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Traditional birth attendants help reduce perinatal and neonatal deaths in developing countries. Some 52 million births occur each year in developing countries without a physician, nurse, or midwife present. Often, traditional birth attendants-who typically acquire skills through apprenticeship and whose roles vary by local custom-must take their place, in some countries as often as 90% of the time. According to a review of controlled trials published in the December 2011 BMJ, providing traditional birth attendants with basic training in newborn care and resuscitation and with support, such as clean delivery kits and effective pathways to other clinicians and facilities in emergent situations, reduces perinatal death rates by an average of 27%, and neonatal death rates by an average of 30%. The meta-analysis, encompassing nearly 111,000 births, also shows that maternal death rates are reduced, but that finding doesn't reach significance.