title: Understanding High Utilization of Unscheduled Care in Pregnant Women of Low Socioeconomic Status.
abstract: 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.
  
  
  
  We sought to understand maternal preference for unscheduled hospital-based obstetric care to inform interventions and improve value of publicly funded care during pregnancy.
  
  
  
  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.
  
  
  
  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.
  
  
  
  Low-value, unscheduled, hospital-based care utilization by pregnant women of low socioeconomic status was driven by unmet clinical and psychosocial need.
  
  
  
  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.
authors.affiliation: Robert Wood Johnson Clinical Scholars Program, University of Pennsylvania/ Department of Veterans Affairs, Philadelphia, Pennsylvania. Electronic address: pooja.mehta@bmc.org.
authors.forename: Pooja K
authors.initials: PK
authors.lastname: Mehta
authors.affiliation: Penn Center for Community Health Workers, Philadelphia, Pennsylvania.
authors.forename: Tamala
authors.initials: T
authors.lastname: Carter
authors.affiliation: Mixed Methods Research Laboratory, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Cjloe
authors.initials: C
authors.lastname: Vinoya
authors.affiliation: Penn Center for Community Health Workers, Philadelphia, Pennsylvania; Department of Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
authors.forename: Shreya
authors.initials: S
authors.lastname: Kangovi
authors.affiliation: Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
authors.forename: Sindhu K
authors.initials: SK
authors.lastname: Srinivas
mesh_terms: D000328:Adult; D001071:Appointments and Schedules; D003695:Delivery of Health Care; D036861:Delivery, Obstetric; D005260:Female; D006760:Hospitalization; D006801:Humans; D007182:Income; D007407:Interviews as Topic; D036801:Parturition; D011203:Poverty; D011247:Pregnancy; D011256:Pregnancy Outcome; D037841:Pregnant People / Q000523:psychology*; D011295:Prenatal Care / Q000706:statistics & numerical data*; D036301:Qualitative Research; D012923:Social Class