UBC Faculty Research and Publications

Quality of prenatal care questionnaire: instrument development and testing Heaman, Maureen I; Sword, Wendy A; Akhtar-Danesh, Noori; Bradford, Amanda; Tough, Suzanne; Janssen, Patricia A; Young, David C; Kingston, Dawn A; Hutton, Eileen K; Helewa, Michael E Jun 3, 2014

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
52383-12884_2013_Article_1085.pdf [ 1.11MB ]
Metadata
JSON: 52383-1.0223411.json
JSON-LD: 52383-1.0223411-ld.json
RDF/XML (Pretty): 52383-1.0223411-rdf.xml
RDF/JSON: 52383-1.0223411-rdf.json
Turtle: 52383-1.0223411-turtle.txt
N-Triples: 52383-1.0223411-rdf-ntriples.txt
Original Record: 52383-1.0223411-source.json
Full Text
52383-1.0223411-fulltext.txt
Citation
52383-1.0223411.ris

Full Text

RESEARCH ARTICLE Open AccessQuality of prenatal care questionnaire: instrumentdevelopment and testingMaureen I Heaman1*†, Wendy A Sword2†, Noori Akhtar-Danesh2, Amanda Bradford3, Suzanne Tough4,Patricia A Janssen5, David C Young6, Dawn A Kingston7, Eileen K Hutton8 and Michael E Helewa9AbstractBackground: Utilization indices exist to measure quantity of prenatal care, but currently there is no publishedinstrument to assess quality of prenatal care. The purpose of this study was to develop and test a new instrument,the Quality of Prenatal Care Questionnaire (QPCQ).Methods: Data for this instrument development study were collected in five Canadian cities. Items for the QPCQwere generated through interviews with 40 pregnant women and 40 health care providers and a review ofprenatal care guidelines, followed by assessment of content validity and rating of importance of items. Thepreliminary 100-item QPCQ was administered to 422 postpartum women to conduct item reduction using exploratoryfactor analysis. The final 46-item version of the QPCQ was then administered to another 422 postpartum women toestablish its construct validity, and internal consistency and test-retest reliability.Results: Exploratory factor analysis reduced the QPCQ to 46 items, factored into 6 subscales, which subsequently werevalidated by confirmatory factor analysis. Construct validity was also demonstrated using a hypothesis testingapproach; there was a significant positive association between women’s ratings of the quality of prenatal care and theirsatisfaction with care (r = 0.81). Convergent validity was demonstrated by a significant positive correlation (r = 0.63)between the “Support and Respect” subscale of the QPCQ and the “Respectfulness/Emotional Support” subscale of thePrenatal Interpersonal Processes of Care instrument. The overall QPCQ had acceptable internal consistency reliability(Cronbach’s alpha = 0.96), as did each of the subscales. The test-retest reliability result (Intra-class correlation coefficient= 0.88) indicated stability of the instrument on repeat administration approximately one week later. Temporal stabilitytesting confirmed that women’s ratings of their quality of prenatal care did not change as a result of giving birth orbetween the early postpartum period and 4 to 6 weeks postpartum.Conclusion: The QPCQ is a valid and reliable instrument that will be useful in future research as an outcome measureto compare quality of care across geographic regions, populations, and service delivery models, and to assess therelationship between quality of care and maternal and infant health outcomes.Keywords: Prenatal care, Quality of care, Measurement, Instrument, Reliability, Validity, Psychometric testingBackgroundThe evidence for the effectiveness of prenatal care remainsequivocal, despite its widespread use [1,2], and substantialamounts of health care resources “continue to be ex-pended on a tradition of care that has not proven itselfequal to the perinatal health issues of today” [3]. Previousresearch has frequently relied on prenatal care utilizationindices to study the association between adequacy of pre-natal care and pregnancy outcomes [4-6]; however theseindices focus solely on quantifying the use of care and donot adequately assess the content or quality of care [1].Several studies have highlighted the potential importanceof content and quality of care [7-14]. In fact, the “role ofadequate utilization has more recently been downplayedand greater credence has been given to the importance ofthe content, comprehensiveness, and quality of prenatalcare” [1].* Correspondence: Maureen.Heaman@umanitoba.ca†Equal contributors1College of Nursing and Departments of Community Health Sciences andObstetrics, Gynecology and Reproductive Sciences, College of Medicine,Faculty of Health Sciences, University of Manitoba, 89 Curry Place, WinnipegR3T 2N2, Manitoba, CanadaFull list of author information is available at the end of the article© 2014 Heaman et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited. The Creative Commons Public DomainDedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,unless otherwise stated.Heaman et al. BMC Pregnancy and Childbirth 2014, 14:188http://www.biomedcentral.com/1471-2393/14/188The content and quality of prenatal care have beenmeasured in different ways. For example, Beeckman andcolleagues recently developed the Content and Timingof Care in Pregnancy (CTP) tool to assess women’sreceipt of recommended content based on recommenda-tions in national and international guidelines [8]. Partici-pants recorded the timing and content of prenatal careusing diaries. These investigators concluded the contentitems need further refinement prior to larger scale testingof the new measure [8]. Content has also been measuredin studies that examined the effect of adherence to recom-mended prenatal care content, assessed from medical re-cords, on pregnancy outcomes [9-11]. Other studies haveinvestigated the impact of enhanced or augmented pre-natal services [12,13,15] or new models of care, such asgroup prenatal care [16], on outcomes. The quality ofprenatal care has been evaluated using focus groups to ex-plore quality as experienced by women [17-19], develop-ing audit indicators of quality of prenatal care [20], orusing checklists, observations and exit interviews [21].Wong and colleagues developed an instrument to meas-ure the quality of interpersonal processes of care [22], butthis instrument measures only one dimension of quality.To date, research on the effectiveness of prenatal care hasbeen hindered by the lack of an instrument that compre-hensively measures quality of prenatal care.Assessment of prenatal care has focused primarily onwomen’s satisfaction, but often without clear distinctionbetween the constructs of satisfaction and quality ofcare. Research to empirically test the relationships be-tween these variables provides evidence that perceivedquality affects satisfaction with health care, and thatquality of care and consumer satisfaction are distinctconstructs [23,24]. Quality is defined as a judgment orevaluation of several dimensions specific to the servicebeing delivered, whereas satisfaction is an affective oremotional response to a specific consumer experience[23,24]. Satisfaction measures tend to include compo-nents that are considered elements of quality, such asstructure of service delivery (wait time, continuity ofcare, physical environment) and process of care (advicereceived, explanations given by care provider, technicalquality of care) [25-27]. These instruments have limita-tions in that they do not discriminate between quantityand quality of care [28], generally lack psychometricevaluation [27], and do not adequately tap varying di-mensions of the uniqueness of prenatal care [27]. Finally,satisfaction measures are insensitive, as most women re-port high levels of satisfaction with prenatal care [25,26],particularly when measured after delivery [29].Approaches to the assessment of quality of prenatalcare have been largely atheoretical. Among the few stud-ies that have based their selection of measures on a the-oretical framework [21,30-32], the two frameworks mostcommonly used were Donabedian’s [33,34] model of qual-ity and Aday and Andersen’s [35,36] theoretical frame-work for the study of access to medical care. The lattermodel is primarily focused on health service utilization is-sues. There is a need to develop a theoretically-groundedmeasure of prenatal care quality that is distinct from satis-faction measures in order to better evaluate the relation-ship between quality of prenatal care and pregnancyoutcomes. The conceptual framework guiding this re-search was Donabedian’s systems-based model of qualityhealth care [34]. The framework encompasses a three-partapproach to quality assessment, in which “good structureincreases the likelihood of good process, and good processincreases the likelihood of a good outcome” [34]. Struc-ture