supporting national 
engagement in IR countries and in others to bring 
attention to PTB and LBW.
LEARNING—broadly disseminating findings 
from landscape analyses; supporting the 
development and dissemination of global 
products and publications; sharing 
implementation research findings to influence 
country level action.
EVIDENCE-DRIVEN—ensuring that global and 
national stakeholders had access to the most 
recent evidence on the safe and effective care of 
small and sick newborns; generating evidence for 
country programming.
BUILDING SCALE 
60
was also appreciation for partners supporting each other in advocacy and that “there was more 
convergence than five to ten years ago” (GP06).
A project like Every Preemie that accelerates change is “designed mostly on focusing on global leadership 
rather than providing support to country implementation” (GP07). However, informants also recognized the 
importance of linking global and national evidence generation for continued learning and action. 
“The goals will never be achieved by just the global partners sitting out there and planning and 
targeting things. The changes have to happen at the country levels for any of us to achieve the 
targets and goals set for newborn health.” (GP02)
“Whatever we do at the global level eventually it has to hit the ground on the local level. So if we do 
any research it has to be done at a country level, but it has to be a topic … it … should be like a burn￾ing need to understand at the global level … [or] a question that we are asking for global replication. 
So for example, the antenatal corticosteroids study in India was of interest to India as well as of 
great interest at the global level. … Similarly, we had the same question, the Malawi study … Can 
you empower a family even after the baby goes home from the facility to empower these families to 
continue taking care of that very vulnerable baby? …
Learning that informs the global agenda must come from evidence emanating from the grassroots. 
“My expectation from a program [was] that [it] would work as a catalyst in bringing attention, so 
it’s like a mixture of advocacy and also additional – some experience on the ground to inform what 
are the solutions for managing preterm births” (GP02).
… So that’s how we keep learning, we move from the global level down to the national, country level 
and then pick it up again, the lessons we learnt, pick it up again to the global level for global 
replication and advocacy.” (GP07)
Findings from the implementation research need further dissemination and uptake in order to develop 
into implementable and scalable models. Findings will be shared nationally and will ideally be used to 
shape future action for improved newborn outcomes. At the same time, findings will be shared globally 
via peer-reviewed journal articles and global networking and can be used to both shape the global￾country conversation around care of vulnerable newborns and drive change across countries.
A few informants wished that the project could be extended for another 6 to 12 months in order to 
wrap up their country projects for greater learning.
“The thing that we always have it’s a three year project, two year project, so there isn’t really time to do 
that, so it’s always difficult – only a year post the closure of the project you can be able to see whether 
things have been embedded in the routine system.” (MW12)
The question is: should other organizations pick up where Every Preemie ended and if so, how? Some 
informants referred to the importance of a succession plan that “will also help inform future programs 
that we are going to be embarking on” (GP08-3). Every Preemie’s succession plan for the scale-up of the 
Family-Led Care model in Malawi (and beyond) was the transition to ONSE and the development of a 
Global Family-Led Care Package. How Malawi and other countries will continue the management of the 
implementation and scale-up of Family-Led Care or similar models will depend on advocacy and funding 
support. It is anticipated that the succession plan for the activities in Ethiopia and India will be the 
61
uptake of findings and recommendations in future strategic planning and in the development and 
revision of policies and guidelines.
One informant was of the view that at the global level “some of the things are going to carry forward,
like World Prematurity Day is not going to stop” (GP01). It can be expected that partners such as WHO,
UNICEF and USAID will continue to work on issues highlighted by Every Preemie. The care of small and 
sick newborns will continue to be highlighted through the Survive and Thrive document, the nurturing 
care activities aligned with the Nurturing Care for Early Childhood Development framework, the ENAP 
activities and in the work on the standards of care for small and sick newborns coordinated by the WHO.
“I think that it’s going to be incumbent on the global newborn community overall to sort of support 
some of this continuity. … So I think it’s sort of a multi-pronged effort and so no one entity holds 
responsibility, but there are opportunities at various levels.” (GP08-1)
“USAID will continue to shepherd the legacy, will continue to advocate and talk 
about it with WHO and UNICEF and national governments in our bilateral 
projects. Things don’t just happen on their own, you have to have somebody to 
continue advocating for them and shepherding it along. And then when there is a 
new project ... you make sure that these are integrated into that follow-on 
project, that’s how we make sure that it continues to be alive.” (GP07)
5.1 Recommendations
Three main recommendations for future projects at the global and national level emerged from 
informant interviews:
1. Do not lose the focus on essential care for every newborn including early/small newborns whose 
main needs are thermal care and appropriate feeding. As more emphasis is placed on technology for 
the care of sick newborns, there is a concern that “fairly simple clinical interventions” (GP11) may 
not be prioritized.
“I feel it’s not just technology that partners should be paying attention to, the work that we are 
doing just recently on nurturing care is going to be important. In low-income countries … I am 
getting more convinced that it’s not about just saving them ... it’s about the longer-term
implications and that’s where I think the people-centered care, the nurturing care, respect for 
newborn care is going to be important.” (GP02)
2. Increase the focus on community engagement in the care of early and small newborns – “preemies 
can’t be saved without community” (CO5). Ensure that the Family-Led Care model is “used to inform 
ongoing work which, maybe in a different country or maybe in multiple countries, but we shouldn’t 
lose that” (GP08-2).
“I think the involvement of the families themselves, the involvement of the community, that’s 
something that needs to [be expanded to] ... other districts, or other countries … the 
62
communities are the pillars for the Family-Led Care. If the mother doesn’t get the support from 
the community she might as well abandon the care of the baby.” (MW14)
3. Have an “advocacy push” (GP01) with innovative ways to advocate for preterm and LBW newborns 
and rely more on parent groups. 
“I feel this time if they have a second phase they should really build an advocacy program, a 
[stand] alone advocacy program … or with the parent organizations, because we see a lot of 
work for parent organizations in Europe and also in some of the African countries, but it has [to 
be] more organized and [with] more support globally and at country level.” (GP03)
Other priority recommendations include the need to determine how the global leadership established 
under the PTB/LBW TWG will continue and with whom; invest in implementation research as the issues 
related to preterm birth are “countless” (CO5); develop and share evidence around models of care that 
improve newborn outcomes; and translate research findings into policy and practice. Additionally, acs 
countries move to strengthen inpatient care for small and sick newborns, it is expected that they will 
need significant support to effectively establish and provide that care, including support for innovative 
technologies and bundles of care for low- and middle-income settings. 
63
Annexures
A. Evaluation tools
__________________________________________________________________________________
TOOLS FOR OUTCOME 1
(Improved translation of evidence into action)
__________________________________________________________________________________
TOOL 1A: 
Target audience: Implementation research partners (demonstration countries)
Data collection method: key informant individual or group interviews
Interviewer: Anne-Marie Bergh
Introductory e-mail: Judith Robb-McCord
Organization of the date/s and time/s: Anne-Marie in follow-up e-mail
1. Could you tell me a little bit about yourself,
• [Bangladesh] your work and the kinds of research projects that you are involved with
• [Ethiopia] the St. Paul’s Hospital Millennium Medical College and the kinds of research projects 
that you are involved with
• [India] the Post Graduate Institute of Medical Education & Research and the kinds of research 
projects that you are involved with
• [Malawi] where you work in the College of Medicine and the kinds of research projects that you 
are involved with 
[For Maikhanda Trust this will be the second part of the interview and one does not need this 
icebreaker]
2. How did you become involved in this study on
• [Bangladesh] the prediction of gestational age before birth in low-income settings?
