PROJECT SUMMARY Almost all maternal and perinatal deaths worldwide are in low-income countries (LICs). Delays in accessing and receiving appropriate quality pregnancy care, particularly during labor and delivery, is a major reason for these outcomes. Reducing adverse pregnancy outcomes is a current and high global priority. The University of Alabama at Birmingham's (UAB) maternal and fetal medicine and neonatology groups are the primary referral services for high-risk pregnancies and newborns statewide in underserved Alabama. Through UAB's highly valued, busy and pioneering toll-free 24/7 Medical Information Service via Telephone (MISTTM), timely, and often life-saving point-of-care consultation and guidance is available to rural providers caring for pregnant women and newborns. Although such provider support services are now part of standard-of-care in the United States, their implementation and assessment of that implementation are often unavailable in LICs with the worst maternal and perinatal outcomes. The rapid rise in mobile phone ownership in LICs provides a tremendous opportunity to adapt, implement, and evaluate innovative, potentially life-saving interventions such as MISTTM. The mobile platform can help mitigate structural barriers and enhance healthcare access needs of the patient by providing clinical support for remotely-located providers facing medical emergencies -- while also enhancing local care systems in resource-constrained settings. Thus, the purpose of this study is to adapt and evaluate the implementation of mobile-phone based MIST (mMIST) to improve maternal and newborn outcomes in a LIC. The proposed mMIST intervention will be adapted from our ongoing experience at UAB and implemented in Cameroon, which has the 9th highest maternal mortality ratio and one of the highest rates of perinatal mortality in the world. We propose three Specific Aims: 1) Adapt and develop a 24/7 mHealth support system for peripheral providers who provide healthcare to pregnant women and newborns; 2) Test mMIST's feasibility and acceptability in one health district in northwest Cameroon, and 3) Evaluate the effectiveness - using a stepped wedge cluster randomized trial design - of full-scale implementation of mMIST in reducing maternal and perinatal deaths, and serious maternal and newborn morbidities in 19 districts (clusters) of northwest Cameroon with 65,000 deliveries per year. A participatory approach involving stakeholders and a representative task force will inform the development and delivery of the intervention. Three frameworks will inform this study, WHO Model for Quality of Care, ADAPT-ITT for intervention adaptation, and the implementation science Exploration, Preparation, Implementation, Sustainment (EPIS) model. Additional features include plans to ensure sustainability by engaging the government and mobile service providers, and attention to m-health capacity building within this rigorous research study. If demonstrated effective,...