Background: The underutilization of formal, facility-based maternal care is a major contributor to the high maternal mortality rates among women living in rural Africa. Increasing the use of formal maternal care requires exploration of important maternal health issues affecting community members and comprehension of how they perceive the use of formal and traditional maternal care. This thesis aimed to identify the key factors, challenges, and needs of rural populations for the uptake of formal maternal care. Paper 1 explored rural women's preferred choices for sources of maternal care as well as the factors that contribute to their preferences in Africa. Paper 2 explored elders' perceptions about reasons for the underutilization of maternal healthcare and maternal death, as well as potential solutions to improve formal care use in rural Nigeria. Methods: 1) In paper 1, a systematic search on Ovid Medline, Embase, CINAHL, and Global Health identified 40 qualitative studies that elicited women's preferences for maternal care in rural Africa. Reviewers collated the findings and reported on patterns identified across findings using the narrative synthesis method. 2) Data were collected through 9 community conversations with 158 elders in 9 rural Nigerian communities. The data were analyzed inductively through thematic analysis. Results: 1) A variety of preferences for formal, traditional and both formal and traditional maternal care during antepartum, intrapartum and postpartum periods were identified. The majority of the studies reported preferences for formal antenatal care or a combination of traditional and formal antenatal care. During intrapartum, rural women held a wide range of preferences, including facility-based births, traditional births in a domestic setting, as well as a combination of formal and traditional care depending on the onset of complications. The majority of the studies reported preferences for traditional postnatal care involving traditional attendants, self-care, and cultural rituals that fend off witchcraft. The factors that contributed to these preferences were related to the perceived need of formal or traditional maternal care, accessibility to formal or traditional care, and cultural and religious norms, beliefs and obligations. 2) The perceived reasons for the underuse of formal maternal care included poor qualities of care, physical and financial inaccessibility of facility-based services, and lack of knowledge and awareness. Reasons for women's maternal deaths included malaria and blood displacement, facility-based service deficiencies, uptake of traditional maternal care, and poor community awareness and negligence. Increased access to high-quality care, health promotion and education, community support and supernatural assistance were the proffered solutions. Conclusions: The major areas that need improvement across rural Africa include human and material resources availability, technical and interpersonal quality of care in health facilities, physical accessibility, financial accessibility, sociocultural accessibility, cultural and religious sensitivity, and community knowledge and awareness. Generally, the findings reflect the need for multifaceted interventions that engage target populations and consider local contexts, realities, and related needs in order to develop locally acceptable interventions. Such interventions will increase the likelihood of effective and long-lasting positive changes in healthcare utilization and maternal mortality.