• [Ethiopia] the assessment of services for small and sick newborns?
• [India] the assessment of antenatal corticosteroids use and the implementation of the national 
operational guidelines?
• [Malawi] providers’ knowledge and perceptions of the Family-Led Care project? [COM]
 families’ experience of Family-Led Care? [Maikhanda]
3. Can you tell us more about the process you are following in this implementation research? 
Possible probes to use: 
• [Bangladesh] At what point did Every Preemie come on board? What was their role?
64
[All countries:] 
• Can you tell me something about the process of developing the research design and the 
protocol?
Further probes:
i. How were the implementation research questions identified and prioritized?
ii. Who were the key players in the design process and what were their roles? What 
was the role of Every Preemie?
iii. How did the research plan evolve over time? Did it change from its original intent? 
(What changes were / had to be made in relation to the original thinking and 
intent?)
• What would you consider as the highlights during the process of doing the research?
• What were the challenges encountered or issues that needed to be resolved? 
4. Now we’d like to talk a bit more about data analysis. 
[Bangladesh] Your study has been completed. 
• How was Every Preemie involved in the data analysis?
India, Ethiopia and Malawi:
• How has Every Preemie been involved in the analysis of data?
[India and Ethiopia] 
• How far are you with the analysis of data and the writing up of results? 
[Malawi] You have most of the results of your study already and you shared the results of the 
first round of data collection in August last year with the Balaka District Management Team.
i. In your view, which of the results are the most striking / powerful / significant?
ii. What surprised you about the results?
5. [Dissemination of results]
[Bangladesh] Although the results of your study were not what you had hoped for/anticipated, how 
have you disseminated the results? [Probe for role of Every Preemie if needed]
[India & Ethiopia] Have the results of your study already been disseminated or used? (Y/N) 
If Yes: Can you give some examples? 
What are the plans for dissemination (who is it important to reach with these findings and what are 
planned dissemination strategies)? 
[Malawi] How have the results of your study been disseminated up to now? What are the plans for 
the dissemination of results?
Possible probes to use for all countries:
a. Stakeholder meetings (government, funders, NGOs, health facilities, research participants, 
etc)
b. Research days
65
c. Conference presentations
d. Other ….
6. [Use/Application of results] 
[Bangladesh] Although the results of your study were not what you had hoped for/anticipated, how 
have/will the results influenced future thinking? 
Possible probes to use: 
a. In Bangladesh?
b. For future research on your topic in general?
India, Ethiopia and Malawi: 
Have the results of your study been used? (Y/N/Unsure)
If No or Unsure: 
How do you think the results could be used?
If Yes: 
How have the results been used? 
Possible probes to use: 
• ………..
• ……..….
7. How do you think the results of your study could be used to influence change? 
Possible probes to use: 
a. Influence on clinical practice and quality of care
b. Influence on the government and other development partners for programmatic or funding 
priorities
c. Influence on changes in policy or guidelines for clinical practice
d. What else could be done to influence change?
e. Other ……….
8. [Ethiopia] One intervention related to preterm birth in which there is currently a lot of interest is the 
use of antenatal corticosteroids. Your country was part of the landscape analysis that was done in 
seven sub-Saharan African countries in 2016. 
• Are you aware of any activities with regard to ACS that took place in the past few years? (Y/N)
• Have there been any changes in the utilization of ACS for maternal health or in the government 
policies and guidelines for clinical practice? 
[If informants do not know, ask if they can refer the interviewer to a knowledgeable person to write 
to, and add this to Tool 3E]
9. Undertaking this research, what do you think was the value of being involved / conducting this 
research? [Bangladesh: for institutions or organizations in Bangladesh]
Possible probes to use: 
a. Capacity building? [Ask to elaborate]
b. Partnerships? [Ask to elaborate]
c. Visibility? [Ask to elaborate]
d. For you personally and for your institution?
66
e. Other …..
10. Looking back: If you had to do this research again, what would you do differently? 
Possible probes to use: 
a. Design of project
b. Protocol development
c. Scope of the project
d. Management of the research
e. Liaison with partners
f. Other …..
11. In conclusion, what would you say are the three main lessons you learned from doing this research?
Possible probes to use: 
a. Research topic and question(s)
b. Management of the research
c. Dissemination and use of results 
d. Other …..
__________________________________________________________________________________
TOOL 1B: 
Target audience: In-country stakeholders 
Data collection method: individual or group interviews
Interviewer: Anne-Marie Bergh
Introductory e-mail: Anne-Marie Bergh
Organization of the date/s and time/s: Anne-Marie in follow-up e-mail
1. Icebreaker: Tell me a bit about the work that you are involved with.
2. When / how did you first become involved in the implementation research? 
3. Were you engaged / Did you assist in identifying research partners, location and defining the 
implementation research question / priorities on 
[Bangladesh] the prediction of gestational age before birth in low-income settings?
[Ethiopia] the assessment of services for small and sick newborns?
[India] the assessment of antenatal corticosteroids use and the implementation of the national 
operational guidelines?
[Malawi] client and health care provider perspectives on Family-Led Care?
(Y/N)  If No: Go to Question 5
If Yes: What was your role?
67
4. What were your initial expectations of the research?
Possible probes to use: 
a. What did you want to see as outcomes of the research?
b. Did your expectations change over time? (Y/N) [Probe: Can you elaborate?]
5. Have you seen any findings of the implementation research study? 
• If Yes:
i. In what format were the findings presented? (Probes: informal communication, 
presentation at a specific meeting)
ii. Did the presentation of findings meet your expectations? (Y/N) 
If Yes: Could you please explain/elaborate? (Probes: powerful or surprising findings}
iii. Looking at the [government/agency] structure you work in, how else do you think should 
the findings be disseminated?
• If No:
i. Do you have any information on how the findings will be disseminated? (Y/N) 
If Yes: Could you give some more information?
6. What value would you say research such as 
• [Ethiopia] the assessment of services for small and sick newborns
• [India] the assessment of antenatal corticosteroids use and the implementation of the 
national operational guidelines
will add / added to the improvement of the outcomes for preterm birth and low birth weight?
Possible probes to use: 
• Influence on clinical practice and quality of care
• Influence on the government and other development partner priorities and health sector 
investments
• Influence on changes in policy or guidelines for clinical practice
• How do you think the research will influence changes in policy and guidelines in the state / 
districts? 
[Probe: How do you anticipate these changes will impact on the care of preterm and low 
birth weight babies?]
• Wider influence – other countries take up the findings in changing their guidelines/policies –
improvement at a global level 
• Value of capacity building of in-country researchers
• Other ……….
7. [Ethiopia] One intervention related to preterm birth in which there is currently a lot of interest is the 
use of antenatal corticosteroids. Your country was part of the landscape analysis that was done in 
seven sub-Saharan African countries in 2016. 
• Are you aware of any activities with regard to ACS that took place in the past few years? 
