Background Pregnant high utilizers of unscheduled care may be at particular risk for poor perinatal outcomes, but the drivers of this association have not been explored from the patient perspective. Purpose We sought to understand maternal preference for unscheduled hospital-based obstetric care to inform interventions and improve value of publicly funded care during pregnancy. Methods We conducted a comparative qualitative analysis of in-depth semistructured interviews. Low-income pregnant women presenting to an inner city hospital-based obstetric triage unit were purposively sampled, categorized as either high or low utilizers of unscheduled care, and interviewed about challenges faced in obtaining pregnancy care and reasons for choosing between unscheduled versus scheduled care delivery. Results Demographically, high utilizers were similar to low utilizers, but were more likely to report adverse childhood experiences (p = .01). All 40 participants reported resource constraints and perceived hospital-based unscheduled obstetric care to be more accessible than outpatient prenatal care. Beyond this, high (n = 20) and low (n = 20) utilizer narratives differed significantly. Two distinct high utilizer profiles emerged. Some high utilizers repetitively used unscheduled hospital-based services owing to psychosocial determinants. Other high utilizing participants were driven by severe experiences of illness insufficiently addressed by outpatient prenatal care. Low utilizer narratives demonstrated high self-efficacy and social support compared with high utilizers. Conclusions Low-value, unscheduled, hospital-based care utilization by pregnant women of low socioeconomic status was driven by unmet clinical and psychosocial need. Implications for Policy and/or Practice Tailored community-focused innovations that use unscheduled visits as signals of risk may improve value of both outpatient and inpatient maternity care and better address adverse perinatal outcomes in vulnerable subgroups.

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