Barriers to Maternal Health-Seeking Behavior in the DRC: The Role of Perceptions, Affordability, and Health System Financing

Efforts to improve maternal health in the Democratic Republic of Congo (DRC) have often focused on expanding access and improving structural readiness. These are critical first steps, but this analysis reveals a critical missing link: womens perceptions of care--including how they are treated, how much they trust providers, and how affordable care seems--which are more predictive of health-seeking behavior than objective facility infrastructure or actual cost. Drawing on two rounds of household and facility surveys, we find that care seeking is strongly impacted by perceptions. Womens perceptions of quality was defined by a composite index that captures interpersonal experiences (e.g., respectful treatment, clear communication, and provider competence), alongside perceptions of facility conditions like cleanliness and drug availability. In regression models, we found that perceived quality was more predictive of care-seeking than structural readiness. Women who perceived care as good were significantly more likely to initiate antenatal care, return for postnatal visits, and seek help for complications--even in under-resourced facilities. These findings highlight the individual-dependent nature of health system interaction: perceived quality modulates behavior even within the same infrastructure. Similarly, perceptions of affordability better predicted care utilization than objective financial hardship, operating through household coping strategies like asset sales. The type of asset sold mattered: selling food reserves was linked to earlier care but reduced continuity, while selling productive assets enabled sustained engagement. These patterns highlight womens agency and that affordability is shaped by expectations, vulnerability, and risk assessment. Health financing models also shaped these dynamics. Performance-based financing (PBF) drove improvements in centrally-incentivized services such as vaccination and laboratory testing, while direct facility financing (DFF) enabled more responsive delivery for high-burden local priorities like malaria care. Crucially, perceptions had a stronger influence on utilization in DFF settings, where facility responsiveness varied more. This suggests that in more adaptive systems, interpersonal trust and perceived quality play a greater role in guiding behavior, highlighting how systems-dependent factors mediate how care is delivered and how patients respond to it. Improving maternal health in fragile settings requires re-centering perceptions as core indicators of system performance. Respect, clarity, cleanliness, and competence must not only be measured but actively addressed. Financing reforms should empower frontline providers to respond to patient feedback, not just meet centrally imposed targets. And affordability interventions must reflect behavioral realities: what feels affordable is shaped by hardship, expectations, and perceived benefit. Measuring household coping strategies like selling assets can offer insight into the how to mitigate the sacrifices households make to access care and suggest interventions. Contrary to traditional models of primary healthcare investment, far more attention must be placed on the drivers of perception--friendliness, affordability, trustworthiness--if we aim to expand coverage. Perception data are not mere satisfaction scores; they are proxies for trust, predictors of use, and a missing link in health systems that aspire to be people centered.