(Y/N)
• Have there been any changes in the utilization of ACS for maternal health or in the 
government policies and guidelines for clinical practice? 
[If informants do not know, ask if they can refer the interviewer to a knowledgeable person 
to write to, and add this to Tool 3E]
8. What key developments or milestones do you anticipate in the next 1-3 years in preterm birth and 
low birth weight programming in Ethiopia / India? 
a. Probe for those that may be directly related to work of Every Preemie versus other 
development/milestones that may be occurring in broader landscape
68
9. Looking back: If you (or the country) had to do this research again, what would you do differently? 
Possible probes to use: 
a. Design of project
b. Protocol development
c. Scope of the project
d. Management of the research
e. Liaison with partners
f. Other …..
10. In conclusion, what would you say are the three main lessons you learned from this implementation 
research?
Possible probes to use: 
a. Research topic and question(s)
b. Management of the research
c. Dissemination and use of results 
d. Other …..
__________________________________________________________________________________
TOOLS FOR OUTCOME 2
(Increased capacity of local, national and global entities to scale-up and sustain the utilization of high￾impact interventions)
__________________________________________________________________________________
Tools 2A 
Target audience: Malawi: Implementation/targeted technical assistance stakeholders
a) MoH & Newborn Steering Committee: 
b) District management:
c) Implementers (Balaka district): 
d) Partners: 
e) USAID: 
Data collection method: key informant individual or group interviews
Interviewer: Anne-Marie Bergh
Organization of the date/s and time/s: Irene Kamanga
[Questions will vary slightly, depending on the person / stakeholder group that is interviewed]
1. Icebreaker: Tell me a bit about the work you do.
2. How were you involved in the Every Preemie/Family-Led Care project in Malawi?
69
3. Can you tell me more about the process of developing and implementing Family-Led Care? Possible 
probes to use: 
a. What was the original intent of the Family-Led Care model? What were the needs it was trying 
to address? 
b. How did the model evolve over time?
c. What do you see as the key or most significant components that took place as part of the 
implementation of Family-Led Care? (Probe: Training, Quality improvement) 
d. What additional resources were made available as part of the implementation of Family-Led 
Care?
e. What would you say went well in the implementation of Family-Led Care?
f. What were the challenges encountered or issues that needed to be resolved? 
g. What would you say were the highlights of the project? 
[Specific questions for MaiKhanda:]
a. What was the original intent of the QI model developed/adapted to support Family Led Care? 
What were the needs it was trying to address? How did the model evolve over time?
b. How did the QI initiative work together with the Family-Led Care project? 
• Overlaps
• Tensions
c. What additional resources were made available as part of the implementation of the QI 
activities?
d. What would you say went well in the implementation of QI to support Family-Led Care?
e. What were the challenges encountered or issues that needed to be resolved? 
f. What would you say were the highlights of the activities? 
4. In your view, what has changed as a result of the implementation of Family-Led Care in Balaka 
district? 
Possible probes to use: 
General:
a. Awareness of the special needs of preterm and LBW babies and their families?
b. Knowledge on care of preterm and LBW babies
c. Impact on families / community 
Balaka district:
d. Provision of care (Balaka) – better quality care
e. System: staffing support 
National: 
f. In Balaka district vs National MOH
g. Operationalization of KMC Guidelines
h. Adaptation of policy
i. Expansion of the model
70
5. What would you say were the main lessons learned through the implementation of Family-Led Care 
in Balaka? 
Possible probes to use: 
a. What do you consider to be the successes and achievements of the Every Preemie project? 
• Outcome 1: Improved translation of evidence into action
• Outcome 2: Increased capacity to scale-up and sustain the utilization of high impact 
interventions – local, national and global entities
• Outcome 3: Increased prioritization of PTB and LBW with decision makers (in-country) and 
other relevant stakeholders (national and global level) 
b. What are the conditions for sustaining Family-Led Care beyond the Every Preemie project?
c. What is needed for scaling up the Family-Led Care model in other districts in Malawi?
d. If you implement Family-Led Care in other districts in Malawi, what will you do differently? 
6. What do you think the influence of the Family-Led Care model is? 
a. In Balaka district?
b. Beyond Balaka district?
7. What would you say will be the legacy of Family-Led Care in the next 1-3 years? 
What key developments or milestones do you anticipate in the next 1-3 years in preterm birth and 
low birth weight programming in Malawi? 
a. Probe for those that may be directly related to work of Every Preemie versus other 
development/milestones that may be occurring in broader landscape
__________________________________________________________________________________
(TOOL 2B)
Additional questions on the implementation research for country stakeholders with information/insight 
about the research:
8. Have you been involved with or have you heard about the implementation research among health 
care providers and clients about their experiences with the implementation of Family-Led Care? 
(Y/N/Not really)
• If No or Not really: Conclude interview
• If Yes: Could you please tell me more?
9. What were your initial expectations of the research?
Possible probes to use: 
a. What did you want to see as outcomes of the research?
b. Did your expectations change over time? (Y/N) [Probe: Can you elaborate?]
10. Have you seen any findings of the implementation research study? 
• If Yes:
i. In what format were the findings presented? (Probes: informal communication, 
presentation at a specific meeting)
ii. Did the presentation of findings meet your expectations? (Y/N) 
If Yes: Could you please explain/elaborate? (Probes: powerful or surprising findings}
iii. Looking at the [government/agency] structure you work in, how else do you think should 
the findings be disseminated?
71
• If No:
i. Do you have any information on how the findings will be disseminated? (Y/N) 
If Yes: Could you give some more information?
11. What value would you say the research on the implementation of Family-Led Care will add / added 
to the improvement of the outcomes for preterm birth and low birth weight?
Possible probes to use: 
• Influence on clinical practice and quality of care
• Influence on the government and other development partner priorities and health sector 
investments
• Influence on changes in policy or guidelines for clinical practice
• How do you think the research will influence changes in policy and guidelines in the 
country? 
[Probe: How do you anticipate these changes will impact of the care of preterm and low 
birth weight babies?]
• Wider influence – other countries take up the findings in changing their guidelines/policies –
improvement at a global level 
• Value of capacity building of in-country researchers
• Other ……….
MaiKhanda: Use Tool 1A for probing on their research experience
__________________________________________________________________________________
TOOLS FOR OUTCOME 3
(Increased prioritization of PTB and LBW with in-country decision makers and other relevant 
stakeholders at global and national level)
__________________________________________________________________________________
TOOL 3A 
Target audience: USAID health officers, or his/her designee, in the 20 of 24 USAID priority MCH 
countries (less Ethiopia, India, Malawi who are interviewed separately as demonstration countries and 
Yemen, a non-presence country)
Data collection method: online questionnaire 
Introductory email: to be sent by Lily Kak
1. In what country do you currently work? ______________________________________
2. Which of the following are currently important components of the Ministry of Health’s national 
maternal and newborn health response? (Tick all that apply.)
 Maternal health 
72
 Newborn health
 Preterm birth and low birth weight 
 Inpatient newborn care
 Other
2.1. Please give more detail for ALL your answers above.
3. Managing newborn health, including preterm birth and low birth weight, is an important component 
of our USAID Country Development Cooperation Strategy.