includes attributes of the setting in which care isprovided, such as material and human resources andorganizational structure [34]. The process component re-flects the actual care given. There are two processes ofcare: clinical or technical, and interpersonal [37]. Accord-ing to Donabedian, the goodness of technical performanceshould be judged in comparison with best practice, whileinterpersonal process is the vehicle by which technicalcare is implemented and includes information exchange,privacy, informed choice, and sensitivity [34].In keeping with the findings of qualitative studies thatdemonstrated the value women place on the interper-sonal processes of prenatal care (including communica-tion, decision-making and interpersonal style), recentattention has been focused on the conceptualization ofthese processes, their measurement, and their impact onwomen’s satisfaction and perception of quality of care[7,22]. Research has demonstrated that ineffective com-munication is a barrier to prenatal care utilization [38-40].Care provider characteristics, such as lack of perceivedconcern and respect, being task focused and conveying anauthoritarian approach, also deter use of prenatal care[40-42]. These characteristics also can be a barrier towomen disclosing health concerns [43]. Thus interper-sonal processes are important in keeping women engagedin prenatal care and, ultimately, in enhancing outcomes.The development of an instrument to measure qualityof prenatal care can be informed by multiple sources, in-cluding the available research evidence regarding effectiveclinical practices and the perspectives of care providersand women [21,37]. Because quality of care is determinedby the structure of service delivery and service-givingprocesses [34,44], it encompasses content dimensionsthrough its attention to the technical (e.g., physical exami-nations and tests) and interpersonal (e.g., health promo-tion counseling) aspects of care. Care providers are bestpositioned to comment on clinical aspects of care [21], in-cluding that which is knowledge-based but does not ne-cessarily have scientific evidence of effectiveness [37]. Fewstudies have considered the perspectives of pregnantHeaman et al. BMC Pregnancy and Childbirth 2014, 14:188 Page 2 of 16http://www.biomedcentral.com/1471-2393/14/188women in the development of measurement instruments[26,27], and only one tool incorporated both women’s andhealth care providers’ perspectives [45].Purpose and aims of the studyThe development of a valid and reliable instrument tomeasure prenatal care quality is a critical scientific foun-dation for research to monitor the provision and benefitsof prenatal health care services. Donabedian states thatconsumers make an indispensable contribution to defin-ing and evaluating the quality of care [15]. The purposeof this study was to develop and test a new instrument,the Quality of Prenatal Care Questionnaire (QPCQ), tobe completed by consumers (women receiving prenatalcare). Specific aims were:1. To generate items for the QPCQ;2. To conduct content and face validity assessment andexploratory factor analysis of the QPCQ todetermine final items; and3. To conduct psychometric testing of the final versionof the QPCQ.MethodsThis study addressed the development, validation, andevaluation of a research instrument. Guided by themethodological frameworks for developing measurementscales described by Streiner and Norman [46] and Pett,Lackey and Sullivan [47], the study consisted of fivephases implemented over the course of 4 years. Refer toFigure 1 for a flow chart of the five phases. Phase Onewas development of an instrument to measure quality ofprenatal care, and included item generation, content val-idity, rating of importance of items, and item presenta-tion. Phase Two consisted of face validation andpretesting. Phase Three was item reduction using factoranalysis. Phase Four involved instrument evaluation, thatis, psychometric testing to establish its construct validity,internal consistency reliability, and test-retest reliability.Phase Five involved temporal stability testing. Ethical ap-proval for this study was received from Hamilton HealthSciences/McMaster University Faculty of Health SciencesResearch Ethics Board, the University of Manitoba Educa-tion/Nursing Research Ethics Board, the University ofCalgary Conjoint Health Research Ethics Board, the IWKHealth Centre Research Ethics Board, and the Universityof British Columbia Clinical Research Ethics Board.Phase one: item generation, content validation, rating ofimportance of items, and item presentationItem generationThe first step of the instrument development process wasto generate a comprehensive list of items to represent thevarious components of the construct quality of prenatalcare. The items for the initial questionnaire were gener-ated from two sources. The first source was a qualitativedescriptive study involving in-depth semi-structured inter-views with 40 pregnant women and 40 prenatal care pro-viders from five urban centers across Canada (Vancouver,Calgary, Winnipeg, Hamilton, and Halifax), conducted be-tween April and November 2008. The qualitative descrip-tive study is described in detail elsewhere [48]. In keepingwith Donabedian’s suggestion that the goodness of clinicalor technical performance should be judged in comparisonwith best practice [34], the second source of items was areview of the evidence from 15 international guidelinesthat inform the provision of prenatal care. Table 1 pre-sents a list of the prenatal care guidelines reviewed.Rating importance of itemsA clinimetric or “clinical sensibility” approach was used toselect which of the 206 items in the QPCQ would beretained for the next step of instrument development [49].This approach relied on the judgments of patients and cli-nicians rather than on mathematical (psychometric) tech-niques to determine which items to include [50]. Thesample of 40 women and 40 health care providers whoparticipated in the qualitative descriptive study [48] weremailed a copy of the 206-item instrument along with acover letter and self-addressed, stamped envelope for re-turn in June and July of 2009. Four randomly generatedversions of the list of QPCQ items were prepared to avoidresponse fatigue toward the end of rating all the items. Tomaximize response rate, a modification of Dillman’s tai-lored design method was utilized, including a reminderletter and second mailing of surveys to respondents [51].In the cover letter, participants were given the followinginstructions: “When you rate the items, we are not askingyou to reflect on your own experiences with prenatal care.Rather, we would like you to rate how important you thinkeach item is in the care provided by health care profes-sionals to pregnant women using a 7-point rating scalefrom 1 (not very important) to 7 (extremely important).”Data for this phase were entered into Microsoft Excel. Amean rating score was generated for each item.Item presentationOnce the most important items were selected for inclu-sion in the QPCQ, the research team discussed andmade decisions regarding instrument format, printedlayout, wording of instructions to the subjects, wordingand structuring of the items, and response format [47].Our intent was to develop an instrument suitable forself-administration to pregnant or postpartum women.Phase two: face validation and pretestingOnce the newly formed instrument had been drafted, itwas assessed for face validity and pretested. Face validityHeaman et al. BMC Pregnancy and Childbirth 2014, 14:188 Page 3 of 16http://www.biomedcentral.com/1471-2393/14/188refers to the appearance of the instrument to a layper-son, and whether the instrument appears to measure theconstruct [52]. Pretesting was used to ensure that itemswere clearly written and were being interpreted correctly[46]. Research assistants administered the 111- item ver-sion of the QPCQ to 11 pregnant women in two sites(Winnipeg and Hamilton) between November andDecember 2009 in a location of the participants’ choice(e.g., prenatal care facility, own home). Women wereinstructed to respond to each item as if they were actu-ally participating in a study, but to mark items that weredifficult to read or confusing. The length of time tocomplete the QPCQ was recorded. Women were thenasked a series of questions by the research assistantabout the clarity of the instructions and the items,whether the items appear to be related to the constructof quality of prenatal care, suggestions for alternatewording, items that should be added or removed, andthe overall appearance of the instrument. The feedbackregarding the quality of prenatal care instrument wasdiscussed by the researchers and revisions were