The Russian health system seeks to ensure consistent models of care through a series of nationwide decrees. Yet patterns of care vary widely, often unrelated to evidence of effectiveness. This study examines care provided by obstetricians in all 19 facilities in a typical Russian region. A first set of structured interviews was conducted with 52 obstetricians, with emerging themes explored in a second set of interviews with 36 of the original interviewees. Accounts were compared with quantitative data on patterns of practice.Obstetricians had little access to information, with only limited use of Russian journals and textbooks and minimal access to international evidence.The decisions made by obstetricians largely determined the overall pattern of care, with midwives, nurses and anaesthetists clearly subordinate. Care was highly medicalized, with many interventions long discarded in the west. There was no obvious reason for widespread variations.Obstetric care in Russia is characterized by widespread use of many harmful or ineffective practices, while many effective ones are not used. Effective policies to tackle these problems will require wide-ranging policies addressing factors ranging from educational policies to the status of professionals but, above all, will have to confront the legacy of Soviet science that prioritized ideology over evidence.