 Strongly agree
 Agree
 Neutral
 Disagree
 Strongly disagree
3.1 Please give a reason or reasons for your answers above.
4. Which of the following are currently important components of your health project portfolio? (Tick all 
that apply.)
 Maternal health
 Newborn health
 Preterm birth and low birth weight
 Inpatient newborn care
 Other
4.1.Please describe ALL your answers above.
5. Is USAID supporting the management of preterm birth and low birth weight within the current 
health project portfolio? 
 Yes
 No 
(Branch: Yes = 5.1 and No = 5.2)
5.1.If Yes, which of the following mechanisms are being used? (Tick all that apply.)
 Bilateral health project
 Field support project (specify): ______________________________________
73
 Other (specify): ______________________________________
5.2.If USAID is not currently supporting this work, are there plans in the future to become engaged 
in preterm birth/low birth weight programming? 
 No, we have no plans in place
 Yes, we have plans in place (specify): ______________________________________
6. Which Every Preemie – SCALE tools/materials are you familiar with? (Tick all that apply.)
 None ( enable skipping Question 7)
 Country profile
 Do No Harm technical briefs
 Continuum of care matrix
 Joint statement on preterm birth
 Family-Led Care materials
 Inpatient newborn care assessment protocol and tools
 Other (specify): ______________________________________
7. Which of the Every Preemie tools/materials have you used and how? (Tick all that apply.)
 None ( enable skipping Question 7.1)
 Country profiles
 Do No Harm technical briefs
 Continuum of care matrix
 Joint statement on preterm birth
 Family-Led Care materials
 Inpatient newborn care assessment protocol and tools
 Other (specify): ______________________________________
7.1. Please describe how you have used these materials, including with whom you have shared 
them.
8. Do you have any other comments or recommendations about the project or about the topic of 
preterm birth/low birth weight programming that you would like to share?
 No
 Yes
8.1.If Yes, please describe below:
Thank you for completing this survey
74
__________________________________________________________________________________
TOOL 3B
Target audience: Global partners
Data collection method: online questionnaire 
Introductory email: to be sent by Anne-Marie Bergh
1. What is the main focus of your work?
2. To what extent have you been engaged in initiatives of the Every Preemie – SCALE project? 
 A lot 
 Somewhat
 A little
 Not at all ( enable skipping Question 2.1)
2.1.Please describe your engagement or participation: 
3. Which of the following Every Preemie tools/materials have you used? (Tick all that apply.)
 None 
 Country profiles
 Do No Harm technical briefs
 Continuum of care matrix
 Joint statement on preterm birth
 Family-Led Care materials
 Other (specify): ______________________________________
3.1 Please describe any specific examples of use of these tools/materials:
4. Please list 1-5 key accomplishments or areas in which the Every Preemie—SCALE project had a 
significant influence. 
75
5. What do you think are the most significant contributions or influence the Every Preemie—SCALE 
project has made at the global level?
6. In what areas (if any) do you think the Every Preemie—SCALE project could have made a more 
significant contribution? 
7. What key developments or milestones do you anticipate in the next 1-3 years in preterm birth and 
low birth weight programming, globally and/or in specific countries where you may work that may 
occur as a result of the work or influence of the project?
Thank you for completing this survey
__________________________________________________________________________________
TOOL 3C
Target audience: USAID/Washington Newborn Health Team
Data collection method: Key informant interview (preferably as a focus group)
Organization of the date/s and time/s: Lily Kak (in collaboration with Anne-Marie Bergh)
Interviewer: Anne-Marie Bergh
1. Can you give me a short overview of how your team has been involved with the Every Preemie—
SCALE project?
2. What were your initial expectations of the Every Preemie project and what the project was designed 
to achieve?
Probes if needed: 
(a) How did your expectations change over time and why? 
(b) After nearly five years, which expectations have been met? Why? Which have not been met 
(and why)? 
(c) How did the design, approach and coverage of the Every Preemie project change over time?
(d) Other: ………………
3. What has been most effective in informing you about progress with the Every Preemie project 
throughout the life-cycle of the project?
76
Probes if needed:
(a) Formal documents (e.g. project reports)
(b) Informal communications (e.g. emails, monthly or ad hoc calls)
(c) Review of project products
(d) Participation in project meetings (e.g. technical working group)
(e) Other ……………….
4. FOUR of the priority USAID countries were involved in conducting implementation research under 
the umbrella of the Every Preemie—SCALE project. [Recap of the projects, if needed.] How 
important do you think the prioritization of these themes was?
Probes if needed: 
(a) How useful will the results of these studies be within the research country and in other 
countries?
(b) To what extent do you think countries will be able to apply and utilize results? 
(c) Other: …………………
5. What do you consider to be the successes and achievements of the Every Preemie—SCALE project?
Probes if needed:
(a) Outcome 1: Improved translation of evidence into action
(b) Outcome 2: Increased capacity to scale-up and sustain the utilization of high impact 
interventions – local, national and global entities
(c) Outcome 3: Increased prioritization of PTB and LBW with decision makers (in-country) and 
other relevant stakeholders (national and global level) 
6. What do you consider to have been the challenges of the Every Preemie—SCALE project? 
Probes if needed: 
(a) Outcome 1: Improved translation of evidence into action
(b) Outcome 2: Increased capacity to scale-up and sustain the utilization of high impact 
interventions – local, national and global entities
(c) Outcome 3: Increased prioritization of PTB and LBW with decision makers (in-country) and 
other relevant stakeholders (national and global level) 
7. Do you think the development investment made in the Every Preemie—SCALE project had a 
catalytic influence? [Re-explain the understanding of “catalytic” if needed]
Probes if needed:
(a) Could you elaborate on your answer? (If Yes or No)
(b) How did the project influence change?
(c) How did the project add value to preterm birth and low birth weight globally?
(d) What would be the lasting impact of the project globally and in specific countries?
(e) Changes in government policies with regard to resource allocation for the care of preterm 
and low birth weight babies? 
(f) Would you say the project led to improved preterm and low birth weight care in some of the 
demonstration countries? (Yes/No) If yes, in what respect?
8. Are there any other comments about the project that you would like to share with us?
Thank informant/s
__________________________________________________________________________________
77
TOOL 3D
Target audience: Selected global partners (4-8):
Data collection method: Key informant interviews 
Interviewer: Anne-Marie Bergh 
Introductory email: to be sent by Anne-Marie Bergh (personalized e-mails)
1. Can you give me a short overview of how you or your team have been involved with the Every 
Preemie—SCALE project?
2. What were your initial expectations of the Every Preemie--SCALE project and what the project was 
designed to achieve?
Probes if needed: 
(a) How did your expectations change over time and why?
(b) After nearly five years, which expectations have been met? Why? Which have not been met 
(and why)?
(c) How did the design, approach and coverage of the Every Preemie project change over time?
(d) Other: ………………
3. What has been most effective in informing you about the priorities of the Every Preemie—SCALE
project throughout the life-cycle of the project?
Probes if needed:
(a) Formal documents (e.g. project reports)
(b) Informal communications (e.g. emails, monthly or ad hoc calls)e
(c) Review of project products
(d) Participation in project meetings (e.g. technical working group)
(e) Other ……………….