madeaccordingly.Figure 1 Flow chart of five phases of development and testing of the QPCQ.Heaman et al. BMC Pregnancy and Childbirth 2014, 14:188 Page 4 of 16http://www.biomedcentral.com/1471-2393/14/188Phase three: item reduction using exploratory factor analysisThe purpose of this step was to further reduce the num-ber of items in the QPCQ by eliminating any that wereredundant or not congruent with the overall constructbeing measured. We aimed to recruit a conveniencesample of at least 400 women (approximately 80 womenper study site) to participate in the item reduction step.A sample size of 400 women was determined to be suffi-cient as Devillis [53] suggests that a sample size of 200 isadequate in most cases of factor analysis, while Comreyand Lee state that a sample size of 300 is good and 500is very good [54].Setting and sampleSubjects were recruited from hospitals providing obstet-rical services in each study site. These hospitals includedBC Women’s Hospital, Vancouver, BC; FoothillsHospital, Calgary, AB; St. Boniface General Hospital andHealth Sciences Centre Women’s Hospital, Winnipeg,MB; St. Joseph’s Healthcare, Hamilton, ON; and IWKHealth Centre, Halifax, NS. Women were eligible to par-ticipate if they had given birth to a singleton live infant,were 16 years of age or older, had at least 3 prenatal carevisits, and could read and write English. We excludedwomen with a known psychiatric disorder that pre-cluded participation in data collection, and women whohad a stillbirth or early neonatal death because it wouldbe inappropriate to collect data from these women dur-ing the grieving process.Recruitment and data collection procedureNursing staff of the postpartum units were asked toidentify women who met the inclusion criteria and de-termine their willingness to learn more about the study.Women were then approached by the site research as-sistant (Vancouver, Calgary, Winnipeg, Halifax) or theresearch coordinator (Hamilton), who provided a verbalexplanation and written information about the study.Signed, informed consent was obtained from those whoagreed to participate. Participants completed the QPCQand a brief demographic form, and received a $20 giftcertificate in appreciation for their time and contributionto the study. Data collection for Phase Three was con-ducted between March and June 2010.Data analysisExploratory factor analysis was conducted using SPSSVersion 18.0. Exploratory factor analysis is used whenthe researcher does not know how many factors areneeded to explain the interrelationships among a set ofitems, indicators, or characteristics [47]. This analyticapproach involves a series of structure-analyzing proce-dures to identify the interrelationships among a large setof observed variables and group the variables into di-mensions or factors that have similar characteristics[47]. First, a correlation matrix was constructed tosummarize the interrelationships among the items in thescale [47]. The matrix was examined to identify anyitems that were either too highly correlated (r ≥ 0.80) orTable 1 Prenatal care guidelines reviewed to generate items for the QPCQ based on “A” grade evidenceOrganization name Guideline title Publication dateThe American College of Obstetricians and Gynecologists &American Academy of PediatricsGuidelines for Perinatal Care (6th edition) October 2007The American College of Obstetricians and Gynecologists Committee Opinion-Psychological Risk Factors: Perinatal Screeningand InterventionAugust 2006The Society of Obstetricians and Gynaecologists of Canada Healthy Beginnings: Guidelines for Care During Pregnancyand ChildbirthDecember 1998Fetal Health Surveillance: Antepartum and IntrapartumConsensus GuidelineSeptember 2007Public Health Agency of Canada Family-Centered Maternity & Newborn Care: National Guidelines 2000National Institute for Health and Clinical Excellence Antenatal Care: Routine care for healthy pregnant women March 2008The Royal Australian and New Zealand College ofObstetricians and GynaecologistsObstetricians and childbirth responsibilities July 2007Prenatal screening for trisomy 21, trisomy 18 and neural tube defects July 2007Mineral and vitamin supplementation in pregnancy July 2008Antenatal screening tests June 2008Diagnosis of Gestational Diabetes Mellitus June 2008Guidelines for the use of Rhd immunoglobulin in Obstetricsin AustraliaMarch 2007Royal College of Obstetricians and Gynaecologists Clinical Standards: Advice on Planning the Service in Obstetricsand GynaecologyJuly 2002World Health Organization What is the effectiveness of antenatal care? (Supplement) December 2005New WHO antenatal care model 2002Heaman et al. BMC Pregnancy and Childbirth 2014, 14:188 Page 5 of 16http://www.biomedcentral.com/1471-2393/14/188not correlated sufficiently with one another (r <0.30),and these items were dropped from the analysis. Ex-ploratory factor analysis was then used to explore theunderlying dimensions of the construct of interest [47],since the conceptual framework did not clearly specifya set number of subconcepts or process of care dimen-sions [55,56]. Principal axis factoring was used to extractthe factors, followed by oblique rotation using the directoblimin procedure [55]. We chose oblique rotationbecause we did not expect the dimensions to be orthog-onal, i.e., uncorrelated with one another. A factor pat-tern matrix was generated, which contained the loadingsthat represented the unique relationship of each itemto a factor, after controlling for the correlation amongthe factors [47]. Items with weak loadings (less than0.40) or that did not load reasonably on any factor weredeleted.Phase four: validity and reliability testingPhase Four involved administering the newly designed46-item QPCQ to women to establish its construct val-idity, internal consistency reliability, and test-retest reli-ability. Similarly to the previous phase, participants wererecruited from hospital postpartum units in each studysite using the same eligibility/ineligibility criteria and re-cruitment procedure. Study participants were asked tocomplete a brief demographic questionnaire, the 46-itemQPCQ, the Patient Expectations and Satisfaction withPrenatal Care Instrument (PESPC) [27], and the PrenatalInterpersonal Processes of Care (PIPC) instrument [22].Women were given a second copy of the QPCQ to becompleted 1 week later and returned in a stamped self-addressed envelope. Each participant received a $20 giftcertificate in appreciation for their time and contributionto the study. Data collection for Phase Four was con-ducted between September and December 2010.Construct validityValidity testing of an instrument is on an ongoingprocess to determine whether there is sufficient evidenceto support that it accurately measures the construct itwas designed to measure, and the degree to which it per-forms according to theoretical predictions [57]. First,confirmatory factor analysis was conducted, using theAmos version 7 statistical analysis program, to test theutility of the underlying dimensions of the construct thatwere previously identified though exploratory factor ana-lysis [47]. A second approach to determining constructvalidity was through hypothesis testing. According toDonabedian, patient satisfaction is one of the desiredoutcomes of quality of care [34]. Although different defi-nitions of quality were used, a randomized controlledtrial [12] and a cross-sectional study [7] found thatwomen who received “high quality” prenatal care weresignificantly more likely to be satisfied with their care.We hypothesized that women who rated the quality oftheir prenatal care higher would have higher ratings ofsatisfaction with prenatal care. The Pearson correlationbetween the total QPCQ score and the satisfaction sub-scale score of the Patient Expectations and Satisfactionwith Prenatal Care instrument (PESPC) [27] was esti-mated. The PESPC is a 41-item self-administeredquestionnaire designed to measure pregnant women’sexpectations and satisfaction with the prenatal care theyanticipated and received. The PESPC is structurallyvalid, and the satisfaction subscale demonstrates an ac-ceptable level of internal consistency (Cronbach’s alphaof 0.94). The third approach was to test the convergentvalidity principle, whereby different measures of thesame construct should correlate highly with each other[52]. Although there is no other instrument that mea-sures quality prenatal care in all its dimensions, one in-strument has been developed to measure the quality ofinterpersonal processes of prenatal care, known as thePrenatal Interpersonal Processes of Care (PIPC) [22].The PIPC has seven subscales and 30 items that reflectthree underlying dimensions: Communication, Patient-Centered Decision