Each year, more than 500,000 women worldwide die 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 care. An enabling environment for skilled attendance at delivery and prompt attention for women arriving at a medical facility with an obstetric complication are also key factors. 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 arrives at a healthcare facility. Through its Safe Motherhood Research Program, the Quality Assurance Project carried out 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 in-hospital delays in receiving obstetric care. All three studies occurred between September 2001 and July 2002 in Benin, Rwanda, Ecuador, and Jamaica. This report presents the results from Rwanda, where three hospitals participated: a tertiary care referral hospital with an active maternity department and two regional hospitals. The competency study measured knowledge with a 58-question test covering six subject areas. We also tested skills in several key areas, including ability to use a partograph, neonatal resuscitation, manual removal of placenta, bimanual uterine compression, and insertion of an intravenous needle. Finally, we asked participants to assess their own ability to carry out common obstetric procedures. Results show low competency levels with a mean score of 47% correct. Active management of third stage labor merits specific mention, as the mean score was only 7%. The overall test scores for doctors, professional nurses, and midwives were quite similar, while scores for technical nurses were significantly lower. There were too few doctors and midwives to compare skills scores in a statistically reliable way; however, professional nurses scored significantly higher than technical nurses overall, for mouth-to-mouth and nose resuscitation, and asepsia. There was no 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. We reviewed medical records to evaluate performance in managing obstetric complications. We also surveyed providers in each facility about supervision, training, and motivation. 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. Providers used a partograph only about a third of the time. Few washed their hands before assisting at delivery, and only about half cleaned the perineum before birth; most administered oxytocin to the mother after delivery. The third delay study used direct observation to analyze patient flow in all three study hospitals. In addition, three physicians reviewed medical records to reveal any delays at different points in patient care: Most of the delays they found occurred during diagnosis, especially for obstructed labor. Waiting times after arrival at the hospital or the OB department were short, averaging 13 minutes, with one regional hospital averaging only 3 minutes. The mean time from decision to operate and start of a cesarean section at the tertiary hospital was about two hours. Antibiotics were administered only 44 minutes on average after an order at the tertiary hospital. (author's)