4. Have you used any of the materials or tools made available by Every Preemie—SCALE? (Yes/No)
Probes if needed (if Yes): 
(a) Country profiles
(b) Do No Harm technical briefs
(c) Continuum of care matrix
(d) Joint statement on preterm birth
(e) The Family-Led Care materials
(f) Inpatient newborn care situation analysis protocol and tools
If yes, how have you used these materials or tools?
5. What do you consider to be the successes and achievements of the Every Preemie project? 
Probes if needed: 
(a) Outcome 1: Improved translation of evidence into action
(b) Outcome 2: Increased capacity to scale-up and sustain the utilization of high impact 
interventions – local, national and global entities
(c) Outcome 3: Increased prioritization of PTB and LBW with decision makers (in-country) and 
other relevant stakeholders (national and global level) 
78
6. Do you think the development investment made in the Every Preemie—SCALE project had a 
catalytic influence? [Re-explain the understanding of “catalytic” if needed]
Probes if needed:
(a) Could you elaborate on your answer? (If Yes or No)
(b) How did the project influence change?
(c) How did the project add value to preterm birth and low birth weight globally?
(d) What would be the lasting impact of the project globally and in specific countries?
(e) Changes in government policies with regard to resource allocation for the care of preterm 
and low birth weight babies? 
(f) Would you say the project led to improved preterm and low birth weight care in some of the 
USAID priority or the demonstration countries? (Yes/No) If yes, in what respect?
7. Are there any other comments about the project that you would like to share with us?
Thank informant/s
__________________________________________________________________________________
TOOL 3E
Target audience: Participants providing information for the antenatal corticosteroids landscape analysis:
Data collection method: Personalized e-mails (in French to DRC)
Person responsible: Anne-Marie Bergh
E-mail template:
Subject: Evaluation of the Every Preemie—SCALE project 
Dear …….
You participated in providing information for the landscape survey on the use of antenatal 
corticosteroids (ACS) for women in imminent preterm labour for the Every Preemie—SCALE project. I 
am doing an evaluation of the project and would like to know more about recent changes in ACS policy, 
guidelines and use for maternal health in your country. 
Would you be able to provide us some information on the following questions? 
1. Since the landscape survey in 2016, are you aware of any changes in policies and guidelines 
related to ACS for maternal health? (If so, please describe)
2. Since the landscape survey in 2016, are you aware of any change in the uptake and use of ACS? 
(If so, please describe)
3. How would you rate the current interest in ACS in …….. [add country name]?
Great interest / Some interest / Little interest
Your inputs are highly appreciated. Attached please find a copy of the paper that has been published on 
the analysis.
Yours sincerely,
Anne-Marie Bergh
79
B. Details of the implementation research studies
Study titles, aims and objectives in the four countries
The information for this table was derived from the study protocols and reports and Every Preemie annual reports.
Bangladesh Ethiopia India Malawi
Study title(s) Maternal anthropometrics 
and statistical modeling to 
improve prediction of 
gestational age before birth 
in low-income settings
Assessment of the scope and 
implementation of services for 
small and sick newborns within 
the Ethiopian public health care 
system: a health systems 
implementation study
Assessment of use of antenatal 
corticosteroids and national 
operational guidelines in Haryana 
state, India
1. Knowledge, perceptions and practices of families 
who have experienced family-led care in Balaka 
District, Malawi
2. Health care providers’ experience of 
implementing family-led care for preterm and low 
birthweight newborns in Balaka District, Malawi
Aims and 
objectives
To develop and validate 
methods for AG and SFH 
measurement to improve 
prediction of gestational age 
before birth
• Develop and standardize 
programmatically feasible 
procedures for reliably 
measuring maternal SFH 
and AG in pregnancy
• Test the inter-rater and 
intra-rater agreement for 
the measurement of 
maternal SFH and AG in 
pregnancy across different 
levels of health care 
providers
• Evaluate maternal SFG, 
AG and estimated uterine 
volume as predictors of 
gestational age compared 
to the gold standard of 
early ultrasound measures 
To describe how maternal and 
newborn interventions and 
services for small and for sick 
newborns are implemented 
across the Ethiopian 
Government public health care 
system in Kobo, Dolo Mena and 
Addis Ababa regions, and to 
identify key challenges to and 
opportunities for improving 
preterm, LBW and sick newborn 
services nationally. 
• Identify health system 
structural factors that hinder 
and enable implementation of 
interventions that improve 
outcomes among small/sick
newborns, and to describe 
factors that can be modified to 
improve implementation of 
small/sick newborn 
interventions within the health 
system
To assess the utilization and 
practice of ACS administration at 
antenatal and intra-partum 
settings in selected facilities 
providing childbirth care in 
Haryana State (including 
estimates of the proportion of 
facility clients who receive ACS, 
methods used for appropriate 
identification of clients to receive 
ACS and relevant newborn and 
maternal services available at 
facilities providing ACS)
• Identify essential health system 
preconditions required for the 
implementation of ACS in 
alignment with the WHO 
Recommendations on 
Interventions to Improve 
Preterm Birth Outcomes, 2015
• Document the difference 
between report and actual 
To assess experiences of participating in the 
Family-Led Care model in Balaka District, Malawi
Study 1:
• Explore family perceptions of their inpatient care 
experience in relation to the implementation of the 
Family-Led Care model
• Assess family perceptions of whether Family-Led 
Care prepared them to confidently assume care 
for their newborn at home 
• Assess family readiness/knowledge to continue 
care provision of their early/small newborn at 
home post discharge
• Assess family knowledge on the management of 
kangaroo mother care prior to discharge
• Assess actual home-based care practices post 
discharge
Study 2: 
• Assess provider ability to accurately identify 
preterm/LBW newborns for admission, referral 
and discharge (knowledge
80
Bangladesh Ethiopia India Malawi
• Develop a predictive 
statistical model to 
estimate gestational age 
before birth using AG, 
SFH, and/or estimated 
uterine volume
controlling for potential 
maternal confounders 
including nutritional status
• Describe the current essential 
service delivery processes 
that will facilitate or hinder 
implementation of priority 
services for small/sick 
newborns within the public 
health care system
• Describe select outcomes of 
the existing programs for 
small/sick newborns
practices of health providers on 
the administration of ACS
• Identify enablers and barriers to 
implementation of GOI ACS 
operational guidelines
• Document and evaluate 
approaches to implementation 
of the revised ACS operational 
guidelines at delivery points that 
meet the health system 
preconditions for ACS 
administration. 
• Assess provider adherence to the clinical care 
standards set out in the Family-Led Care model 
(adherence)
• Assess provider competency in providing care 
(inpatient and follow-up care) for early/small 
newborns (competence) 
• Explore provider attitudes towards the Family-Led 
Care model, the Quality Improvement intervention 
and material/equipment donations provided to 
implement the model (attitudes)
• Explore provider perceptions of how 
mothers/families reacted to the Family-Led Care 
model (perceptions)
Timeline of implementation research activities in the four demonstration countries
Most of the information in this table has been derived from the Every-Preemie—SCALE annual and semi-annual reports. A few pieces of 
information were obtained via the interviews with key in-country partners or Every-Preemie—SCALE team members.
