Background: Neonatal mortality is a major contributor to childhood mortality in the developing world. In Nicaragua, neonatal mortality rates have been slow to improve despite significant improvements in childhood mortality over the last 2 decades. As in many parts of Latin America, disparities in neonatal mortality between rural and urban areas in Nicaragua are significant. Studies have demonstrated that the implementation of evidenced-based bundles of care reduces neonatal mortality, and widespread implementation of training in these practices may improve outcomes in resource-limited areas. A challenge for many health authorities is how to implement these guidelines at scale. Helping Babies Breathe (HBB) and Essential Care for Every Baby (ECEB) are two simplified, low fidelity training programs that could be used to improve newborn care in rural regions of Nicaragua. Other elements of implementation, including monitoring and evaluation, continuous quality improvement (CQI) and supportive supervision, may be necessary adjuncts for implementation. Objective: To pilot an HBB-ECEB implementation package using HBB-ECEB training combined with monitoring and evaluation, CQI and supportive supervision in rural Nicaragua. We hypothesized that evidence-based newborn care practices and critical short-term outcomes would improve. Methods: We employed an HBB-ECEB implementation package in the rural municipalities of El Ayote and Santo Domingo. We used a pre-post data collection design. Following a period of baseline data collection from June to August 2015, all providers were trained in HBB-ECEB using a train-the trainer model. Representatives from each health center were also trained in CQI using a QI workbook. An external supportive supervisor conducted monitoring and evaluation and QI coaching. Data on newborn care processes and short-term outcomes were continuously collected from facility medical records and analyzed using standard run charts. Home visits were conducted to determine breastfeeding rates at 60 days. Results: There were 444 institutional births and 24 home births during the study period (June 2015-May 2016). No neonatal deaths occurred. Following the HBB-ECEB implementation package, cord care improved (pre-intervention median 73%; post-intervention shift to ≥96%) and early skin-to-skin care improved (pre-intervention median 0%; post-intervention shift to ≥76%). Rates of administration of tetracycline and vitamin K were high pre-intervention (median 98% and 100%) and remained unchanged. Early initiation of breastfeeding increased with a pre-intervention median of 40% and post-intervention shift to ≥88% through April 2016, though declined to 38% in May 2016. The percentage of mothers reporting exclusive breastfeeding at 60 days of life increased from 9.5% to 19% post-intervention. Conclusions: Overall, essential newborn care practices improved following the HBB-ECEB implementation package. Nonetheless, rates of exclusive breastfeeding remained low. CQI may provide a mechanism for continued improvements in essential newborn care practices, including exclusive breastfeeding. Longer term follow-up will be needed to determine effects of CQI.