<![CDATA[Background. Midwifery care in marginalized communities is shaped by gendered professional hierarchies, institutional surveillance, and unequal resource distribution. However, these structural conditions are often overlooked when maternity experiences are explained primarily through individual-level accounts of healthcare access and service use. Purpose. This study aimed to examine how institutional power and political-economic arrangements shape women’s maternity care experiences and influence the working conditions, professional authority, and relational labor of midwives in marginalized communities. Method. A qualitative critical institutional ethnography was conducted across three community settings involving 52 participants, including women, midwives, community representatives, healthcare managers, and policymakers. Data were collected through individual interviews, six focus group discussions, 84 hours of observation, and analysis of 24 workforce, policy, and budget documents. The data were analyzed using reflexive thematic analysis, institutional mapping, and an intersectional political-economic approach. Results. The analysis generated five major themes: visible risk and invisible experience, gendered devaluation of relational labor, constrained midwifery authority, transferred institutional scarcity, and community resistance. Women were highly visible within institutional risk classifications, while structural barriers affecting their maternity experiences remained insufficiently recognized. Midwives’ advocacy, interpretation, care coordination, and emotional support were essential to healthcare access and safety, yet these forms of relational labor were inadequately documented, funded, and rewarded. Conclusion. Equitable maternity care requires structural reform beyond interpersonal respect and individualized approaches to service delivery. Health systems should recognize relational care as skilled clinical labor, redistribute interpretive and decision-making authority, strengthen midwifery professional autonomy, and provide adequate funding for transportation, language access, continuity of care, and community-based maternity services as essential components of quality and equitable healthcare.]]>
