A pilot program was implemented in 1975 in rural areas surrounding the city of Fortaleza in northeastern Brazil to improve maternal and infant health care using previously untrained local personnel and limited resources. The ongoing program has been unusual, in that not only have traditional birth attandants received basic training, but they have overseen deliveries in small maternity centers provided by the local communities involved, instead of overseeing them in the homes of the expectant mothers. The 1st group of attendants received a 3-month practical and theoretical course at the Assis Chateaubriand Teaching Maternity Hospital, 1 of the 2 free maternity hospitals in Fortaleza and part of the medical school of the Federal University of Ceara. Subsequent courses were given at the obstetric unit, because experience with the course at the hospital indicated that a sophisticated medical setting was an inappropriate place for training unskilled personnel. The basic questions addressed by the study reported here are as follows: 1) how do deliveries by traditional birth attendants compare with hospital deliveries in terms of maternal and infant morbidity and mortality, 2) do the attendants recognize high risk patients and make appropriate referrals, 3) what are the factors affecting the decision to refer a patient, and 4) do complication rates suggest additional areas of training for the attendants or additional services that could be provided to improve perinatal and maternal health. Data were obtained on women delivering at 4 obstetric units. The survey found that almost 30% of the women over 39 years of age and 20% of those with 6 or more previous live births were referred. Some 95% of those with prepartum hemorrhage or hypertensive disorders were referred, and all those with reported premature rupture of the membranes were referred. Almost 25% of the women presenting at the obstetric units were designated as being at high risk. 20% of these women were referred to the hospital for delivery. Almost 98% of the women presenting at the obstetric units delivered babies who were alive at discharge. The traditional birth attendant training project achieved its primary goal of making deliveries safer for rural women. It also demonstrated that traditional birth attendants with little or no formal education can be trained to refer high risk women for hospital delivery while conducting safe deliveries in their own communities.