Catalyzing change in rural guatemalan childbirth care: Evidence for a low-tech, low cost obstetric and neonatal emergency simulation training program, pronto

Background: Rates of maternal and perinatal mortality in Guatemala remain unacceptably high. PRONTO training uses low-tech, highly realistic simulation to provide the opportunity for medical teams to practice managing obstetric and perinatal emergencies in their daily work environment. It also includes a strategic planning session whereby trainees set goals to address problems in care identified during training. Methods: From 2012-2013 PRONTO International, CIESAR and the Ministry of Health in Guatemala implemented an intervention package to decrease maternal and perinatal mortality. The intervention package included PRONTO trainings in 15 randomly selected rural clinics among 30 clinics meeting selection criteria. We measured provider knowledge and self-efficacy pre- and post- training in key content areas: obstetric hemorrhage, neonatal resuscitation, preeclampsia/eclampsia, and shoulder dystocia. At 3 months after initial training, we assessed progress towards implementation of strategic planning goals to improve childbirth care. Results: 217 providers were trained. Increases in provider knowledge were dramatic and statistically significant, averaging 20.8 percentage points from pre- to post-tests (p<0.0001), as were increases in self-efficacy ratings, averaging 11.2 points on a scale of 0-100 (p<0.0001). Three months later, clinic staff reported accomplishing 68% of strategic goals. Conclusions: PRONTO in Guatemala has succeeded in improving knowledge and self-efficacy among providers for key concepts in obstetric and perinatal emergency care; system changes were also achieved. These results, together with similar findings from PRONTO trials in Mexico, encourage us that PRONTO can improve practices in low-resource clinics and hospitals. Impact data is currently being collected on maternal and perinatal outcomes.