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Childbirth, though a common yet highly valued social event in Africa, is a major risk for the mother and child. During these last few decades, extension of health services has gained attention and their accessibility has improved. However, these health services remain inefficient because of their poor quality, especially for prenatal screening. This study with 59 cases and 177 controls was carried out in a rural district of Zaire. The objectives were to first assess the quality of the diagnosis of high risk pregnancy (HRP) and secondly to identify the main risk factors associated with complicated deliveries. The diagnosis of HRP has a low sensitivity (53%) yet a high specificity (95%). The diagnosis is based on postpartum hemorrhage and maternal height but does not consider primiparity or previous complicated deliveries. By improving the use of currently available information, a higher sensitivity (72%, could be obtained, identifying close to 3 out of 4 HRPs, but with a lower specificity (67%). The current diagnosis is conservative, partly because health personnel are reluctant to refer pregnant women, who could deliver normally, to the district hospital. Predictive criteria of complicated pregnancy are: primiparity, maternal height, previous difficult childbirth (dystocia), previous postpartum hemorrhage and lack of prenatal care. Prenatal screening should be a major component of safe motherhood programs. Our results show that in developing countries where emphasis is mainly put on the accessibility of health services, the quality of these services should become a priority. Quality is linked to efficiency, yet good quality gives a better image of services and improves compliance of the women.