Maternal mortality among indigenous women in Guatemala is high. To reduce deaths during transport from far-away rural communities to the hospital, maternity waiting homes (MWH) were established near to hospitals where women with high-risk pregnancies await their delivery before being transferred for labour to the hospital. However, the homes are under-utilised. We conducted a qualitative study with 48 stakeholders (MWH users, family members, community leaders, MWH staff, Mayan midwives and health centre and hospital medical staff) in Huehuetenango and Cuilco to identify barriers before, during and after the women’s stay in the homes. The women most in need—indigenous women from remote areas—seemed to have least access to the MWHs. Service users’ lack of knowledge about the existence of the homes, limited provision of culturally appropriate care and a lack of sustainable funding were the most important problems identified. While the strategy of MWHs has the potential to contribute to the prevention of maternal (as well as newborn) deaths in rural Guatemala, they can only function effectively if they are planned and implemented with community involvement and support, through a participatory approach.