Background: Nepal needs to improve its quality of maternal and neonatal health (MNH) services to achieve the Sustainable Development Goals. However, there is limited research on the impacts of the country's political transformation on the quality of care. Hence, this study explores (1) the existing provision of care at the primary level and health actors’ perspective on the quality of MNH services, and (2) the impact of federalisation on the quality of MNH services in Nepal.Methods: The study utilised an explanatory sequential mixed-method approach, a health facility (HF) survey in Jumla and semi-structured interviews with health service users, health service providers (HSP) and health managers/policy makers from Jumla, Surkhet and Kathmandu, Nepal. Quantitative data were analysed using SPSS version 26, while qualitative data were analysed using NVIVO 11 and thematic analysis. The findings were presented through joint display where appropriate. Findings: The survey was conducted in 31 public HFs in Jumla, and the interviews were conducted with pregnant women (N-7), mothers having children under 2 years of age (N-8); 8 health facilities in-charge (N-8) and nursing staff (N-8); central level managers/policy makers (N-7), provincial level and local level (N-5) each. All the HFs provided antenatal and postnatal care, and delivery and newborn care were provided by all the birthing centres (N-23), Primary Health Care Centre and hospital. The interviews with HSPs found that partograph was used by some HFs only for complicated cases during referrals even though all the HFs claimed to use it for recording the delivery process during the HF survey. Most of the HFs did not have an anonymous complaint box available, as a result, women were afraid to voice their dissatisfaction due to the fear of mistreatment when they returned to HFs. Although women preferred to have either their mothers, sisters, or mothers-in-law for emotional support during labour and after childbirth, they preferred none during childbirth. Communication to the families about the importance of health for mother and baby, availability of health workers and supplies and equipment, quality maternity service provision along with timely identification of high-risk cases and referral, upgraded HFs and accessible health services were considered as important components of quality maternity services in this study. The health worker availability was found to be improved after the federalisation along with a quick decision-making process and local-level planning. However, after the federalisation, there have been delays in health workers' salaries, which has demotivated them to work, and delays in medicine procurement which has led to HFs running out of stock. This has impacted HFs from providing quality maternity services occasionally. Other challenges faced after the federalisation were coordination among the three-tier government, lack of training opportunities for health workers, and hesitation in budget allocation for MNH along with frequent movement of health workers due to the repositioning. However, this study found that going forward, clarity of roles and responsibilities in a federal structure, investing in MNH, and orientation to local representatives about the importance of maternity services along with community participation and engagement could save the lives of mothers and newborns. Conclusion: Upgraded HFs along with accessible MNH services and training opportunities for health workers can significantly impact the quality of maternity services. Moreover, better resource allocation in MNH along with community engagement could offer opportunities for providing high-quality MNH services. Clarity in roles and responsibilities among the three-tier government could improve the coordination among them resulting in better management of HFs for quality maternity services. Keywords: Federalisation, Maternal Health, Neonatal Health, Nepal, Primary care, Quality of care, Responsive