Despite significant improvements in its maternal health indicators, sub-Saharan Africa remains one of the most dangerous regions in the world in which to give birth. Ensuring safe motherhood for rural African women requires a package of goods and services, provided by a number of different actors. But every part of this package can face delivery challenges. Typical bottlenecks at the local point of delivery include poor quality health care and professional standards, low staff morale and motivation, delays in transferring women to higherlevel health facilities and choices about health-care that reflect suspicion of modern health services.