Thus, in many countries the emphasis in clinical licensure and recertification has shifted from specifying a particular number of births to be conducted, to participation in educational activities and structured supervision that are more likely to assure the maintenance of competencies. For midwives and doctors practicing in smaller units, lifethreatening emergencies will be encountered infrequently so that skills are best taught and maintained through the use of simulation, as taught in the various obstetric skills programs. There is evidence that skills gained through such courses can be maintained in a public health system context although there are challenges in maintaining continuity and overcoming practical hurdles, such as procurement of supplies even when funds are available [30]. Program managers need to undertake periodic district level skills audits to ensure ongoing compliance with such skills training in the service setting