Making, and Interpersonal Style. Themajority of the seven subscales have acceptable internalconsistency reliability (ranging from 0.66 to 0.85) andpreliminary evidence of construct validity has beenestablished. It was anticipated that one or more of thePIPC subscales (such as respectfulness/emotional sup-port) would measure similar constructs as one or moreof the QPCQ subscales, and if so, the Pearson correl-ation between the subscales would be estimated.ReliabilityReliability of an instrument is the degree of consistencywith which it measures the attribute it is intended tomeasure [58]. Both internal consistency reliability andtest-retest reliability of the QPCQ were assessed.Internal consistency is based on the average correl-ation among items within a test [59] and assesses homo-geneity or the extent to which all items measure thesame construct [58]. Cronbach’s alpha was used to assessthe extent to which performance of any one item on theinstrument was a good indicator of performance of anyother item on the same instrument [57], and was calcu-lated for both the overall scale and each of the subscales.A Cronbach’s alpha coefficient of at least 0.70 is consid-ered acceptable, while 0.80 or greater is desirable[46,59]. In addition, item-to-total scale correlation coeffi-cients for the instrument subscales were examined, aswell as whether the Cronbach’s alpha increased if any ofthe items were deleted.The test-retest method is a test of stability to deter-mine whether the same results are obtained on repeatHeaman et al. BMC Pregnancy and Childbirth 2014, 14:188 Page 6 of 16http://www.biomedcentral.com/1471-2393/14/188administration of the instrument to the same sample. Asmentioned previously, women participating in this phaseof the study were given a second copy of the QPCQ tobe completed one week later and returned by mail. Thistime interval is within the recommended retest intervalof 2 to 14 days [46]. For each participant who returnedthe second questionnaire, their scores on the QPCQwere summed for time one and time two, and the levelof agreement between the two sets of scores was deter-mined using the intra-class correlation coefficient (ICC).Reliability coefficients above 0.70 are considered accept-able [58]. For the sample size calculation, the minimalacceptable level of ICC was set at 0.75 and the upperlimit of ICC at 0.85, with α = 0.05 and β = 0.20. Usingthe method suggested by Walter, Eliasziw and Donner[60], a minimum sample size of 79 subjects was needed.Phase five: temporal stability testingThis phase was conducted to assess whether or notwomen’s responses to the QPCQ were stable betweenlate pregnancy and the postpartum period, in order todetermine whether or not the birth experience and out-come might have influenced women’s recall of quality ofcare and their responses to the questionnaire. This infor-mation is needed to inform timing of administration ofthe questionnaire in future research.For this phase of the study, we collected data from 234women in four of the study sites. Women were asked toprovide background information and complete a packageof questionnaires shortly before they gave birth (after36 weeks gestation) (Time 1), again during their postpar-tum hospital stay (Time 2), and then again 4 to 6 weeksafter the baby was born (Time 3). Data collection wasconducted between January and July 2011. Mean scoreson the total QPCQ and each of the subscales were cal-culated. At first, we used a randomized block design(RBD) analysis of variance to evaluate the differences be-tween the three time points. RBD was used to adjust forthe correlations between time points for the same indi-viduals. However, because of an imbalance in the num-ber of participants at different time points and to usethe most information available in the data, we followedRBD with conducting a paired t-test between each twotime points (i.e., Time 1 and Time 2, Time 1 and Time3, Time 2 and Time 3). The intra-class correlation coef-ficient (ICC) was used to examine stability of the QPCQtotal score and subscale scores across the three timeperiods.ResultsPhase one: item generation, content validation, rating ofimportance of items, and item presentationResults from the qualitative descriptive study [48] andthe review of prenatal care guidelines were used tocreate a blueprint to establish the specific scope and em-phasis of our instrument to measure quality of prenatalcare, including the major domains to be assessed [52].The Co-Principal Investigators (MIH & WAS) generatedan initial list of 210 items for the preliminary version ofthe Quality of Prenatal Care Questionnaire (QPCQ).Several of the items were generated from the interviewdata that informed the development of themes. Thesethemes were organized into three main categories in-formed by the structure and process components ofDonabedian’s [34] model of quality health care. Structureof care themes included access to care, staff and providercharacteristics, and the physical setting. Themes underclinical care processes included screening and assess-ment, health promotion and illness prevention, continu-ity of care, information sharing, women-centeredness,and non-medicalization of pregnancy. Themes concern-ing interpersonal care processes included emotional sup-port, approachable interaction style, taking time, andrespectful attitude [48]. Items generated from the guide-line review reflected components of prenatal care ratedas having a high certainty of net benefit (i.e., “A” gradeevidence) [61]). The research team then met to reviewand discuss the list of 210 items, and as the content ex-perts, assessed the content validity of the QPCQ byevaluating each item for its relevance and clarity, and forany repetition of items. Four items judged to duplicateother items were removed.Ratings of the importance of the 206 items for theQPCQ were received from 56 participants (70% responserate). The overall top 100 items that were rated as mostimportant were retained for the next version of the in-strument; these items had a mean rating of 5.7 or higheron a scale of 1 to 7. In order to ensure that the perspec-tives of women and health care providers were equallyrepresented, we also added any items ranked in the top50 from either women or providers that were not in theoverall top 100. Because there was generally good con-gruence between women and providers in rating the im-portance of items, this resulted in only 3 items with highratings from health care providers and 2 items fromwomen being added to the top 100 items. Six items de-rived from A-level evidence but not in the top 100 itemswere also retained. These steps resulted in a QPCQ with111 items.When constructing the QPCQ, the research team de-cided that each item would be rated using a Likert scalewith five response categories consisting of “StronglyDisagree” (1), “Disagree” (2), “Neither Agree Nor Dis-agree” (3), “Agree” (4) and “Strongly Agree” (5). Allpoints on the scale were labeled to prevent the tendencyfor respondents to endorse labeled points more oftenwhen only some are labeled [46]. A selection of itemswas “reversed” to reduce responder bias that may occurHeaman et al. BMC Pregnancy and Childbirth 2014, 14:188 Page 7 of 16http://www.biomedcentral.com/1471-2393/14/188when all items are written as positive [46]. The 111items were then formatted into the initial version of theQPCQ with the following instructions: “This question-naire asks about the prenatal care you received from aphysician, midwife, or other health care providers duringyour pregnancy. You might have seen more than onehealth care provider for your care but please think of theprenatal care you received overall when completing thisquestionnaire. Please read each statement carefully andindicate how much you agree or disagree with it by circ-ling the appropriate number.”Phase two: face validation and pretestingDuring the pretesting phase, the mean length of time forwomen to complete the 111-item version of the QPCQranged from 10 to 23 minutes, with a mean of 16 mi-nutes. Women indicated that the QPCQ was easy tocomplete, and only a few items were identified as poten-tially problematic. Based on this feedback, 11 items wereremoved from the QPCQ, either because the item wastoo vague (e.g., “My prenatal care provider was thor-ough”) or the item was not universally applicable to allpregnant women (e.g., “My prenatal care provider tooktime to answer my partner’s/family member’s ques-tions”). This resulted in a 100-item questionnaire. Inaddition, four items underwent wording changes to im-prove their clarity or completeness (e.g., The item “I fullyunderstood the reasons for tests my prenatal care pro-vider (s) ordered for me” was changed to “I fully under-stood the