Maternal healthcare in Southern Africa, particularly in Madagascar, faces challenges due to resource limitations and cultural barriers. Biomedical obstetric services are often inaccessible or mistrusted, while traditional Malagasy medicine remains a primary, culturally embedded source of care. This disconnect contributes to poor maternal health outcomes. This study aimed to develop and pilot a sustainable model for integrating traditional Malagasy medicine with biomedical obstetrics in rural Madagascar. Its objectives were to document common traditional practices for pregnancy and childbirth, assess community and healthcare worker perceptions of integration, and evaluate the feasibility of a co-management pilot programme. A mixed-methods design was employed in two rural districts. Data collection included ethnographic fieldwork with traditional healers, focus group discussions with women of reproductive age, and semi-structured interviews with biomedical midwives and doctors. A six-month pilot integration protocol was then co-designed and implemented, with process evaluation through key informant interviews and clinic utilisation data. A consistent theme was the complementary, non-competitive roles of each system: traditional medicine was predominantly used for preventative care, spiritual wellbeing, and postnatal recovery, while biomedical care was sought for acute complications. In the pilot, most participating traditional healers successfully referred cases to clinics and reported satisfaction with the collaborative framework. Midwives noted an increase in first-trimester antenatal bookings in pilot areas. A structured, respectful integration of traditional Malagasy medicine and biomedical obstetrics is feasible and can enhance early engagement with the formal health system. The model leverages existing community trust in traditional medicine to improve maternal health service utilisation. National health policy should formally recognise the role of trained traditional healers as community health liaisons. Training programmes for both traditional healers and midwives on collaborative practice and safe referral pathways are essential. maternal health, traditional medicine, medical integration, Madagascar, obstetrics, healthcare delivery, midwifery This research provides an evidence-based framework for integrating traditional and biomedical maternal healthcare, offering a culturally sustainable model for improving service uptake in rural Southern African contexts.