More than 500,000 women worldwide die each year from complications related to childbirth. With good quality obstetric care, approximately 90% of these deaths could be averted. The assistance of a skilled birth attendant during labor, delivery, and the immediate postpartum period is one important component of quality obstetric (OB) care. Other key factors are an enabling environment for skilled attendance at delivery and prompt attention at a medical facility for women arriving with an OB complication. However, little is known about the competence of skilled birth attendants (SBAs), the elements that contribute to an enabling environment, and the causes of what is commonly known as the "third delay": the delay in receiving medical attention after a woman with an OB complication arrives at a healthcare facility. Through its Safe Motherhood Research Program, the Quality Assurance Project implemented three studies to explore these issues in countries with high maternal mortality ratios. The first study examined the competency of SBAs. The second measured SBA performance and the relative contribution to performance of different enabling factors in the work environment. The last examined causes of inhospital delays in providing OB care. All three occurred between September 2001 and July 2002 in Benin, Rwanda, Ecuador, and Jamaica. This report presents the results from Jamaica. The Competency Study measured knowledge with a 55-question test covering six subject areas. It also tested skills in several key areas, including neonatal resuscitation, manual removal of placenta, bimanual uterine compression, and insertion of an intravenous needle. Third, it asked participants to assess their own ability to carry out common obstetric procedures. The knowledge and skills tests were completed by providers from the four hospitals in the study plus a representative sample of community-based midwives. Results yielded a mean score of only 58% correct for the knowledge test and 46% on the skills test. Hospital-based provider scores were higher than the community-based providers in both tests, and in all topics except asepsis in the knowledge test and mouth-to-mouth and resuscitation in the skills test, which were slightly higher in the community-based group. Knowledge scores related to pregnancy-induced hypertension were higher for both hospital-based and community-based providers than for any other topic. Community-based providers' knowledge about sepsis and active management of third stage labor was low. In the skills test, manual removal of placenta and bimanual uterine compression mean scores were low for all types of providers--only about 38% for hospital-based and 14% for community-based providers. There was little correlation between providers' self-assessment and their competency as measured by the knowledge and skills tests. The Enabling Environment Study addressed the contribution of enabling factors and essential elements to health worker performance. We used an observation checklist to evaluate performance during labor, delivery, and the immediate postpartum period and reviewed medical records to evaluate performance in managing OB complications. We also surveyed providers in each facility about supervision, training, and motivation, and, finally, we inventoried the availability of essential drugs, equipment, and supplies in each study hospital. Labor monitoring, including checking fetal heart rate and the mother's blood pressure, was inadequate in most observed cases. Key tasks for intrapartum and postpartum care for the mother were performed adequately in most observed cases, although use of sterile drapes and clothing was done in far less than half the cases. Most administered oxytocin to the mother after delivery. However, some key tasks for postpartum care for the newborn in the first two hours after birth were frequently not done, including suctioning, putting the baby into skin-to-skin contact with the mother, checking baby's temperature, checking the umbilical cord, and keeping baby under constant supervision The Third Delay Study used direct observation to analyze patient flow in all four study hospitals. In addition, three physicians reviewed medical records to identify any delays at different points in patient care: Most of the delays they found occurred during diagnosis, especially for obstructed labor. For women who were not in labor, waiting times after arrival at the OB department to initial exam averaged 19 minutes, and to exam by a professional averaged 43 minutes, although these times differed substantially by hospital. Waits were significantly longer on weekdays than weekends at all hospitals, but whether wait times were different during the day or night differed by hospital. Delays in treatment were documented for all types of emergencies, with many resulting from delays in C-sections, which average 102 minutes from order to beginning of surgery. Sepsis was the emergency with the longest time from order to its administration: 205 minutes on average. (author's)