Dissertation (MSc Midwifery)Mwanza Region is one of the Regions in Tanzania with high maternal deaths with a burden of 305 MMR per 100,000 live births. Inadequate partograph compliance among nurse-midwives and poor structural quality for maternal referral system at the dispensary, health centers and hospital level can be among the contributing factors of the reported maternal deaths in the Region. This study aimed to assess the effect of structural quality of the maternal health referral system on midwives’ competence on partograph compliance. A hospital-based cross-sectional study involved 384 study respondents and 50 health facilities selected using simple random sampling technique. A structured questionnaire and a checklist were used to collect data for nurse-midwives competence, compliance on partograph and structural quality respectively. SPSS v20 was used for data analysis. Descriptive statistics was used to univariate data. Bivariate and multivariate data were analysed using Chi Square, Binary Logistic and multinomial regression models. The results were presented using tables and figures. Of all 384 respondents, 226(58.9%), 142(37.2%) and 265(69%) had adequate knowledge, positive attitude and adequate skills on partograph. Only 22% had inadequate partograph compliance. The study findings showed that 96.7% and 60.4% of dispensary and health centers/hospital had substandard structural quality, respectively, and the structural quality was not the predictor of partograph compliance (p>0.05). Age of 19-29 years was the predictor for partograph compliance at dispensary and health centre/hospital (AOR=0.350, 95%CI 0.157-0.780, p=0.010) and (AOR=3.502, 95%CI 1.326-9.247, P=0.011) respectively. While certificate qualification was the only predictor for partograph compliance at dispensary level (AOR=0.232, 95% CI: 0.070-0.775; p=0.018). Partograph should be used correctly and consistently used to all women attending labour for childbirth as it alerts the midwife for a quick action to be undertaken. There is a need for health facility management teams in Mwanza Region to establish consistent on-job training (OJT) particularly on how to use partograph.