This article describes a programme to scale up post-abortion care services in 22 of the 33 public sector district hospitals in Guatemala from July 2003 to December 2004. The main interventions included strengthening the knowledge and technical capacity of staff, expanding post-abortion care, enhancing related infrastructure, distributing informational materials and instituting an abortion surveillance system. A facilitator supported the work through week-long, monthly visits at each hospital. Attention was also devoted to building institutional consensus in support of post-abortion care at government, district hospital and hospital staff levels. During this period, 13,928 women with incomplete abortions were admitted to the 22 hospitals. Use of manual vacuum aspiration for treatment of incomplete first trimester abortion increased from 38% to 68% of cases (p<0.0001). Provision of family planning counselling also increased, from 31% to 78% of women (p<0.0001), and the proportion of women selecting a contraceptive method before leaving hospital from 20% to 49% (p<0.0001). Infection was associated with 71% of the incomplete abortions, of which 90% were septic. There were nine deaths and 768 women suffered severe complications, the level of which remained unchanged during the study period. Guatemala still has much to do to institutionalise post-abortion care fully and reduce deaths and complications, but our efforts to date will be valuable to others.