COUNTRY YEAR 1 (2014/5) YEAR 2 (2015/6) YEAR 3 (2016/7) YEAR 4 (2017/18) YEAR 5 (2018/19) (incomplete)
Bangladesh • Finalization of research 
protocol
• Standardization of 
measurement procedures 
• Sub-agreement finalized
• Field data collections 
started
• First disbursement of sub￾grant
• Field data collection 
completed 
• Poster presentation at 
Global Health & Innovation 
Conference
• Study data collection 
completed
• Data cleaning and 
preparation of data set for 
analysis 
• Primary data analysis 
• Preliminary findings drafted
• End of substantive support
• Technical support for final 
report writing 
• Dissemination meeting 
(June 2018) 
• Technical support to journal 
manuscript preparation
• Comments on a manuscript 
provided
• Continued reviews and 
inputs as requested
81
COUNTRY YEAR 1 (2014/5) YEAR 2 (2015/6) YEAR 3 (2016/7) YEAR 4 (2017/18) YEAR 5 (2018/19) (incomplete)
Ethiopia • Trips to Ethiopia to 
introduce the project, meet 
with stakeholders, travel to 
the field, conduct site visits 
and review relevant 
documents
• Extensive dialogue with 
partners
• Project’s concept note 
finalized and submitted to 
USAID and the FMOH and 
approved 
• Discussions with possible 
local research institutions
• National stakeholders 
meeting held
• Protocol writing workshop 
and planning of study 
instruments 
• Protocol and study 
instrument refinement 
workshop 
• Draft research protocol 
completed 
• Additional field support 
from USAID/Ethiopia 
identified
• Draft sub-agreement with 
St. Paul’s Hospital 
Millennium Medical College
completed
• Protocol and study 
instrument refinement 
workshop 
• Draft research protocol 
completed 
• Field support from 
USAID/Ethiopia secured
• Sub-agreement with St. 
Paul’s Hospital Millennium 
Medical College finalized
• Locations revised and 
approvals for new study 
facilities secured
• Study protocol and data 
tools finalized and 
submitted to USAID/W and 
USAID/Ethiopia for review
• Final IRB approval in 
Ethiopia and the US.
• Approval from USAID/W 
• Data collection completed 
for two study components
• Ongoing data collection for 
the third component 
initiated 
• On-site compliance review 
of St. Paul’s financials
• Data analysis for first two 
study components initiated
• Data collection third study 
component completed
• Data analysis and 
synthesis for the qualitative 
and cross-sectional 
components completed;
• Two draft manuscripts 
prepared
• Planning with FMOH for 
stakeholder dissemination 
meeting initiated
To be completed:
• Data analysis and 
manuscript for post￾discharge care utilization 
and mortality study
• National stakeholder 
meeting to disseminate 
preliminary results
• Presentation of findings 
(Every Preemie legacy 
event)
• Final manuscripts for 
relevant findings, and 
submission to journals
• Close out of sub-grant with 
St. Paul’s
82
India • Dialogue with 
representatives of the 
MOHFW and other 
stakeholders on Every 
Preemie engagement
• Articulation of the focus on 
implementation of ACS 
• Health facility visits 
• Review of government 
documents 
• Every Preemie concept 
note developed, submitted 
and accepted.
• Postgraduate Institute of 
Medical Education and 
Research, Chandigarh
identified as local research 
institution
• Full approval of district 
selection from the state of 
Haryana
• Formal approval of 
proposal by the GOI
• National GOI ACS PAG 
formed
• Protocol writing workshop 
conducted
• Provisional IRB approval 
obtained
• Sub-agreement with 
PGIMER developed and 
submitted to USAID/W for 
approval 
• Sub-agreement approval 
from USAID/W
• Sub-agreement with 
PGIMER finalized 
• Updated documented 
approval obtained from 
National Health Mission 
directorships of the state of 
Haryana and MOHFW
• First meeting of the GOI 
Project Advisory Group
• Study protocol and data 
collection tools; finalized 
approval received from 
USAID/W and USAID/India
• Approval of protocol and 
study tools from US and 
India IRBs
• Field data collection in one 
district completed and 
almost complete in second 
district
• Completed data collection 
and developed preliminary 
findings; 
• Convened second meeting 
of the PAG in January 2018 
and shared findings from 
initial assessment; 
• Developed and obtained 
approval of revised 
operational guidelines from 
MOHFW; 
• Finalized job aids and 
appendices to guidelines 
for use in pilot 
implementation of revised 
guidelines in Year 5; and 
• Supported first of two 
districts to launch pilot 
implementation of revised 
guidelines. 
• Pilot implementation of 
revised guidelines 
completed with Haryana 
state government in two 
districts
• Assessment of pilot 
implementation in both 
districts completed 
• Findings prepared for 
dissemination at next PAG 
meeting
• Two manuscripts of 
findings prepared
To be completed:
• Sharing of findings at next 
PAG meeting 
• Final recommendations to 
MOHFW for revised ACS 
operational guidelines
• Dissemination final revised 
ACS operational guidelines 
to state governments at 
national stakeholder 
meeting with MOHFW
• Completion of manuscripts, 
and submit to appropriate 
journals
• Participation in 
collaborative gestational 
age meeting with MCSP 
and India MOHFW
• Presentation of findings at 
MCSP Technical 
Consultation on gestational 
age
83
COUNTRY YEAR 1 (2014/5) YEAR 2 (2015/6) YEAR 3 (2016/7) YEAR 4 (2017/18) YEAR 5 (2018/19) (incomplete)
• Presentation of findings in 
global webinar
• Close-out of sub-grant with 
PGIMER
Malawi • Exploration of Every 
Preemie engagement 
• Participation in launch of 
national Every Newborn 
Action Plan 
• Concept note designed, 
submitted and approved
• Discussions with PCI on 
administrative and logistical 
support 
• Technical advisor: scope of 
work developed and 
recruitment 
• Design for national 
stakeholders meeting 
• National stakeholders 
meeting 
• Learning priorities identified 
and local approval of IR 
concept note obtained 
• University of Malawi, 
College of Medicine 
identified as IR partner 
• Study design workshop in 
September 2016
• Refocus of IR to better 
meet needs of project and 
stakeholders
• Data collected for key 
indicators from MOH facility 
records; 
• Local partners selected and 
contracting process 
initiated 
• Protocol and tools for 
caregiver/client study 
finalized and submitted to 
IRBs in Malawi and US 
• Draft protocol and tools for 
health care provider study 
prepared
• Contracts with COM and 
MaiKhanda Trust finalized 
• IRB approval (with 
amendments) for both 
studies obtained
• Phase one of data 
collection for health care 
provider survey conducted
• Ongoing data collection for 
caregiver/client survey 
launched 
• Preliminary results of 
health care provider survey 
phase one disseminated 
locally 
• Report on results of health 
care provider survey phase 
one finalized 
• Second phase of data 
collection for health care 
provider survey conducted
• Data collection for 
caregiver/client survey 
completed
• Final report for caregiver / 
client survey completed
• Draft report of second 
phase of provider survey 
completed
To be completed:
• Health care provider study 
final report
• Local approvals to 
disseminate IR results
• District and national level 
stakeholder meetings for 
dissemination of findings
• Manuscripts to be 
developed and submitted to 
journals for publication
• Close out of contracts with 
COM and MaiKhanda Trust
84
C. Answering the evaluation questions for Outcome 1
Question Achievement
a. How has the project’s IR agenda 
contributed to or influenced 
improved knowledge among key 
stakeholders / decision makers 
around PTB/LBW interventions 
and/or programming in 
demonstration countries?
