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Abstract Quality and respect are increasingly recognized as critical aspects of the provision of health care, and poor quality may be an essential driver of low health care utilization, especially for maternal and neonatal care. Beyond differential access to care, unequal levels of quality exacerbate inequity, and those who need services most, including displaced, migrant, and conflict-affected populations, may be receiving poorer quality care, or may be deterred from seeking care at all. Examples from around the world show that mothers and their children are often judged and mistreated for presenting to facilities without clean or “modern” clothing, without soap or clean sheets to use in the hospital, or without gifts like sweets or candies for providers. Underfunded facilities may rely on income from those seeking care, but denying and shaming the poor further discriminates against vulnerable women and newborns, by placing additional financial burden on those already marginalized. The culture of care needs to shift to create welcoming environments for all care-seekers, regardless of socio-economic status. No one should fear mistreatment, denial of services, or detainment due to lack of gifts or payments. There is an urgent need to ensure that health care centers are safe, friendly, respectful, and hospitable spaces for women, their newborns, and their families.

Abstract Background Despite global gains, women in hard-to-reach areas are at a relatively higher risk of death and disability related to childbirth. Traditional methods of measuring satisfaction may mask negative experiences (such as disrespect and abuse) that can drive down demand for institutional care. Better measurement of women’s perceptions of care quality, especially among marginalized populations with historically low utilization of institutional care, are needed to inform how to improve services and foster greater utilization of (potentially life-saving) clinical care. Methods A population-based household survey was conducted in 15 purposively selected villages in the rural Western Highlands of Guatemala among women who gave birth to a child within the last 5 years. Demographic and health information including experiences and perceptions of maternity care were collected. Two sets of nested multivariate logistic regression models were estimated to identify factors associated with future intention to give birth in a health facility, separately among women who gave birth to their last child at home and women who gave birth to their last child in a facility. The independent variables of interest were access to care, perceived need for maternity care, and two measures of perceived quality: satisfaction with last birth and disrespect and abuse (perceived or experienced). Thematic analysis was performed on open-ended responses. Results Perceived need for facility-based childbirth services and satisfaction with last childbirth experience, either at home or in a facility, emerged as the key factors influencing intention to give birth in a health institution in the future. Among the facility birth group, reporting disrespect and abuse is a deterrent to seeking facility-based care in the future. However, select perceptions of disrespect and abuse did not have an association with future intention (among the home birth group). Conclusions Women’s perceptions of care quality influence care-seeking. Women who feel they were mistreated in health facilities are more likely to avoid or delay seeking care in the future. Health systems need to reinforce trust and positive perceptions of respectful care. Developing better measures of women’s perceptions of maternity care experiences among indigenous populations in Guatemala can inform improvements in care provision.