The second intervention prong, aimed at objectives two and three, was Collaborative Quality Improvement. Collaborative Quality Improvement basically involves multiple teams working on common improvement aims who meet regularly to learn from one another. The improvement approach used required training and deployment of Woreda-level coaches and Kabele-level improvement teams. Coaches were drawn from the Woreda health office and health center personnel who are already supervising the health extension workers and community health development agents. Quality improvement team members were selected by their Kabele's and comprised of 10 to 15 members representing a cross section of stakeholders. Including frontline health workers, pregnant women and their families, community elders, representatives of local community organizations such as agriculture and Women's Associations, and local administrators. The coach's provided monthly support to the quality improvement teams, assisting them to implement improvement activities. Each quality improvement team selected a leader who organized the teams and facilitated the relationship between teams and coaches. The coaches and quality improvement team members, like the guide team members, were all volunteers. MaNHEP's improvement work focused on five key areas thought to be necessary to ensure that women and newborns reliably receive CNMH care during birth and the early postnatal period. These areas were pregnancy identification, anti-natal care registration, participation in the CMNH family meetings, labor and birth notification to a health extension worker, and postnatal care within 48 hours of birth by a health extension worker. While the guide teams implemented the CMNH family meetings on an ongoing basis, the quality improvement teams worked to develop and test potential solutions to improve each of the key areas described. MaNHEP improvement approach was based on the Institute for Healthcare improvement model. This model guides the team to ask three questions. What are we trying to accomplish? How will we know when a change has occured? And, what changes can we make that will result in improvement? First, the teams identified barriers to each of the key areas mentioned earlier in their own communities. Next, they brainstormed or tried ideas from other quality improvement teams and prioritized potential solution. What we call change ideas. They then implemented Plan, Do, Study, Act or PDSA cycles to test these change ideas to determine if the changes lead to improvement based on the data they collected and reviewed monthly. Every four to six months in each of the regions, the quality improvement team sent three to four team members to attend a two day learning session. In these sessions, the participants learned more about improvement methods, and shared findings from their own team's PDSA cycles. That is, which of their change ideas worked and which did not for a given improvement area? An example of a change idea might be sending a family member or using a cellular phone to contact a health extension worker when a woman goes into labor. At the end of a learning session the coaches also receive feedback and more advanced training on monitoring and data analysis. This provided an opportunity for Woreda administration, and Woreda health office representatives to address and improve common issues within and across the Woreda in their region. In the last six months of the project MaNHEP's staff and coaches assisted the quality improvement teams to rank and compile their most successful change ideas, those that had led to real improvement across the projects 51 kabeles. These were incorporated into a CMNH change package that was a return back to the kabeles and spread back to other new kabeles. Here we can see a quality improvement team in action during a learning session. It is hard to capture in the photo the overwhelming enthusiasm of the participants. At each of the learning sessions over the course of the projects participants often stayed long after the 5:00 p.m. close of the session to problem solve. Sometimes as late as 9:00 p.m. Although there have been many adaptations of the institute for healthcare improvements model, MaNHEP's adaptation is one of the first applications in which the quality improvement teams were drawn from and run by community members rather than health facility staff. That is, we believe the main reason for its success in generating enthusiasm, local engagement, and ownership.