• All countries are planning local and/or national stake￾holder meetings to disseminate their findings 
• Possible journal articles with results from some of the 
projects would further highlight the importance of the 
interventions included in the studies
b. How has the project’s IR agenda 
contributed to or catalyzed 
change/s in policy and/or action 
targeting PTB/LBW interventions 
and/or programming in Every 
Preemie demonstration and focus 
countries?
• Because the findings are still in the dissemination process,
knowing how countries would move forward after 
receiving the findings is beyond the scope of this 
evaluation
• Bangladesh: Conclusive recommendation: the importance 
of expansion of ultrasonography; services to enable 
screening for gestational age 
• Ethiopia: Potential of influencing programming and plan￾ning
• India: Revised ACS implementation guidelines
• Malawi: Potential of scale-up of Family-Led Care
ii. Assess the project’s IR agenda 
including key milestones and 
results related to IR in 
Bangladesh, Ethiopia, India and 
Malawi.
• All countries completed the data collection for their 
studies
• Data analysis and reports of findings range from not yet 
completed to totally completed and findings written up
iii. Explore changes in policy or 
practice and the pathways of 
change related to the IR and 
related technical support in 
demonstration countries. 
• Although the in-country partners were confident that their 
governments would take up their recommendations, not 
enough information was available to get a sense of how 
these will feature in the way forward
• Bangladesh: It is not clear how the Bangladesh govern￾ment will take forward the bottom-line recommendation 
for improved sonography services for screening pregnant 
women. The results should inform global-level planning of 
future projects on the assessment of gestational age 
• India: There are high expectations that the revised ACS 
guidelines will be taken forward by the GOI
• Ethiopia: Informants expected the findings to inform a 
number of initiatives, but some of these activities had
already started before the findings could be disseminated
• Malawi: It is expected that Family-Led Care will be rolled 
out to other districts as part of ONSE and other partners’ 
projects, but there is uncertainty how it will be done (see 
Section 3.2.5 below)
85
Question Achievement
iv. 3.1.5 Highlight unanticipated 
achievements, milestones, or 
outcomes that Every Preemie 
has supported or contributed to 
at the country level in 
demonstration countries or 
elsewhere.
• Increased capacity of research partners and a better 
understanding of how implementation research could 
inform programming
• Ethiopia: A third district was added to be able to cover all 
three types of geographies in the country
• Malawi: Resource materials already used beyond the 
project and more materials printed by ONSE
• Multiple delays required innovative planning to still reach 
the outputs
v. Share expected / anticipated 
changes that are likely to occur 
after the close of the project 
(next 1 – 3 years).
• It is expected that recommendations mentioned in b. 
above will be implemented and included in government 
guidelines and strategic plans 
• Malawi: Recommendations should be taken up in the 
District Implementation Plans
vi. Assess how the 
project is 
perceived and 
valued among 
demonstration 
country partners, 
including 
stakeholder 
perceptions at the 
country level 
regarding Every 
Preemie’s 
contributions.
• Bangladesh: The study was the output
• India: Results have been used to revise the 
guidelines/training package of ACS
• Ethiopia and Malawi: In-country stakeholders are still 
waiting to learn about the findings, although they have 
positive expectations
D. Answering the evaluation questions for Outcome 2
Question Achievements
a. What progress has been achieved in 
enhancing PTB/LBW interventions in 
Malawi (and other countries where 
relevant) and what has been the role of the 
project in these changes? 
• Raised awareness of the Family-Led Care model and 
its potential impact on the care of preterm/LBW 
newborns
• Introduced a system that has the potential to work if 
implementation and scale-up is well planned with 
appropriate resources
• The contribution of Every Preemie to nationally 
scale-up and sustain the utilization of high-impact 
interventions (i.e. KMC in the Family-Led Care 
model) may have been modest, although there are 
86
Question Achievements
expectations of this happening in future through 
other partners
i. Assess and document the pathways of 
change, including key milestones and 
results related to program technical 
assistance in Malawi
• The Family-Led Care model presents a pathway of 
change for care of preterm and LBW babies –
implemented in Balaka district
• Perception that Family-Led Care is there to stay in 
Balaka district
ii. Explore changes in policy or practice 
(e.g. SOPs, systems changes) in Malawi 
to improve PTB/LBW outcomes
• Visibility of Every Preemie in the Every Newborn 
Steering Committee and all other national meetings 
and events related to maternal and newborn health
• Potential use of Family-Led Care materials beyond 
Balaka district
iii. Highlight any unanticipated achieve￾ments, milestones, or outcomes that 
Every Preemie has supported or 
contributed to in Malawi or elsewhere 
(as relevant)
• High expectations of a stronger implementation of 
community component (the practices pathway as 
weak link)
iv. Share any expected /anticipated 
changes that are likely to occur in 
Malawi (or elsewhere) after the close of 
the project (in next 1 - 3 years)
• Transition to ONSE – some uncertainty, but Family￾Led Care concept settled in Balaka district
• Continued influence on the work of the Newborn 
Steering Committee
v. Document the role that the project has 
played in contributing to and/or 
catalyzing these changes during the 
project period
Change in quality of care and follow-up because of 
Family-Led Care:
• Training (health providers and support staff)
• Materials (flipchart and brochure) and tools (forms 
and charts)
• Follow-up system that seems to work
• QI component
b. Assess how the project is perceived and 
valued among partners in Malawi, including 
stakeholder perceptions at the country 
level regarding Every Preemie’s 
contributions
• At district level high enthusiasm for the changes 
brought about by the introduction of the Family-Led 
Care model
• Praise at the national level, especially for strength￾ening the community component through facility￾based follow-up care of preterm/LBW newborns
• See Subsection 3.2.3 for the details
87
E. Organizations contributing to the development of the Do No Harm briefs
According to the Year 3 Annual Report the following organizations were involved in the development of 
the Do No Harm briefs:
• All India Institute of Medical Sciences (AIIMS)
• American College of Nurse Midwives (ACNM)
• Council of International Neonatal Nurses (COINN)
• Global Alliance to Prevent Prematurity and Stillbirth (GAPPS)
• International Council of Nurses (ICN)
• Illinois Eye and Ear Infirmary 
• London School of Hygiene and Tropical Medicine (LSHTM) 
• Makerere University, Uganda 
• Maternal and Child Survival Program (MCSP)
• Oregon Health and Science University
• PCI
• Program for Appropriate Technology in Health (PATH) 
• Saving Newborn Lives (SNL)/Save the Children
• Soapbox Collaborative 
