Exploring Positive Deviant Behaviors Among High-Risk Pregnant Women With Different Birth Outcomes: A Qualitative Study From Palwal, India

Introduction India has set the goals to reduce stillbirths (SBs) and neonatal deaths by 2030. However, despite continued efforts to improve maternal health, these adverse outcomes remain a concern in many regions. This highlights the importance of identifying strategies that are both community-acceptable and sustainable. This study explores positive deviant (PD) practices among pregnant women who, despite high-risk pregnancies (HRPs), achieved healthy birth outcomes - unlike many of their peers. Methods This qualitative exploratory study was conducted to explore PD practices among HRP women in Palwal district, Haryana, India. It focused on identifying what enabled some of these women to achieve positive birth outcomes, in contrast to their peers who experienced SB or early neonatal death (END). A total of 28 in-depth interviews (IDIs) were conducted with women with HRPs, categorized as women with live births (LBs) (N = 14), SBs (N = 9), and ENDs (N = 5). Data were analyzed thematically using Colaizzi's seven-step method, and emerging themes were further interpreted using the "Theory of Planned Behavior" (TPB) framework to explore the role of individual attitudes, subjective norms, and perceived behavioral control in shaping maternal health behaviors. Results The PD women reported proactive health-seeking behavior, balanced nutrition, culturally rooted physical activity, and safe sleep positions, often supported by Accredited Social Health Activists (ASHAs), husbands, and family members. In contrast, women with SB or END outcomes faced delays, adverse traditional practices, partial information, and barriers in healthcare seeking. Family dynamics - especially the influence of mothers-in-law - strongly shaped decision-making around diet, supplements, and place of delivery. Higher perceived behavioral control enabled some women to navigate constraints and seek timely care. Discussion The findings highlight broader health and well-being challenges faced by pregnant women in low-resource settings. Physical vulnerabilities were often heightened by emotional stress, limited autonomy, and lack of support. Despite these challenges, some women showed agency by prioritizing their health and seeking timely care. These PD women adopted practices such as balanced nutrition, early antenatal care (ANC), and culturally accepted behaviors that contributed to healthy outcomes. Their actions offer valuable lessons that can be promoted through community awareness campaigns and health education materials. This study suggests the need for an integrated approach beyond physical care, including mental health support, respectful communication, and active family and community engagement. Conclusion To reduce preventable SBs in low-resource settings, maternal health interventions must go beyond clinical care to foster family-inclusive, culturally sensitive, and psychosocially supportive environments. Strengthening health worker capacities, aligning traditional practices with evidence-based care, and empowering women with accurate information, emotional support, and greater control over health choices are essential to promote positive health-seeking behavior.