reasons for blood work and other tests myprenatal care provider (s) ordered for me”).Phase three: item reduction using exploratory factor analysisThe final sample for Phase Three consisted of 422 par-ticipants. Demographic characteristics of the participantsare summarized in Table 2; cases with missing data oneach item were excluded from the analyses. Use of ex-ploratory factor analysis extracted 5-, 6- and 7-factor so-lutions. The researchers examined the 3 solutions, andselected the 6-factor solution because the items werejudged to be the most relevant and grouped into factorsin the most meaningful way based on our clinical know-ledge and experience. The 6-factor solution reduced theQPCQ to 46 items. These final factors or dimensionscomprised the subscales of the QPCQ; the research teammet to agree on the names to be assigned to each factor.The six factors are as follows:1. Information Sharing: The 9 items within this factorfocus on how prenatal care providers answerquestions, keep information confidential, and ensurewomen understand reasons for tests and their results.2. Anticipatory Guidance: The 11 items in this factorfocus on women being given enough information tomake decisions about their prenatal care and howtheir prenatal care providers prepare and givewomen options for their birth experience.3. Sufficient Time: The 4 items within this factor focuson the time prenatal care providers spendaddressing women’s questions and the time spent inan appointment.4. Approachability: The 4 items in this factor addressthe health care provider’s approachability (e.g.,woman was afraid to ask questions, felt like she waswasting prenatal care provider’s time).5. Availability: The 5 items in this factor include knowinghow to contact the prenatal care provider and howavailable the clinic/office staff or prenatal care providerare to respond to questions, concerns or needs.6. Support and Respect: This factor has 12 itemsrelated to women being respected and supported bytheir prenatal care providers in regard to theirconcerns and decisions.We used the Flesch-Kincaid Grade Level test, availablein Microsoft Word, to assess the readability of the 46-item QPCQ. This test rates text on a U. S. school gradelevel, which is similar to the Canadian grade level sys-tem. The QPCQ had a Flesch-Kincaid grade level scoreof 8.7, which means that women with a grade 9 educa-tion can read and understand the items in the QPCQ.Phase four: validity and reliability testingThe final sample for Phase Four consisted of 422 women.Demographic characteristics of the participants are sum-marized in Table 2.Confirmatory factor analysis verified and confirmedthe presence of six factors, and all 46 items were there-fore retained in the QPCQ. Refer to Table 3 for a list ofthe items loading on each factor. The factor (or sub-scale) means and standard deviations are presented inTable 4. Each subscale mean score was calculated by firstreversing the scores of any reverse scored items in thesubscale, then summing the scores for the items of thesubscale and dividing the sum by the number of items.The QPCQ is a norm-referenced measure, in which anindividual’s score takes on meaning when compared withthe scores of others (e.g., in the same sample) [46].Higher scores on the QPCQ and its subscales reflect ahigher rating of quality of prenatal care. The meanscores for the factors ranged from 3.84 to 4.37 out of atotal score of 5, indicating that women rated the qualityof their prenatal care toward the higher end of the con-tinuum. The factor “Anticipatory Guidance” had thelowest mean rating, while “Information Sharing” had thehighest mean rating.A significant positive correlation between the QPCQtotal score and the satisfaction subscale score of theHeaman et al. BMC Pregnancy and Childbirth 2014, 14:188 Page 8 of 16http://www.biomedcentral.com/1471-2393/14/188Table 2 Demographic characteristics of participants inphases three, four, and five1Characteristic Phase three Phase four Phase fiveItemreductionValidity &reliabilityTemporalstabilityN = 422 N = 422 N = 234n (%) n (%) n (%)Recruitment SiteVancouver 82 (19.4) 64 (15.2) 9 (3.8)Calgary 98 (23.2) 61 (14.5) 79 (33.8)Winnipeg 77 (18.3) 112 (26.5) 67 (28.6)Hamilton 86 (20.4) 106 (25.1) 79 (33.8)Halifax 79 (18.7) 79 (18.7) 0*Marital StatusMarried 281 (66.6) 284 (67.3) 168 (70.9)Common-law 49 (11.6) 74 (17.5) 35 (14.8)Living with a partner 10 (2.4) 15 (3.6) 13 (5.5)Single (never married) 30 (7.1) 45 (10.7) 16 (6.8)Separated or divorced 2 (0.5) 1 (0.2) 2 (0.8)Household IncomeBelow $10,000 21 (5.0) 25 (5.9) 13 (5.5)$10,000 to $19,999 20 (4.7) 40 (9.5) 11 (4.6)$20,000 to $39,999 43 (10.2) 50 (11.8) 29 (12.2)$40,000 to $59,999 56 (13.3) 65 (15.4) 27 (11.4)$60,000 to $79,999 70 (16.6) 48 (11.4) 33 (13.9)$80,000 and above 199 (47.2) 179 (42.4) 114 (48.1)Highest Level of EducationLess than high school 35 (8.3) 34 (8.0) 16 (6.8)Completed high school 40 (9.5) 54 (12.8) 19 (8.0)Some community collegeor technical school40 (9.5) 31 (7.3) 24 (10.1)Completed communitycollege or technical school93 (22.0) 92 (21.8) 41 (17.3)Some university 39 (9.2) 39 (9.2) 20 (8.4)Completed bachelor’sdegree122 (28.9) 107 (25.4) 77 (32.5)Graduate degree 52 (12.3) 63 (14.9) 36 (15.2)Racial/Ethnic BackgroundWhite 316 (74.9) 291 (69.0) 174 (73.4)Aboriginal 14 (3.3) 23 (5.5) 17 (7.2)Black 13 (3.1) 4 (0.9) 3 (1.3)Chinese 18 (4.3) 15 (3.6) 9 (3.8)Filipino 18 (4.3) 27 (6.4) 4 (1.7)Latin American 8 (1.9) 5 (1.2) 5 (2.1)South Asian 13 (3.1) 7 (1.7) 6 (2.5)Other 18 (4.3) 40 (9.5) 16 (6.8)Born in CanadaYes 324 (76.8) 318 (75.4) 191 (80.6)No 92 (21.8) 102 (24.2) 42 (17.7)Table 2 Demographic characteristics of participants inphases three, four, and five1 (Continued)Language Spoken Most Often at HomeEnglish 352 (83.4) 352 (83.4) 205 (86.5)French 8 (1.9) 5 (1.2) 1 (0.4)Chinese 9 (2.1) 7 (1.7) 4 (1.7)Tagalog (Filipino) 3 (0.7) 13 (3.1) 2 (0.8)Other 32 (7.6) 24 (5.7) 13 (5.6)Prenatal Care Provider**Family physician 254 (60.0) 253 (60.0) 149 (62.9)Obstetrician 270 (64.0) 281 (66.6) 158 (66.7)Midwife 46 (11.0) 39 (9.2) 27 (11.4)Nurse practitioner 30 (7.0) 56 (13.3) 45 (19.0)Site of Prenatal CarePrivate office 211 (50.0) 165 (39.1) 73 (30.8)Clinic 175 (41.5) 201 (47.6) 87 (36.7)Outpatient departmentof a hospital28 (6.6) 42 (10.0) 47 (19.8)Type of Delivery***Vaginal 289 (68.5) 318 (75.4) 154 (65.0)Planned C-section 62 (14.7) 47 (11.1) 12 (5.1)Unplanned C-section 71 (16.8) 55 (13.0) 28 (11.8)Parity***Primipara 169 (40.0) 157 (37.2) 113 (48.3)Multipara 239 (56.6) 248 (58.8) 103 (40.0)Maternal HealthChronic health problem 49 (11.6) 37 (8.8) 37 (15.6)Complication duringpregnancy104 (24.6) 100 (23.7) 39 (16.7)Medical problem sincedelivery20 (4.7) 18 (4.3) 21 (8.9)Infant***Boy 224 (53.1) 194 (46.0) 87 (36.7)Girl 198 (46.9) 227 (53.8) 106 (44.7)Variable Mean (SD) Mean (SD) Mean (SD)Maternal age (years) 30.2 (5.3) 30.2 (5.1) 29.7 (4.8)Gestational age at firstprenatal care visit (weeks)10.9 (9.0) 10.6 (5.8) 10.2 (5.4)Gestational age atdelivery (weeks)***39.2 (1.4) 39.3 (2.0) 39.6 (1.2)Birth weight ofinfant (grams)***3406.3 (544.3) 3465.9 (496.3) 3506.8 (472.2)1Missing responses were excluded from analyses.*Halifax did not participate in Phase Five of the study.**Percentages reported for prenatal care providers do not add to 100 aswomen were instructed to check off all that applied.***In Phase Five, responses for these items are reported for Time 2 participants(n = 194 postpartum women).Heaman et al. BMC Pregnancy and Childbirth 2014, 14:188 Page 9 of 16http://www.biomedcentral.com/1471-2393/14/188Table 3 Items loading on each factor, corrected item-total subscale correlations, and Cronbach’s alpha if item deletedfrom subscaleFactor (Subscale) items Corrected item-totalsubscale correlationCronbach’s alphaif item deletedfrom subscaleFactor 1: Information Sharing (9 items) Cronbach’s Alpha = .86- I was given adequate information about prenatal tests and procedures .60 .84- I was always given honest answers to my questions .56 .85- Everyone involved in my prenatal care received the important information about me .45 .86- I was screened adequately for potential problems with my pregnancy .47 .85- The results of tests were explained to me in a way I could understand .67 .83- My prenatal care provider(s) gave straightforward answers to my questions .70 .83- My prenatal care provider(s) gave me enough information to make decisions for myself .67 .83- My prenatal care provider(s) kept my information confidential .51 .85- I fully understood the reasons for blood work and other tests my prenatal care provider(s) ordered for me .66 .83Factor 2: Anticipatory Guidance (11 items) Cronbach’s Alpha = .85- My prenatal care provider(s) gave me options for my birth experience .55 .83- I was given