 The study aimed to evaluate continuous quality improvement, CQI, targeting antinatal HIV care quality in rural South Africa. The study used a step-wedge cluster randomized controlled trial, management and optimization of nutrition, antinatal, reproductive, child health, monarch, and an embedded process evaluation. The study found that CQI held promise, but also identified several health system challenges. Priorities for policy makers included improving staffing and strategies to improve clinical documentation. Additionally, additional support with implementing clinical guidelines and improving routine data quality are needed. Finally, normalizing CQI may be challenging without concurrent health system improvements. This article was authored by H. Manisha Yapa, Wendy Dlomom-Fatswi, Mosa Mashabila, and others.