This paper complements the other papers in the Lancet Series on midwifery by documenting the experience of lowincome and middle-income countries that deployed midwives as one of the core constituents of their strategy to improve maternal and newborn health. It examines the constellation of various diverse health-system strengthening interventions deployed by Burkina Faso, Cambodia, Indonesia, and Morocco, among which the scaling up of the pre-service education of midwives was only one element. Eff orts in health system strengthening in these countries have been characterised by: expansion of the network of health facilities with increased uptake of facility birthing, scaling up of the production of midwives, reduction of fi nancial barriers, and late attention for improving the quality of care. Overmedicalisation and respectful woman-centred care have received little or no attention.