Objectives. This study examines the relatively low use of modern pregnancy-related care in Guatemala, especially among indigenous women, and explores the role of socioeconomic status, social and cultural variables, and access to biomedical health facilities in accounting for ethnic differences in care. Methods. The data for the analysis come from the Guatemalan Survey of Family Health?a population-based survey of rural women that contains detailed data on care received during pregnancy and delivery along with extensive background information. Binomial and multinomial logit models are used to identify the variables that affect the likelihood of receiving different types of care during pregnancy and delivering in a medical facility and the extent to which sociocultural factors and measures of access account for the observed ethnic differences. Results: The estimates not only confirm previous findings of a large ethnic difference in the use of modern pregnancy-related care, but also extend them by identifying a gradient within the indigenous population. The analysis demonstrates that, in general, sociocultural variables are more strongly associated with modern pregnancy-related care than are measures of access and that the former variables explain more of the ethnic variation in care than the latter. The results also demonstrate that pregnant women, especially indigenous women, are more likely to seek biomedical care in conjunction with traditional midwifery care rather than to rely solely on the former. Conclusion. The findings suggest that midwives are likely to continue to be key providers of pregnancy-related care in the future, even as access to modern health facilities improves. Current efforts directed toward the training and integration of midwives into the formal health system are likely to be much more effective at improving pregnancy-related care than the replacement of midwives with biomedical providers.