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Objective  To explore conceptions of obstetric emergency care among traditional birth attendants in rural Guatemala, elucidating social and cultural factors.

Study design  Qualitative in-depth interview study.

Setting  Rural Guatemala.

Sample  Thirteen traditional birth attendants from 11 villages around San Miguel Ixtahuacán, Guatemala.

Method  Interviews with semi-structured, thematic, open-ended questions. Interview topics were: traditional birth attendants' experiences and conceptions as to the causes of complications, attitudes towards hospital care and referral of obstetric complications.

Main outcome measures  Conceptions of obstetric complications, hospital referrals and maternal mortality among traditional birth attendants.

Results  Pregnant women rather than traditional birth attendants appear to make the decision on how to handle a complication, based on moralistically and fatalistically influenced thoughts about the nature of complications, in combination with a fear of caesarean section, maltreatment and discrimination at a hospital level. There is a discrepancy between what traditional birth attendants consider appropriate in cases of complications, and the actions they implement to handle them.

Conclusion  Parameters in the referral system, such as logistics and socio-economic factors, are sometimes subordinated to cultural values by the target group. To have an impact on maternal mortality, bilateral culture-sensitive education should be included in maternal health programs.