These have included educating rural midwives in the use of a partograph, introducing pictorial methods of identifying and recording risk conditions in childbirth, recognition of the need for referral, and teaching the importance of good hand-washing and cord care. .
Some of these strategies have been successful while some have not. It is important to mention here that because of the lack of accurate information on performance of birth attendants and statistics on maternal and neonatal deaths prior to implementation of a training programme, it is often difficult to evaluate it's effectiveness. .
An evaluation describing the success of a training programme in Nigeria found that in contrast to the trained attendants, none of the untrained TBAs offered any of the following (Akpala 1994:46): .
Maternal and Child Health services: antenatal care, .
Advice on immunization of children or their mothers during pregnancy.
Family planning .
A small scale training program for birth attendants in the Sahel was evaluated two years after it had begun. The participants were reported to have retained an acceptable level of the knowledge taught. "The findings showed that the program had been moderately successful in imparting knowledge and overcoming cultural inhibitions about assisted deliveries. However, the effectiveness of the program was severely curtailed by structural deficits in the health system, especially lack of skilled staff, supervision and transport- ( Dehne et al. 1995: 415). .
Many would argue that there is little value in a good referral system if the roads and transport are not adequate. Likewise, there is little value in imparting to the TBAs that certain resources are central to care if they are not going to have access to these resources. "To teach them, explicitly or implicitly, that in order to do a proper delivery they should use resources unavailable to them undermines their confidence that they can manage at all- (Jordan 1989:929).