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Objective: This paper describes the package of interventions undertaken by the CARE/AMDD program collaboration to increase the availability and quality of emergency obstetric care for 3 high maternal mortality countries in Africa.Methods: Project implementation over 4 years focused on enhancing the capacity of 10 district hospitals in 3 countries - Tanzania, Rwanda and Ethiopia. Interventions were designed to create functional health facilities with trained and competent staff, working in an enabling environment supporting EmOC service delivery.Results: By keeping a clear focus on EmOC, the project achieved modest improvements in services, even in the face of the considerable constraints of rural district hospitals. Availability and utilization of EmOC increased in Tanzania; the met need for EmOC increased slightly from 14% in year 1 to 19% in year 4, while in Rwanda it increased from 16% to 25% over 4 years. Case fatality rates (CFR) declined by 30-50% in all 3 countries. While still well below UN recommendations, in all 3 countries there was also a progressive increase in the cesarean section rates, a life saving obstetric intervention.Conclusions: The increases in met need and decreases in case fatality suggest that project interventions improved the quality and use of EmOC, a critical component for saving women's lives. [ABSTRACT FROM AUTHOR]