Despite recent improvements in some countries, progress towards reducing maternal mortality rates in sub-Saharan Africa overall lags considerably behind that of other developing country regions. Recent evidence indicates that Rwanda has made impressive progress in this area, particularly in the rural locations. This report presents research findings from a project concerned with identifying the institutional arrangements which have enabled Rwanda to achieve significant improvement in ensuring safe motherhood for growing numbers of women in the rural districts of Nyamagabe and Musanze. Ethnographic research conducted over several months explored how actors, institutions and resources have been combined to overcome the key bottlenecks which might otherwise have undermined the provision of the key services which contribute to good maternal health outcomes. Initial analysis indicates that the coherence of the policy environment has been a key element. In addition to aiding in the clear definition of lines of responsibility, it has facilitated the avoidance of the sorts of overlapping mandates which usually encourage actors to pass the buck for service delivery failures. Laxity in professional standards and related problems ensuing from lack of motivation have been overcome by accountability mechanisms which serve as strong deterrents against misconduct by all actors responsible for service provision. Accompanying performance pressures based on consistent incentives comprising rewards and punishment ensure that all actors work toward the same objective of providing high-quality services. A crucial element in all this has been the facilitation of collaboration through which different actors, including users, can work together to overcome key bottlenecks.