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Simul Healthc. 2016 Feb;11(1):1-9. doi: 10.1097/SIH.0000000000000106.

Impact Evaluation of PRONTO Mexico: A Simulation-Based Program in Obstetric and Neonatal Emergencies and Team Training.

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From the Department of Obstetrics and Gynecology and Global Health (D.M.W.), University of Washington, Seattle, WA; College of Nursing (S.R.C.), University of Utah, Salt Lake City, UT; Division of Reproductive Health (J.F., M.O., A.M., H.L.-F.), Research Center for Population Health, National Institute of Public Health, Cuernavaca, Mexico; Department of Global Health (S.T.Z.), University of Washington, Seattle, WA; Department of Obstetrics and Gynecology (J.O.F.), University of Maryland School of Medicine, Baltimore, MD; and Center for Evaluation Research and Surveys (M.R.-M.), National Institute of Public Health, Cuernavaca, Mexico.



Most maternal deaths in Mexico occur within health facilities, often attributable to suboptimal care and lack of access to emergency services. Improving obstetric and neonatal emergency care can improve health outcomes. We evaluated the impact of PRONTO, a simulation-based low-cost obstetric and neonatal emergency and team training program on patient outcomes.


We conducted a pair-matched hospital-based trial in Mexico from 2010 to 2013 with 24 public hospitals. Obstetric and neonatal care providers participated in PRONTO trainings at intervention hospitals. Control hospitals received no intervention. Outcome measures included hospital-based neonatal mortality, maternal complications, and cesarean delivery. We fitted mixed-effects negative binomial regression models to estimate incidence rate ratios and 95% confidence intervals using a difference-in-differences approach, cumulatively, and at follow-up intervals measured at 4, 8, and 12 months.


There was a significant estimated impact of PRONTO on the incidence of cesarean sections in intervention hospitals relative to controls adjusting for baseline differences during all 12 months cumulative of follow-up (21% decrease, P = 0.005) and in intervals measured at 4 (16% decrease, P = 0.02), 8 (20% decrease, P = 0.004), and 12 months' (20% decrease, P = 0.003) follow-up. We found no statistically significant impact of the intervention on the incidence of maternal complications. A significant impact of a 40% reduction in neonatal mortality adjusting for baseline differences was apparent at 8 months postintervention but not at 4 or 12 months.


PRONTO reduced the incidence of cesarean delivery and may improve neonatal mortality, although the effect on the latter might not be sustainable. Further study is warranted to confirm whether obstetric and neonatal emergency simulation and team training can have lasting results on patient outcomes.

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