enough information to meet my needs about breast-feeding .47 .84- My prenatal care provider(s) prepared me for my birth experience .57 .83- My prenatal care provider(s) spent time talking with me about my expectations for labor and delivery .61 .83- I was given enough information about the safety of moderate exercise during pregnancy .46 .84- I received adequate information about my diet during pregnancy .60 .83- My prenatal care provider(s) was interested in how my pregnancy was affecting my life .58 .83- I was linked to programs in the community that were helpful to me .41 .85- I received adequate information about alcohol use during pregnancy .39 .85- I was given adequate information about depression in pregnancy .58 .83- My prenatal care provider(s) took time to ask about things that were important to me .66 .83Factor 3: Sufficient Time (5 items) Cronbach’s Alpha = .81- I had as much time with my prenatal care provider(s) as I needed .54 .79- My prenatal care provider(s) was rushed .48 .84- My prenatal care provider(s) always had time to answer my questions .70 .75- My prenatal care provider(s) made time for me to talk .73 .73- My prenatal care provider(s) took time to listen .68 .75Factor 4: Approachability (4 items) Cronbach’s Alpha = .73- My prenatal care provider(s) was abrupt with me .50 .68- I was rushed during my prenatal care visits .49 .69- My prenatal care provider(s) made me feel like I was wasting their time .56 .65- I was afraid to ask my prenatal care provider(s) questions .55 .65Factor 5: Availability (5 items) Cronbach’s Alpha = .82- I knew how to get in touch with my prenatal care provider(s) .54 .80- Someone in my prenatal care provider(s)’s office always returned my calls .48 .82- My prenatal care provider(s) was available when I had questions or concerns .63 .77- I could always reach someone in the office/clinic if I needed something .71 .74- I could reach my prenatal care provider(s) by phone when necessary .68 .75Factor 6: Support and Respect (12 items) Cronbach’s Alpha = .93- My prenatal care provider(s) respected me .63 .93- My prenatal care provider(s) respected my knowledge and experience .63 .93Heaman et al. BMC Pregnancy and Childbirth 2014, 14:188 Page 10 of 16http://www.biomedcentral.com/1471-2393/14/188PESPC provided additional support for construct validity(Pearson r = 0.81). Convergent validity was demonstratedby a significant positive correlation (r = 0.63) betweenthe “Support and Respect” subscale of the QPCQ andthe “Respectfulness/Emotional Support” subscale of thePIPC, and a significant positive correlation (r = 0.59) be-tween the “Anticipatory Guidance” subscale of the QPCQand the “Empowerment/Self-care” subscale of the PIPC.Testing showed acceptable internal consistency reli-ability for the overall scale (Cronbach’s alpha = 0.96) andfor the six subscales (ranging from 0.73-0.93). Refer toTable 3 for the results. Item-total scale correlation coef-ficients were positive, and the Cronbach’s alpha did notincrease if any of the items were deleted, with the excep-tion of one item, “My prenatal care provider wasrushed,” showing a slight increase.Of the 422 participants, 182 women (43%) completedthe retest version of the QPCQ 5 to 14 days later andreturned it by mail. The QPCQ demonstrated acceptabletest-retest reliability (ICC = 0.88), indicating stability ofthe instrument on repeat administration.Phase five: temporal stability testingDemographic characteristics of the participants in PhaseFive (Time 1) are summarized in Table 2, and the sam-ple size for each site and time period is shown in Table 5.There were 234 participants at Time 1, 194 at Time 2,and 158 at Time 3, demonstrating some attrition overtime. There were no statistically significant differences inmean scores across time periods for the majority of theQPCQ subscales (Tables 6, 7, and 8). Although therewas a significant difference in mean score for the Antici-patory Guidance subscale between Time 1 and 2 (d =0.22) and between Time 1 and 3 (d = 0.17), and for themean QPCQ score between Time 1 and 2 (d = 0.07), thedifferences in mean scores were small and deemed notto be clinically significant. The intra-class correlation co-efficient (ICC) was also used to examine stability of theQPCQ subscale scores across the three time periods,and varied from 0.67 to 0.76 (Table 9). The ICC for thetotal QPCQ score was 0.81 (95% CI: 0.76-0.85).DiscussionMeasurement of the quality of prenatal care is an essen-tial step in more fully evaluating its effectiveness. Wehave developed a new instrument, the Quality of Pre-natal Care Questionnaire (QPCQ), through a rigorousprocess of item generation and psychometric testing.The QPCQ was designed to be completed by womenwho received prenatal care, consistent with growing ac-knowledgement of the value of the consumer’s viewpointin evaluating quality of health care [22,23,62,63]. Thefinal 46-item version of the QPCQ demonstrated con-struct validity, as well as acceptable internal consistencyand test-retest reliability. Having women complete theQPCQ before delivery, during their postpartum hospitalstay, and again 4 to 6 weeks after delivery confirmed thatwomen’s ratings of their quality of prenatal care did notchange as a result of giving birth or between the earlypostpartum period and 4 to 6 weeks postpartum. Theseresults suggest that the QCPQ can be administered to awoman after 36 weeks gestation and up to 6 weekspostpartum.Exploratory factor analysis resulted in a six-factor so-lution for the QPCQ, with six factors retained in theTable 3 Items loading on each factor, corrected item-total subscale correlations, and Cronbach’s alpha if item deletedfrom subscale (Continued)- My decisions were respected by my prenatal care provider(s) .73 .92- My prenatal care provider(s) was patient .67 .93- I was supported by my prenatal care provider(s) in doing what I felt was right for me .71 .92- My prenatal care provider(s) supported me .75 .92- My prenatal care provider(s) paid close attention when I was speaking .70 .92- My concerns were taken seriously .71 .92- I was in control of the decisions being made about my prenatal care .69 .92- My prenatal care provider(s) supported my decisions .80 .92- I was at ease with my prenatal care provider(s) .68 .93- My values and beliefs were respected by my prenatal care provider(s) .69 .92Table 4 QPCQ factor (or subscale) means and standarddeviations (SD) from phase four (N = 422)Subscale Mean (SD)Factor 1 – Information Sharing 4.37 (0.50)Factor 2 – Anticipatory Guidance 3.84 (0.60)Factor 3 – Sufficient Time 4.16 (0.65)Factor 4 – Approachability 4.22 (0.71)Factor 5 – Availability 4.18 (0.65)Factor 6 – Support and Respect 4.35 (0.52)Total QPCQ 4.19 (0.50)Heaman et al. BMC Pregnancy and Childbirth 2014, 14:188 Page 11 of 16http://www.biomedcentral.com/1471-2393/14/188confirmatory factor analysis. This indicates that the con-cept of quality of prenatal care is multidimensional andthe instrument consists of six subscales [56]. In additionto the total QPCQ score, the score for each of the sub-scales can be examined separately. The derived factorsmade conceptual sense, and were consistent with thethemes arising from our qualitative descriptive study[48]. The six subscales of the QPCQ measure bothstructure and process attributes of Donabedian’s model,with more emphasis on clinical and interpersonal pro-cesses of care. Although the initial draft of the QPCQcontained several items related to structure of prenatalcare, many of these items were rated low on importancein Phase One and were subsequently deleted from thequestionnaire (e.g., “The office/clinic was in a convenientlocation,” “The waiting area was crowded.”). This is con-sistent with Campbell’s viewpoint that structure is not acomponent of care “but the conduit through which careis delivered and received” [37]. As such, structure mayinfluence the way in which care is provided and thuswomen’s assessment of quality. For example, having ad-equate funding, facilities and personnel may influencewomen’s responses to items in the “Sufficient Time” sub-scale (e.g., “I had as much time with my prenatal careprovider as I needed”) and the “Availability” subscale (e.g.,“I could always reach someone in the office/clinic if Ineeded something”). Items in the QPCQ “InformationSharing” and “Anticipatory Guidance” subscales primarilymeasured the clinical or technical processes of care, whileitems in the “Approachability” and “Support and Respect”subscales reflected interpersonal processes. Mean scoresfor the subscales ranged from 3.84 to 4.37, and indicatedthat women rated the quality of “Anticipatory Guidance”the lowest, and “Information Sharing” and “Support andRespect” the highest (Table 4). In the temporal