Guatemala | ProCONE Basic Spread

Date improvement activities began: 
October, 2009

The aim of the Basic ProCONE collaborative is to improve prenatal, postpartum, and neonatal care at ambulatory facilities by increasing the use of the partograph and active management of the third stage of labor (AMTSL) practices during delivery services to reduce maternal and neonatal mortality.

Implementation package/interventions: 

The initial ProCONE demonstration collaborative was implemented through the Calidad en Salud project in 2008 in the San Marcos Health Area. For the ProCONE Basic Spread Collaborative in Guatemala, HCI’s aim was to replicate an initial ProCONE demonstration collaborative’s intervention package in 8 new Health Areas. Basic CONE focuses is on interventions to improve the quality of ambulatory/normal prenatal, postpartum, and neonatal care as well as to improve the use of the partograph, active management of the third stage of labor (AMSTL), and routine immediate care of the newborn in health services. It also aims to reduce maternal and neonatal mortality by scaling up EONC best practices at the primary and secondary levels, including improved compliance with three criteria (prophylactic use of oxytocin, controlled cord traction, and fundal massage immediately after delivery of the placenta ) for active management of the thirds stage of labor.


Measures for the Basic ProCONE collaborative were related to compliance with clinical care standards in the following areas:
• Prenatal care
• Postpartum care
• Neonatal care (ambulatory)
• Well-child care
• Use of the partograph (normal deliveries)
• Active management of the third stage of labor
• Immediate postpartum care

Spread strategy: 

The ProCONE Basic collaborative was a scale up of an initial demonstration collaborative, the work done following the spread collaborative, which then aimed to build higher levels of institutionalization. In the latter half of 2011, the HCI worked to strengthen the capacity of health area staff to provide technical support to QI teams, link the current approach to quality management between the ISO:9001 and QI standards with the continuous process improvement approach, develop a formal institutional mandate that assigns accountability for quality results to facility directors and specific staff at the health area, and lastly to formally link QI efforts to the larger national MOH objectives of reducing maternal and newborn mortality

Number of sites/coverage: 

This work focused on eight of 29 health areas/ 165 of 581 services (in the region). This area includes 16 hospitals, 67 Permanent Attention Centers, 78 health centers and posts for a coverage of 1,850 of 6,215 service providers (in the region) and 1,705,789 people benefitted out of 5,853,230 in the covered region (14 million in the whole country)

 Eight of 29 health areas165 of 581 services (in the region)
 16 hospitals, 67 Permanent Attention Centers, 78 health centers and posts.
 1,850 of 6,215 service providers (in the region)
1,705,789 people benefitted out of 5,853,230 in the covered region (14 million in the whole country)


In the last quarter of FY11, HCI conducted joint supervision/coaching visits in 20 health facilities. Through direct observations they were able to ascertain that providers are following norms, using clinical records, monitoring clinical records for quality improvement, attempting to strengthen integrated care of the infant and child, and guaranteeing supplies, especially micronutrients. In addition, HCI has conducted coaching visits related to expanding ISO certification to 7 additional facilities, all of which are ProCONE sites. QI training and PSDA cycles were used to ensure certification according to ISO norms.

Learning sessions & communication among teams: 

In 2011 other institutionalization mechanisms were defined and implemented by the QI teams in eight hospitals by involving administrative central and local level personnel. During a learning session held it was verified that all QI teams have improvement plans based on documented best practices and four hospitals with the best performance shared their results and lessons learned.


The Basic ProCONE Collaborative teams continue to report data to show that there is over 80 percent compliance with clinical care standards for most of the collaborative indicators. Not only are these indicators all consistently high but the gains have been maintained since the demonstration phase in San Marcos. As an example, reporting from 143 facilities shows compliance with postpartum care standards at the baseline measure was only 23% and rose to 89% in 2010 and remain at 90% in 2011. In addition to this, the application of AMSTL was reported to be about 37% at the baseline measure and rose to 95% compliance at the end of 2010 and 94% in 2011.

Best practices/conclusions: 

Most Basic ProCONE indicators have a reached sustained and high (>80 %) levels, interventions that have contributed to these improvements are training and standardization of staff processes in prenatal, postnatal, and newborn care and improved supervision and tutoring from the health area counterparts. Additionally, improved logistics have contributed to better stock levels of micronutrients and medications for optimal prenatal, postpartum, and childcare, including adequate levels of oxytocin for proper management of the third stage of labor.


Report Author(s): 
Rodrigo Bustamante, Carlos Leon
USAID Health Care Improvement and Ministry of Health and Population
ASSIST publication: 
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