Antenatal care (ANC) is an essential health service for pregnant women. The individual interventions that comprise ANC have been shown to be efficacious and are recommended by the World Health Organization. However, there is poor evidence and guidance for optimal packaging of individual interventions and delivery mechanism(s). This lack of guidance contributes to inconsistent and poorly delivered care, resulting in limited improvements in maternal, fetal and newborn outcomes despite increases in ANC coverage globally. This dissertation comprises three studies which analyze the problems, bottlenecks and potential achievements of ANC policy and implementation at international, national and local levels. The first is a review of the history of ANC policy and politics, in which we identified reasons for ANC's neglect and poor implementation internationally and nationally. The second and third studies examine ANC in rural Haiti. In the second study, we compare the quality of ANC in traditional, fixed clinics to an alternative delivery model, mobile clinics, and assess knowledge and care quality perceptions of care recipients. In the third study, we explore ANC providers' beliefs about ANC based on semi-structured interviews. Our findings show that ANC failed to gain international support due in part to lack of leadership and powerful incentives favoring funding of vertical programs over more complex health services like ANC. In Haiti, we documented similar moderate- to poor-quality of care in both clinic models. The quality of education and counseling was particularly low, but interpersonal relations between providers and women were highly rated. Interviews with care providers revealed conflicts between their beliefs about ANC and the potential to act on these due to environmental barriers. This likely leads to inconsistent and incomplete care. The results of these studies suggest multiple steps to improve ANC. These include forging better leadership for ANC at the international level and performing research to develop comprehensive guidance for ANC packaging and delivery mechanisms. Care providers could benefit from tools to improve decision making that better reflect clinical guidelines, stronger supervision and support, and quality assurance mechanisms. These basic steps have the potential to improve the lives of millions of women and infants.