• United Nations Children’s Fund (UNICEF)
• United Nations Populations Fund (UNFPA)
• University of Cape Town
• University of Georgetown 
• University of Pennsylvania 
• University of Washington 
• USAID Child Blindness Program 
• USAID/Washington 
• WaterAid 
• Weill Cornell Medical College
• World Health Organization (WHO)
88
F. Blog posts and press releases
Title Website / Press release Date
Every Preemie Publishes Article on ACS Landscape Analysis in Global Health: Science and Practice Article Dec 2018
Nearly 30 million sick and premature newborns in dire need of treatment every year Press release 13 Dec 2018
Every Preemie—SCALE Releases Technical Brief on Family Participation in the Care of the Inpatient Newborn Every Preemie website 17 Nov 2018
Midwives Leading the Way with Quality Care Every Preemie website 5 May 2018
Every Preemie Partners with University of Malawi College of Medicine and MaiKhanda Trust to Assess Innovative 
Family-Led Care Model
Every Preemie website 4 April 2018
Helping Newborns Survive and Thrive in Malawi PCI’s End Poverty Blog 1 Feb 2018
Give the Gift of Saving Newborn Lives this Holiday Season Every Preemie website 19 Dec 2017
Prenatal Vitamin Distribution to Boost Newborn Outcomes in Liberia PCI’s End Poverty Blog 18 Dec 2017
Let Them Thrive: Quality Care for the Smallest Healthy Newborn Network 15 Nov 2017
Every Preemie—SCALE Convenes Partners around Respectful Newborn Care Every Preemie website 3 Oct 2017
Multi-country Situation Analysis of Inpatient Care of Newborns and Young Infants Every Preemie website 10 Aug 2017
Every Preemie—SCALE Launches Do No Harm Technical Briefs to Improve the Safe and Effective Use of Key Inpatient 
Newborn Care Interventions
Every Preemie website 19 July 2017
PCI Secures Private Donation to Benefit Fragile Newborns, Mothers in Malawi Every Preemie website 13 July 2017
Happy Father’s Day from Every Preemie Every Preemie website 18 June 2017
Every Preemie Partners with Ethiopian Ministry of Health and St. Paul’s Hospital to Improve Programming for Early 
and Small Babies
Every Preemie website 7 April 2017
Every Preemie Partners with Local Research Institution in India to Study Guidelines for Antenatal Corticosteroids Use Every Preemie website 26 March 
2017
Launch of Network for Improving Quality of Care for Maternal, Newborn and Child Health The Partnership for 
Maternal, Newborn & Child 
Health
15 Feb 2017
Every Preemie—SCALE Convenes Technical Experts Around Safe & Effective Care of Preterm Babies PCI’s End Poverty Blog 17 Nov 2016
89
Title Website / Press release Date
Kangaroo Mother Care Endorsed by Major Pediatric, Obstetric, Nursing, and Midwifery Associations Press release 16 Nov 2016
New WHO Antenatal Care Recommendations: An Important Step Toward Saving Lives, Says Every Preemie PCI’s End Poverty Blog 15 Nov 2016
Every Preemie—SCALE launches multi-country report on antenatal corticosteroid policy and implementation Healthy Newborn Network 20 July 2016
Are Preterm and Low Birthweight Babies Treated as a Priority? Every Preemie website 30 May 2016
Midwives Offer Helping Hands to Ensure Early and Small Babies Survive and Thrive PCI’s End Poverty Blog 5 May 2016
World Prematurity Day: PCI Convenes Congressional Briefing PCI’s End Poverty Blog 8 Dec 2015
Giving Preemies a Fighting Chance PCI’s End Poverty Blog 17 Nov 2015
Breastfeeding: Babies’ Perfect Food PCI’s End Poverty Blog 4 Aug 2015
World Breastfeeding Week: How to Help Your Newborn Grow Up Healthy PCI’s End Poverty Blog 31 July 2015
Huffington Post “Next 10 Challenge” Huffington Post 26 May 2015
Every Preemie Collaboration to Fight Preterm Birth PCI’s End Poverty Blog 8 May 2015
Highlighting the Work of Midwives: IDM 2015 and the Post-MDG Future ACNM blog 5 May 2015
Powerful Cross-Sector Push for Global Action to Prevent Preterm Birth Healthy Newborn Network 2 March 2015
Preterm Birth Linked to Intimate Partner Violence during Pregnancy PCI’s End Poverty Blog 10 Dec 2014
Taking Action to Save Premature Babies Devex 17 Nov 2014
PCI Works for Infant Health on World Prematurity Day PCI’s End Poverty Blog 13 Nov 2014
90
G. Answering the evaluation questions for Outcome 3 
Question Achievement
a. What progress has been achieved in 
raising awareness about and action for 
PTB/LBW and inpatient care for the 
small and/or sick newborn at the global 
level during the project period and what 
has been the role of the project in this 
progress? 
• PTB TWG meetings
• Do No Harm technical briefs 
• Situation analysis for small and sick newborns
• Advocacy activities (e.g. for World Prematurity Day, 
leading or contributing to developing international 
documents) 
b. Assess and document the pathways of 
change to raise awareness and catalyze 
action for PTB/LBW and the role that the 
project has played among global 
partners and stakeholders
• “Raising visibility of small and sick newborns through 
advocacy by expanding the scope to include preg￾nancy-related issues of preterm birth and moving 
beyond the 2015 ENAP focus on birth plus one week 
postpartum” (GP09)
• “Gathered a subset of high-level technical expertise in 
small and sick newborn care” (GP09)
• See Subsection 3.4.5: Advocacy, media and meetings
i. Assess key accomplishments during 
the project period as well as 
expected / anticipated changes after 
the close of the project (in the 1 - 3 
years) 
VISIBILITY
• Products –
- Clinical technical: Do No Harm series – potential 
linkage with the WHO standards for small and sick 
newborns
- Advocacy: Joint statements and country profiles 
that could be linked with the country situation 
analyses 
• Events – laid a foundation for World Prematurity Day 
activities on which others could build
• Surveys (especially situation analyses) – tools for 
others to use
• Stimulation of implementation research – built in￾country capacity
• Clinical and technical capacity in Malawi that will 
continue to bear fruit after the end of the Every 
Preemie project
• Dashboard and single indicator for measuring country 
status on the provision of preterm and LBW services –
baseline for USAID for future measurement
91
Question Achievement
ii. Review project engagement in key 
events and the design of significant 
products and their influence at the 
global level 
• See (i) above.
• “The contributions of the [Do No Harm] briefs and the 
small and sick new-born [situation analysis] … are 
really quite substantial and so I think in that regard 
the project has really been successful. … Those had a 
lot of traction and they were really taking the field 
into some new areas that had not been addressed 
previously. So I felt like it was really sort of a break￾through, the break to endeavors in some ways.”
(GP04)
iii. Share unanticipated achievements, 
milestones, or outcomes that Every 
Preemie has supported or 
contributed to at the global level 
• Shift to broader focus – multi-country situational 
analysis and participation in global documents 
(Survive and Thrive and Nurturing Care)
iv. Document the role that the project 
has played in contributing to and/or 
catalyzing these changes during the 
project period
VISIBILITY
• Responsiveness of the Every Preemie team to 
requests and unexpected situations
c.Assess how the project is perceived and 
valued among global partners, including 
stakeholder perceptions of Every 
Preemie’s contributions / role. 
• Dispersed quotations of global and country role 
players throughout Section 3 and subsections