Maternal health leaders’ perceptions of barriers to midwife-led care in Ethiopia, Kenya, Malawi, Somalia, and Uganda

•This study provides new knowledge on midwife-led care from the perspectives of health leaders in five East African countries.•Key structural barriers to midwife-led care are linked to organisational structures, traditional hierarchies, gender disparities, and inadequate leadership.•To improve midwife-led care, an increase in the number of midwife leaders, role models, norm transformation and intra- and multisectoral collaboration is needed.•Examples of how barriers to midwife-led care have been reduced are given from the five countries.