In Women’s Health Issues, Pooja Mehta and colleagues, including Shreya Kangovi and Sindhu Srinivas, seek to understand maternal preference for unscheduled hospital-based obstetric care, in order to inform interventions and improve value of publicly funded care during pregnancy. Previous research has shown that pregnant high utilizers of unscheduled care may be at particular risk for poor perinatal outcomes; however drivers of this association are unknown. The authors conducted a comparative qualitative analysis of in-depth semi structured interviews. Low-income pregnant women presenting to an inner city hospital-based obstetric triage unit were purposively sampled, categorized as 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. They find that high utilizers were more likely to report adverse childhood experiences, repeatedly used unscheduled care due to psychosocial determinants, and 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. The authors conclude that low-value, unscheduled, hospital based care utilization by pregnant women of low socioeconomic status is drive by unmet clinical and psychosocial needs. Tailored community-focused innovations may improve value of both outpatient and inpatient maternity care and better address adverse perinatal outcomes in vulnerable subgroups.