stabilitytesting phase, the Anticipatory Guidance subscale was theonly one showing significant (although small) differencesin mean scores over time, with both postpartum scoresbeing higher than the prenatal score. Some of the Antici-patory Guidance items may be more accurately assessedby women in the postpartum period (e.g., “I was givenenough information to meet my needs about breastfeed-ing”), possibly resulting in higher rating scores.The subscales and items in the QPCQ measure com-ponents of quality of prenatal care identified by womenas important in other qualitative studies [17-19] and anintegrative review [64]. Wheatley and colleagues foundthat markers of quality prenatal care included the extentto which the provider listened carefully, showed respect,explained things, and spent enough time with the woman[18]. The main elements of quality of maternity care ser-vices identified in Goberna-Tricas’s study were technicalTable 5 Number of participants per site for each time period in phase five of the studyRecruitmentsiteBefore deliveryQPCQ –T1*After deliveryQPCQ –T2*4-6 weekQPCQ –T3*Total matchedT1/T2Total matchedT2/T3Total matchedT1/T2/T3n (%) n (%) n (%) n (%) n (%) n (%)Vancouver 9 (4) 6 (3) 5 (2) 6 (3) 5 (2) 5 (2)Calgary 79 (33) 77 (32) 65 (27) 74 (31) 64 (27) 62 (26)Winnipeg 67 (28) 42 (18) 32 (14) 42 (18) 32 (14) 32 (14)Hamilton 79 (33) 69 (29) 56 (24) 69 (29) 56 (24) 56 (24)SUBTOTAL 234 194 158 191 157 155*T1 = time one, T2 = time two, T3 = time three.Table 6 Comparison of QPCQ subscale and total scoresbetween Time 1 and Time 2 in Phase five, using pairedt-testSubscale N Time 1 Time 2 pLatepregnancyEarlypostpartumMean (SD) Mean (SD)Factor 1 –Information Sharing 191 4.27 (0.52) 4.29 (0.50) 0.41Factor 2 – Anticipatory Guidance 191 3.55 (0.73) 3.77 (0.66) <0.001Factor 3 – Sufficient Time 191 4.09 (0.67) 4.10 (0.68) 0.69Factor 4 – Approachability 191 4.24 (0.68) 4.25 (0.71) 0.92Factor 5 – Availability 191 4.02 (0.63) 4.07 (0.66) 0.19Factor 6 – Support and Respect 191 4.23 (0.55) 4.26 (0.58) 0.52Total QPCQ 191 4.04 (0.53) 4.11 (0.52) 0.01Table 7 Comparison of QPCQ subscale and total scoresbetween Time 1 and Time 3 in Phase five, using pairedt-testSubscale N Time 1 Time 3 pLatepregnancy4-6 weekspostpartumMean (SD) Mean (SD)Factor 1 – Information Sharing 155 4.29 (0.45) 4.27 (0.44) 0.43Factor 2 – Anticipatory Guidance 155 3.53 (0.70) 3.70 (0.67) <0.001Factor 3 – Sufficient Time 155 4.11 (0.64) 4.12 (0.56) 0.73Factor 4 – Approachability 155 4.30 (0.60) 4.31 (0.61) 0.75Factor 5 – Availability 155 4.02 (0.58) 4.04 (0.68) 0.70Factor 6 – Support and Respect 155 4.25 (0.51) 4.25 (0.51) 0.97Total QPCQ 155 4.05 (0.48) 4.09 (0.48) 0.12Heaman et al. BMC Pregnancy and Childbirth 2014, 14:188 Page 12 of 16http://www.biomedcentral.com/1471-2393/14/188expertise of the health professional, the human dimensionof the relationship between the caregiver and the patient(interpersonal skill), and the structural aspects that deter-mine the context in which the health care is provided[17]. Hildingsson and Thomas analyzed responses of 827Swedish pregnant women to an open ended question in asurvey, and grouped the findings into the following cat-egories: technical aspects of care (being skilled and com-petent), psychological aspects of care (being a goodlistener, being supportive, treating the woman with re-spect), personal characteristics (not judging, not beingrushed), health-related content and information (checkingthe baby’s health, providing information about physicaland mental changes and breastfeeding), and structural as-pects of provider visits (enough time during visits, con-tinuity of care) [19]. The items in the QPCQ capture themajority of these aforementioned elements of quality ofprenatal care.Strengths and limitations of the studyThe QPCQ was developed taking into considerationeffective prenatal care practices, the diversity of theCanadian population, and variations in the way prenatalcare is delivered, and with input from both consumersand providers of care. The five study sites provided abroad cross-section of the childbearing population inCanada and its multicultural uniqueness. For instance,Winnipeg has a large and growing Aboriginal popula-tion, Vancouver has a high concentration of immigrantsfrom East Asia, and Halifax serves a large rural popula-tion. Similarly, there are differences in the options forprenatal care available to women across the five studysites. Midwifery care was not regulated or integratedinto the health care system in Nova Scotia at the time ofthis study, but was more widely available to women liv-ing in certain areas of Ontario, such as Hamilton, andother provinces where midwifery was a regulated profes-sion. In some provinces, obstetricians were the most com-mon provider of prenatal care (e.g., Ontario) compared tofamily physicians in others (e.g., British Columbia) [65].Finally, some prenatal programs had integrated additionalor substitutive prenatal care through nurse specialists andnurse practitioners [66]. The study protocol thereby en-sured the development of an instrument that capturedcore elements of quality applicable to the Canadian popu-lation as a whole under a system of universal health care.Our study also has limitations. The QPCQ was devel-oped in the context of the Canadian health care system,so its applicability to health care systems, prenatal careprovision, or populations that are substantively differentwill need to be assessed prior to widespread use. The in-strument was intended to be applicable to all pregnantwomen; therefore the items may not fully capture allelements of quality in specific situations, such as careprovided to women with a complicated or high riskpregnancy. The QPCQ reflects the woman’s perceptionof the quality of prenatal care she received; further re-search is needed to determine the congruence betweenthe woman’s assessment of quality and the extent towhich the care she received conformed to guidelines forprenatal care using methods such as chart audits. Therelatively high mean scores found among some of theQPCQ subscales may be a reflection of selection bias in-curred as a result of using a convenience sample, in thatwomen who agreed to participate in the study may haveviewed the quality of their care more positively thanwomen who declined participation. In addition, the re-sponse rate for completion of the retest version of theQPCQ was relatively low (43%), although the number ofrespondents (n = 182) exceeded the minimum sample sizeof 79 estimated as needed in the sample size calculation.Finally, we acknowledge there are competing views re-garding use of non-parametric versus parametric statis-tics to analyze Likert scales [67,68]. Although individualLikert items are ordinal in character, we support the pos-ition that Likert scales (collections of Likert items) pro-duce interval data, and that it is appropriate to summarizethe ratings generated from Likert scales using means andTable 8 Comparison of QPCQ subscale and total scoresbetween Time 2 and Time 3 in Phase five, using pairedt-testSubscale N Time 2 Time 3 pEarlypostpartum4-6 weekspostpartumMean (SD) Mean (SD)Factor 1 – Information Sharing 157 4.31 (0.44) 4.26 (0.44) 0.05Factor 2 – Anticipatory Guidance 157 3.77 (0.64) 3.69 (0.67) 0.02Factor 3 – Sufficient Time 157 4.14 (0.60) 4.12 (0.56) 0.47Factor 4 – Approachability 157 4.31 (0.65) 4.31 (0.60) 0.99Factor 5 – Availability 157 4.08 (0.60) 4.04 (0.68) 0.16Factor 6 – Support and Respect 157 4.27 (0.54) 4.25 (0.50) 0.36Total QPCQ 157 4.13 (0.47) 4.09 (0.48) 0.05Table 9 Intra-class correlation coefficients for QPCQsubscales across three time points in Phase fiveFactor Name Intra-classcorrelationcoefficient95% confidenceinterval1 – Information Sharing 0.75 0.69-0.802 – Anticipatory Guidance 0.76 0.71-0.813 – Sufficient Time 0.76 0.70-0.814 – Approachability 0.67 0.61-0.745 – Availability 0.76 0.71-0.816 – Support and Respect 0.74 0.69-0.79Total score 0.81 0.76-0.85Heaman et al. BMC Pregnancy and Childbirth 2014, 14:188 Page 13 of 16http://www.biomedcentral.com/1471-2393/14/188standard deviations, and to use parametric statistics toanalyze the scales [68]. Health care providers may find ithelpful to examine the rank order of (dis)agreement forindividual items on the QPCQ to identify specific aspectsof prenatal care in need of quality improvement. However,for research using the QPCQ, we agree with Carifio andPerla’s view that treating the data from Likert scales asinterval in character permits “more powerful and nuancedanalyses” [68].Recommendations for future researchThis valid and reliable instrument can now be used asan outcome measure to evaluate quality of prenatal care,to identify predictors of quality of prenatal care, to com-pare and