Guatemala | ProCONE Complication Demonstration Collaborative

Date improvement activities began: 
September, 2009

The overall aim of the ProCONE collaboratives as a cluster is to reduce maternal and neonatal mortality through the institutionalization of essential obstetric and newborn Care (EONC) best practices at the primary, secondary, tertiary and community levels, specifically the Pro-CONE Complications Demonstration Collaborative, will contribute to this aim by strengthening the management of obstetric and neonatal complications in facilities and decreasing the current obstetric lethality rate.

Implementation package/interventions: 

Interventions implemented by hospitals to improve the management of EONC complications include the following: refresher training for current physicians and nurses, the implementation of standard training for new residents when they begin rotations in the hospital, institutionalizing a registration form for recording when vital signs are tested, and reminder job aids posted on the wall. The “critical link” methodology has also been used in the post-analysis of maternal complications cases (“near miss” obstetrical events), to review if each case was managed according to protocols. In addition to the above, hospitals have tested the introduction of the Code Red concept, which coordinates a team of providers (sometimes called a "code team") to convene at a specific location and to begin immediate life-saving efforts, specifically, hospitals have defined the functions of each staff member in handling obstetric hemorrhage and hipovolemic shock. The hospitals have also defined a “golden hour” after an emergency case arrives in which the team works together to coordinate care and monitor vital signs.


Complications ProCONE Key indicators– % of cases handed in compliance with clinical care standards in relation to the following:
• Management of obstetric hemorrhage
• Management of preeclampsia or eclampsia
• Management of sepsis
• Management of neonatal infections
• Management of respiratory distress
• Management of prematurity

Spread strategy: 

As part of the spread strategy, the MOH official guidelines now include QI monitoring sheets with criteria for managing the most prevalent maternal and neonatal complications.

Number of sites/coverage: 

The obstetric complications ProCONE collaborative was initiated in 16 hospitals and continues in 8 facilities. 1,705,789 people benefitted out of 5,853,230 in the covered region (14 million in the whole country)

Hospitals per Health Area:
Quetzaltenango = 1
Sololá = 1
Chimaltenango = 1
Totonicapán = 1
Huehuetenango = 1
Quiche = 1
Ixil = 1
San Marcos = 1
Alta Verapaz = 1
Total = 9


Quality Improvement teams received ongoing support from HCI through the assignment of three maternal and neonatal health advisors with backgrounds and experiences in EONC. Advisors visited participating hospitals, providing training in to hospital staff in the proper management of obstetric and newborn complications. In addition, job aids, such as the partogram to monitor vital signs during delivery, were designed, produced, and made available to all hospital wards. ProCONE played a key role in building capacity to register data, analyze results for decision making, and documenting best practices along the way.

Learning sessions & communication among teams: 

3 learning sessions have been provided to the teams working the hospitals to assist with clinical direction and QI implementation to manage the most common maternal and neonatal complications. QI teams have based their work on documented best practices and continue to share their results and lesson learned to improve their results. In the past year, eight hospitals have continued worked in the demonstration phase of the Complications ProCONE Collaborative with the purpose of improving the management of the most frequent obstetric and neonatal complications. Learning sessions have also revealed that strengthening support systems, such as logistics for ensuring ongoing stocks of vital medical supplies and drugs for managing complications, is an essential component to improving the quality of managing obstetric and neonatal complications.


The improved management of the main obstetrical complications has been difficult and there have been ups and downs in the monitoring of the indicators; however, the obstetric complication ProCONE collaborative has continued in 8 hospitals and has the work has begun to show some important improvements. For example, compliance with standards for the management of pre-eclampsia and/or eclampsia, which was basically nonexistent at baseline, reached 53% compliance by May 2010, and then in rose to 86 % by July 2011. This positive change has been attributed to the continuous monitoring of management criteria and the use of immediate feedback provided to health staff involved in the cases. In addition, ensuring the consistent availability of magnesium sulfate, used to prevent severe pre-eclampsia from becoming eclampsia (which leads to life-threatening convulsions), has also been key.

Furthermore, advancements in the analisis of maternal deaths and documentation have supported the development and implementation of a maternal death surveillance system implemented by HCI, which decreases the circumstances that lead to those deaths.


Report Author(s): 
Rodrigo Bustamante
The Health Care Improvement Project, The Ministry of Health
ASSIST publication: 
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