Guatemala has one of the highest national maternal mortality ratios in Latin America at 149 per 100,000 live births, and up to 260 per 100,000 in some northern departments. Only 31% of deliveries are attended by a skilled birth attendant. Since early 2004 Guatemala has invested heavily in building and updating northern clinics for 24 hour delivery care. It was expected that as access increased, rates of maternal and perinatal mortality would drop. But as of 2012 this had not occurred. To attack this difficult problem, we propose to scale up an already tested innovative strategy, combining technology, service delivery, and demand creation approaches. Our collaborative effort integrates:

1) a low cost, simulation-based training program (PRONTO) using a low-tech birth simulator (PartoPantsTM) to teach provider teams emergency management during childbirth,

2) a research-driven social marketing campaign encouraging women in the target communities to give birth in clinics rather than at home, and

3) professional midwife liaisons charged with connecting traditional birth attendants to the formal health care system. We expect that this effort will catalyze critical practice changes in maternity care, increase the proportion of births attended in clinics, improve maternal outcomes, and decrease perinatal death in indigenous Guatemalan communities. Our idea represents a creative, unconventional approach to improving childbirth outcomes as it combines several evidence-based strategies, including highly realistic emergency simulation training rarely used in low-resource settings, to address a seemingly intractable problem from multiple angles.