The complexity of childbirth care is characterized by three interfaces: First, the two continua of care from pre-pregnancy to postpartum care and community to referral hospital, meaning that the key health system characteristics and the functioning of the linkages between services points, including the referral systems, have a major impact. Second, childbirth care includes preventive and promotive, thus routine care as well as time-sensitive emergency care. Third, quality childbirth care is provided by a team of nurses, midwives, and obstetricians, as well as neonatologists and pediatric staff, thus a multi-professional team with different pre-service training and professional values and identities, creating frictions. 

Over- and under-provision of evidence-based interventions are seen in all settings, with the overuse of caesarean sections being a well-known example. Abuse and neglect have been raised and responsiveness during birth is high on the international agenda. Improving quality of care within these complex systems demands a careful combination of strategies to address the complexity and the different drivers of this complex system. But complex interventions may also overburden implementers and systems. Complex interventions demand sufficient resources, long-term investments, and sufficient patience to mentor and support implementing teams and institutions. 

Here, we summarize our learning from three complex interventions. We apply a scalability and adaptability lens to highlight critical issues.