In response to the high maternal mortality in Afghanistan, the government emphasised enhancing antenatal care (ANC) coverage to improve skilled birth attendance and reduce maternal mortality. This study aimed to explain how and why ANC interventions worked, for whom, and under what circumstances in Afghanistan between 2000 and 2024.

A rapid realist review was conducted to identify underlying programme theories and examine contextual factors and key mechanisms influencing ANC outcomes, with input from a panel of national experts. Data were extracted using context–mechanism–outcome (CMO) configurations to develop and refine theories for policy recommendations.

From 3502 papers, 1860 duplicates were removed, 63 were screened for full text and 25 were included in the final review. In total, 29 CMOs were inferred across nine interventions, classified at individual, interpersonal, community and institutional levels. We found that ANC interventions could work best by empowering women and healthcare workers (HCWs), involving husbands, hiring female community health workers (CHWs), ensuring regular contact with the same HCWs, endorsing health messages by the government, incentivising CHWs and designing and implementing interventions using participatory approaches. Interventions are less successful when there is a lack of community trust in service quality or HCW qualifications, low decision-making ability among women, discomfort during travel to health facilities, adherence to traditional practices and beliefs, hiring CHWs from outside the community, chronic stress and lack of support among HCWs and unrecognised incentives.

Our evidence synthesis can inform donors, policymakers and implementers on how to design more effective ANC interventions to achieve better health outcomes in Afghanistan. By emphasising intervention evaluation and ANC quality improvement, it highlights the importance of key social elements, such as cultural norms, power dynamics, relationships, beliefs and trust, which are likely to maximise impact. Community involvement is essential for designing and implementing effective and sustainable ANC interventions.