<p>We sought to identify and describe modifying factors influencing adherence to the post-abortion care guidelines, as well as potential strategies to address them in rural health facilities of Chibombo District, Zambia. We used a qualitative descriptive approach, drawing on key informant interviews with program managers (<i>n</i> = 4) and in-depth interviews with post abortion care providers (<i>n</i> = 22). We adopted Carroll et al.‘s Framework for Implementation Fidelity which prescribes four categories of potential moderating factors that may shape adherence to post abortion care guidelines including comprehensiveness of policy description, facilitative implementation strategies, patient responsiveness, and quality of delivery. We analyzed the interview data using deductive thematic analysis. The study revealed shortcomings in the comprehensive description and dissemination of post abortion care guidelines, underscored by limited provider understanding and reference to them during practice, and delayed dissemination of any guideline changes or updates. Facilitative implementation strategies encompassed monitoring and supervision, technical and administrative support, documentation and audit, and community engagement. Inadequate provider training, inconsistent post abortion care drug supply, weak referral mechanisms and funding gaps affected the quality of delivery of post abortion care services. Lastly, patient responsiveness was affected by non-compliance to the guidelines and community reliance on self-treatment. There is a critical need for comprehensive training, supply chain improvements, and stronger health system support to ensure adherence to post-abortion care guidelines in rural settings. Such initiatives may have far-reaching implications for maternal health outcomes and general health equity.</p>