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ntroduction: Health system leaders have a vital role to play in ensuring the delivery of high-quality care. Improving the quality of healthcare, particularly in low-income countries often focuses on the performance of healthcare providers and the availability, acceptability, and uptake of services. The role that health service leaders play in facilitating effective care has received less attention in the literature. This study explored the perspectives of Afghan maternity care providers, managers and other stakeholders on leadership and the provision of quality maternity care.\ud \ud Methods: This ethnographic study used semi-structured interviews, participant observation, and background interviews for data collection. The research setting was a Kabul tertiary maternity hospital. Participants included doctors, midwives and care assistants who were employed in the hospital (n=23). Stakeholders from the health system, government, community and non-governmental organizations provided background interviews (n=41). A thematic framework analysis was conducted across all the data sets and different participants to maintain the context and perspectives of individual groups and identify themes.\ud \ud Results: The results of this study involves 1. Healthcare providers who described their managers as both autocratic and weak. They explained that their managers failed to enforce standards or listen to their concerns. 2. Managers who felt powerless to improve care because the government did not support their initiatives to reform the working environment or discipline staff members who were flouting the rules.\ud \ud 3. Background interviewees who concurred that hidden relationships influenced and undermined the health system at all levels.\ud \ud Conclusion: An unofficial system of connections with powerful people gave some staff privileges and power beyond their roles and undermined the power of managers who were responsible for standards of care. Strong, unwavering political will and tenacious leadership will be needed to address this. We suggest that initiatives to improve the quality of care in other low- and middle income countries (LMICs) look beyond individual staff and official systems to determine who holds the power and how that power is used

Central to respectful care for women giving birth in health facilities are doctors, midwives and care assistants. Often however there is a disconnect between the training and skills of health care providers, and the care that pregnant women receive. What are the reasons for the disconnect in this Afghan maternity hospital?