Abstract
<jats:p>Background Ecuador's Mother- and Baby-Friendly Health Facilities Standard (ESAMyN, Establecimientos de Salud Amigos de la Madre y el Nino) is an integrated national quality improvement strategy that combines evidence-based recommendations for antenatal, childbirth, postpartum, newborn and breastfeeding care within a single implementation and certification framework. However, little is known about the factors influencing its implementation in routine health services. This study explored the organizational, contextual and behavioural factors that facilitated or hindered ESAMyN implementation across public health facilities. Methods We conducted a secondary qualitative analysis of 36 semi-structured interviews originally collected during a programme systematization in 11 public health facilities across five Ecuadorian provinces. Participants included health authorities, managers, ESAMyN focal points, quality coordinators, healthcare professionals and women receiving maternity services. Interview transcripts were analysed inductively using thematic analysis. Results Implementation was perceived as an organizational transformation rather than the adoption of a new clinical guideline. Strong leadership, multidisciplinary teamwork, continuous training and institutional commitment facilitated implementation and promoted the adoption of respectful, family-centred and evidence-based maternity care practices. However, staff turnover, workload, infrastructure limitations, shortages of equipment and funding, and reliance on local adaptation challenged implementation and contributed to variability across facilities. Participants emphasized that sustaining ESAMyN required institutionalization beyond certification through continuous monitoring, refresher training, supportive supervision and stable organizational support. Conclusions Integrated national quality standards can strengthen maternal and newborn care through sustained leadership, adequate resources and continuous quality improvement, providing practical lessons for implementing WHO recommendations in routine health services.</jats:p>