***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background Effective strategies for implementing best practice s in low and middle income countries are needed . RHL is an annually up date d electronic publication containing Cochrane systematic review s , commentaries and practical recommendations on how to implement evidence -based practice s. We are conducting a trial to evaluate the improvement in obstetric practice s using an active dissemination strategy to promote uptake of recommendations in The WHO Reproductive Health Library ( RHL ) . Methods A cluster r and omized trial to improve obstetric practice s in 40 hospitals in Mexico and Thail and is conducted . The trial uses a stratified r and om allocation based on country , size and type of hospitals . The core intervention consists of three interactive workshops delivered over a period of six months . The main outcome measures are changes in clinical practice s that are recommended in RHL measured approximately a year after the first workshop . Results The design and implementation of a complex intervention using a cluster r and omized trial design are presented . Conclusion Design ing the intervention , choosing outcome variables and implementing the protocol in two diverse setting s has been a time-consuming and challenging process . We hope that sharing this experience will help others planning similar projects and improve our ability to implement change OBJECTIVE : Changes in the ability of midwives to perform practical skills , after completion of the Maternal Care Manual of the Perinatal Education Program , were determined . STUDY DESIGN : A prospect i ve , controlled trial in a study town and two control towns . The practical skills of  midwives  caring for pregnant women in the towns were determined . Subsequently , the Maternal Care Manual was studied by midwives in the study town , and the skills of all midwives were subsequently evaluated . RESULTS : A total of 34 midwives in the study town and 39 midwives in the two control towns were studied . The marks showed a significant ( p ≤ 0.000 ) improvement in the study town when comparing the pre- and postintervention marks . The mean improvement in the study town was 36.6 % . DISCUSSION : The practical skills of midwives improved significantly . The Perinatal Education Program can be implemented with confidence as a distance learning program that is especially suited to the needs of health workers in remote regions OBJECTIVE : To assess the ability of midwives to interpret antenatal cards and partograms correctly following completion of the Maternal Care Manual of the Perinatal Education Programme . STUDY DESIGN : We conducted a prospect i ve , controlled trial in a study town and two control towns in the Eastern Cape Province of South Africa . All 93 midwives caring for pregnant women in the three towns were included in the study . Sample s were compared using the two-tailed Student ’s t-test . RESULTS : The marks achieved by the study group for questions from the antenatal card and the partogram improved by 33.0 % ( p < 0.001 ) and 17.5 % ( p = 0.001 ) , respectively . No changes were observed in the control group . CONCLUSION : Midwives that studied the Maternal Care Manual significantly improved their ability to interpret clinical information and apply knowledge . If this ability is applied in clinical practice , a reduction in maternal and perinatal deaths is possible OBJECTIVES To determine whether the Maternal Care manual of the Perinatal Education Programme ( PEP ) is effective in improving the cognitive knowledge of midwives . DESIGN A prospect i ve controlled trial in a region where PEP was not previously used . The midwifery knowledge of all midwives caring for pregnant women in the three towns was tested before the commencement of the study . The Maternal Care manual was then introduced to the midwives in he study town and they worked through the programme . Following the completion of the manual , all midwives were tested again with the same test . The time interval between the pre and post testing was 12 months . SETTING Three towns on the Eastern Cape Province of South Africa . PARTICIPANTS All Midwives caring for pregnant women in three towns . INTERVENTIONS The Maternal Care manual of PEP was studied by the midwives in the study town . MEASUREMENTS AND FINDINGS Changes in cognitive knowledge were tested with multiple choice questions . A significant improvement ( p < 0.0001 ) was achieved in the study town . The mean score ( maximum 70 ) improved by 22.4 ( 32 % ) marks , from 35.9 ( 51 % ) to 58.3 ( 83 % ) . KEY CONCLUSIONS The cognitive knowledge of midwives who completed the Maternal Care manual improved significantly . IMPLICATION S FOR PRACTICE These findings are to particular importance as the method by which the Maternal Care manual of PEP was applied conforms to the method suggested for the its national use OBJECTIVE In this study the changes in attitude of midwives towards their work following completion of the Maternal Care Manual of the Perinatal Education Programme ( PEP ) , were determined . METHOD A prospect i ve , controlled trial was performed in a study , and two control towns in a region where PEP had not previously been used . All midwives caring for pregnant women in the three towns were included in the study . First the attitude of these midwives was determined by means of a question naire . Subsequent to this , the Maternal Care Manual was introduced and studied by the midwives in the study town . Following the completion of the Manual after 12 months , the attitude of all midwives was again evaluated using the same question naire . RESULTS A total of 40 midwives in the study town and 53 in the two control towns were included in the study . There were no differences on comparing the ages of the midwives in the study town to those in the control towns . The attitude of the midwives in the study town improved significantly ( p < 0.001 ) . The mean result in the study town improved by 6.1 ( 24.4 % ) marks from 14.5 ( 58.0 % ) to 20.6 ( 82.4 % ) . A significant shift also occurred in the range of the marks from 0 - 25 to 13 - 25 . No changes were observed in the control towns . CONCLUSION Most studies that have evaluated educational programmes measured improvement in health services , and did not evaluate changes in attitude . This study found that the attitude of midwives improved significantly in the study town . This positive attitude of midwives towards their work and their ability to perform their daily tasks must be an important component of any programme to improve the quality of care rendered to women during pregnancy , labour and the puerperium The presence of a skilled birth attendant at delivery is important in averting maternal and neonatal mortality and morbidity . It has now shown that even trained traditional birth attendants ( TBAs ) can not , in most cases , save women 's lives effectively because they are unable to treat complications , and are often unable to refer . Qualified midwives and doctors are often not available in the rural areas and community setting s where most women in developing countries deliver . Defining the minimum competency level necessary to meet the definition of skilled birth attendant is important , particularly in countries such as Nepal with limited availability of facility-based emergency obstetric care . Maternal and child health workers are local women aged 18 - 35 who completed a 15-week course in maternal and child health . As the role of MCHWs has exp and ed to meet the country 's needs for skilled attendance , a 6-week " refresher " course in midwifery skills is offered . The results of this clinical skills assessment of 104 r and omly selected MCHWs from 15 districts across Nepal supports the premise that MCHWs with appropriate training have an acceptable level of knowledge and skill , demonstrated in a practice situation , to meet the definition of community level skilled birth attendants . Yet , competency alone will not necessarily improve the situation . To affect maternal mortality in Nepal , MCHWs must be widely available , they must be allowed to do what they are trained to do , and they must have logistical and policy support 
    Output:
    
Most papers describe positive reactions , increased knowledge and skills , and improved behaviour after training .
Outcome is assessed less frequently , and positive effects are not always demonstrated .
Measures that can contribute to a positive effect of training programmes include h and s-on practise , team approaches and follow-up on training efforts .
AUTHOR 'S CONCLUSIONS Training programmes may improve quality of care , but strong evidence is lacking .