BACKGROUND:
Afghanistan remains among the countries with the highest maternal mortality ratios worldwide, a situation intensified by ongoing conflict, political instability, and restrictive gender norms that limit access to maternal and child health services. In response to these challenges, innovative service delivery models such as Midwife-Led Maternity Care Centres (MLMCCs) have emerged, offering a promising strategy to protect and expand access to essential maternal and newborn care.

OBJECTIVES:
This study examines the enablers and barriers to implementing midwife-led care in fragile, conflict-affected settings, specifically evaluating the effectiveness, accessibility, and sustainability of MLMCCs in Afghanistan. It also assesses the impact of these centres on women’s satisfaction, and their role in early risk identification and referral systems.

METHODS:
A mixed-methods approach was employed, combining quantitative analysis of service records collected over a six-month period (Oct 2024-Mar 2025) with qualitative insights from in-depth interviews and focus group discussions involving midwives, women, and key stakeholders. The evaluation considers community perceptions, provider experiences, and operational challenges faced by MLMCCs in Afghanistan situation.

RESULTS:
Midwives play a pivotal role in conflict-affected contexts, serving not only as skilled healthcare providers but also as trusted community advocates, often working under severe restrictions. Success factors for MLMCCs include strong community engagement, local ownership, consistent midwifery service availability, and culturally sensitive care delivery. However, persistent barriers remain, including inadequate infrastructure, limited medical supplies, safety risks, and diminishing opportunities for women to enter and remain in the health workforce.

CONCLUSIONS:
The findings provide urgently needed evidence to guide health policy and donor investments in fragile contexts. By amplifying Afghan midwives’ voices and showcasing resilience, it proposes a scalable model for delivering respectful, life-saving maternity care in crisis-affected regions.

KEY MESSAGE:
MLMCCs represent a resilient and adaptable approach to safeguarding maternal and newborn health in Afghanistan’s most challenging environments, offering valuable lessons for similar fragile contexts worldwide. Midwife-led centre 1