There has been considerable attention placed on ‘failures’ of maternity care in high-income countries, with little focus on the drivers of ‘high-quality’ care delivered at the organisational level. We conducted a realist review with this central focus and report on the first phase, initial programme theories (IPTs) generated from the literature, where a future phase will ‘test’ the IPTs.

A realist review methodology was employed, an interpretative, theory-driven approach designed to explore ‘what works, for whom, in what circumstances’ using context, mechanism and outcome (CMO) propositions.

The search strategy used a purposive database (MEDLINE) and hand searches, including peer-reviewed journals, grey literature and policy reports, to identify literature rich and relevant to the research question.

As per realist review approaches, we included any English-language literature from peer-reviewed journals, grey literature, policy reports, service guidance and public or professional commentary, from high-income countries, that provided explanatory insights to the operationalisation of ‘high-quality’ maternity care at the organisational level. Using an a priori definition, high-quality maternity care was defined based on four outcome criteria: higher service user and staff well-being, lower prevalence of complications/adverse outcomes and optimal use of resources.

Data extraction configured evidence using the ‘If, Then, Leading to’ CMO heuristic. The IPTs were iteratively developed from the synthesised data and refined through consultation with a diverse 26-member core stakeholder group.

The iterative search process included 17 index papers, which were a mix of systematic reviews, primary research studies, commissioned reports, evaluations and commentaries. These papers generated 292 initial CMO hypotheses, which were refined into 11 IPTs focusing on organisational-level mechanisms. The IPTs reflect a ‘both-and’ philosophy, balancing clinical excellence (safety) and values-based relational care (personalisation and staff environment). Key themes include visible and supportive leadership, responsiveness to workload assessments, ensuring operational fitness (system and workplace environment support) and broadening the definition of safety beyond physical safety to include psychological, emotional and cultural safety. The IPT related to ‘A culture of equitable care’ was identified as critical in underpinning all maternity service provision.

The 11 IPTs offer crucial insights into the context and mechanisms that may produce desired outcomes in high-quality maternity care. Learning from high-quality services (safety II) provides a novel approach compared with focusing only on failings. These globally relevant IPTs can be applied to high-income contexts as a foundation for designing future improvement programmes.

CRD420251104996.