contrast quality of prenatal care across regions,populations, and types of health care providers and ser-vice delivery models, and to assess the relationship be-tween quality of care and a variety of maternal andinfant health outcomes. The outcomes studied shouldnot be limited to gestational age and birth weight, butrather encompass a range of health status and behavioralindicators. As noted by Alexander and Kotelchuck,“there are several other perinatal outcomes that may bemodified by prenatal care” [1]. Rosenberg has suggestedthat attention should be given to studying the effect ofoptimal prenatal care on maternal self-esteem, attach-ment, connections to both the health care system andsocial services, and maternal physical and mental health[69]. Other appropriate outcomes include postnatalhealth status of mother and infant, the adoption andmaintenance of healthy behaviors, disclosure of sensitiveconcerns, postpartum behaviors, maternal and infanthealth care utilization, and infant injury and diseaserates [1]. The relationship between quality of care and avariety of outcomes may have implications for allocationof resources, program planning, and policy development.With a valid and reliable QPCQ, researchers and decisionmakers will be well positioned to collect evidence that canbe used to design and refine programs to improvewomen’s experiences and enhance perinatal outcomes.ConclusionsThe QPCQ is a new self-report instrument that mea-sures overall quality of prenatal care, and quality of carefor six factors or subscales. Following a rigorous processof development and psychometric testing, the QPCQhas been shown to demonstrate construct validity, in-ternal consistency reliability, and test-retest reliability.This valid and reliable instrument will be useful in futureresearch to evaluate women’s perceptions of quality ofprenatal care, to compare quality of care across regions,populations, types of health care provider, and servicedelivery models, and to assess the relationship betweenquality of care and a variety of maternal and infant healthoutcomes.AbbreviationsQPCQ: Quality of Prenatal Care Questionnaire; CTP: Content and timing ofcare in pregnancy tool; PESPC: Patient Expectations and Satisfaction withPrenatal Care instrument; PIPC: Prenatal Interpersonal Processes of Careinstrument; ICC: Intra-class correlation coefficient; RBD: Randomized blockdesign.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsWAS and MIH wrote the grant application, directed the implementation ofthe study protocol, and had overall responsibility for the research. All authorscontributed to conception and design of the study, and interpretation of theresults, with input from the collaborators. AB coordinated the study. MIH,WAS, ST, PAJ, and DCY supervised participant recruitment in their respectivesites. NA-D performed data analysis, assisted by AB. MIH drafted the manuscript.All authors provided feedback on the draft manuscript, and read and approvedthe final manuscript.AcknowledgementsThis study was funded by an operating grant from the Canadian Institutes ofHealth Research (CIHR) (MOP - 84427). Dr. Heaman received career supportfrom a CIHR Chair in Gender and Health award. We thank our collaboratorsfor their contributions to the study: Melanie Basso (Vancouver), Laurie Blahitka(Calgary), Patricia Gregory (Winnipeg), Lynda Tjaden (Winnipeg), Jackie Barrett(Hamilton), Glenda Carson (Halifax), and Kate Lively (Halifax).The QPCQ is licensed under a Creative Commons Attribution – NonCommercial – No Derivatives 4.0 International License. © Copyright 2013.W. Sword, M. Heaman, and the QPCQ Research Team. McMaster University.All rights reserved.Author details1College of Nursing and Departments of Community Health Sciences andObstetrics, Gynecology and Reproductive Sciences, College of Medicine,Faculty of Health Sciences, University of Manitoba, 89 Curry Place, WinnipegR3T 2N2, Manitoba, Canada. 2School of Nursing and Department of ClinicalEpidemiology and Biostatistics, Faculty of Health Sciences, McMasterUniversity, 1280 Main Street West, Hamilton L8S 4K1, Ontario, Canada.3Gilbrea Centre for Studies in Aging, McMaster University, 1280 Main StreetWest, Hamilton L8S 4M4, Ontario, Canada. 4Departments of Paediatrics andCommunity Health Sciences, Faculty of Medicine, University of Calgary, 2888Shaganappi Trail NW, Calgary T3B 6A8, Alberta, Canada. 5School ofPopulation and Public Health, University of British Columbia, 2206 East Mall,Vancouver V6N 1Z3, British Columbia, Canada. 6Department of Obstetricsand Gynecology, IWK Health Centre, Dalhousie University, 5980 UniversityAvenue, P.O. Box 9700, Halifax B3K 6R8, Nova Scotia, Canada. 7Faculty ofNursing, University of Alberta, 5-258 Edmonton Clinic Health Academy,11405-87th Avenue, Edmonton T6G 1C9, Alberta, Canada. 8Department ofObstetrics and Gynecology and Department of Clinical Epidemiology andBiostatistics, Faculty of Health Sciences, McMaster University, 1280 MainStreet West, Hamilton L8S 4K, Ontario, Canada. 9Department of Obstetrics,Gynecology and Reproductive Sciences, College of Medicine, Faculty ofHealth Sciences, University of Manitoba, 735 Notre Dame Avenue, Universityof Manitoba, Winnipeg R3T 2N2, Manitoba, Canada.Received: 16 September 2013 Accepted: 16 May 2014Published: 3 June 2014References1. Alexander GR, Kotelchuck M: Assessing the role and effectiveness ofprenatal care: history, challenges, and directions for future research.Public Health Rep 2001, 116(4):306–316.Heaman et al. BMC Pregnancy and Childbirth 2014, 14:188 Page 14 of 16http://www.biomedcentral.com/1471-2393/14/1882. Lu MC, Tache V, Alexander GR, Kotelchuck M, Halfon N: Preventing lowbirth weight: is prenatal care the answer? J Matern Fetal Neonatal Med2003, 13(6):362–380.3. Moos MK: Prenatal care: limitations and opportunities. J Obstet GynecolNeonatal Nurs 2006, 35(2):278–285.4. Heaman MI, Newburn-Cook CV, Green CG, Elliott LJ, Helewa ME: Inadequateprenatal care and its association with adverse pregnancy outcomes: acomparison of indices. BMC Pregnancy Childbirth 2008, 8:15.5. VanderWeele TJ, Lantos JD, Siddique J, Lauderdale DS: A comparison offour prenatal care indices in birth outcome models: comparable resultsfor predicting small-for-gestational-age outcome but different results forpreterm birth or infant mortality. J Clin Epidemiol 2009, 62(4):438–445.6. Partridge S, Balayla J, Holcroft CA, Abenhaim HA: Inadequate prenatal careutilization and risks of infant mortality and poor birth outcome: aretrospective analysis of 28,729,765 U.S. deliveries over 8 years. Am JPerinatol 2012, 29(10):787–794.7. Korenbrot CC, Wong ST, Stewart AL: Health promotion and psychosocialservices and women’s assessments of interpersonal prenatal care inMedicaid managed care. Matern Child Health J 2005, 9(2):135–149.8. Beeckman K, Louckx F, Masuy-Stroobant G, Downe S, Putman K: Thedevelopment and application of a new tool to assess the adequacy of thecontent and timing of antenatal care. BMC Health Serv Res 2011,11:213.9. Kogan MD, Alexander GR, Kotelchuck M, Nagey DA: Relation of thecontent of prenatal care to the risk of low birth weight. Maternal reportsof health behavior advice and initial prenatal care procedures. JAMA1994, 271(17):1340–1345.10. White DE, Fraser-Lee NJ, Tough S, Newburn-Cook CV: The content ofprenatal care and its relationship to preterm birth in Alberta. CanadaHealth Care Women Int 2006, 27(9):777–792.11. Handler A, Rankin K, Rosenberg D, Sinha K: Extent of documentedadherence to recommended prenatal care content: provider sitedifferences and effect on outcomes among low-income women. MaternChild Health J 2012, 16(2):393–405.12. Klerman LV, Ramey SL, Goldenberg RL, Marbury S, Hou J, Cliver SP: Arandomized trial of augmented prenatal care for multiple-risk, Medicaid-eligible African American women. Am J Public Health 2001, 91(1):105–111.13. Ricketts SA, Murray EK, Schwalberg R: Reducing low birthweight byresolving risks: results from Colorado’s prenatal plus program. Am JPublic Health 2005, 95(11):1952–1957.14. Carlson NS, Lowe NK: Centering pregnancy: a new approach in prenatalcare. MCN Am J Matern Child Nurs 2006, 31(4):218–223.15. Wilkinson DS, Korenbrot CC, Greene J: A performance indicator ofpsychosocial services in enhanced prenatal care of Medicaid-eligiblewomen. Matern Child Health J 1998, 2(3):131–143.16. Ruiz-Mirazo E, Lopez-Yarto M, McDonald SD: Group prenatal care versusindividual prenatal care: a systematic review and meta-analyses. J ObstetGynaecol Can 2012, 34(3):223–229.17. Goberna-Tricas J, Banus-Gimenez MR, Palacio-Tauste A, Linares-Sancho S:Satisfaction with pregnancy and birth services: the quality of maternitycare services as experienced by women. Midwifery 2011, 27(6):e231–e237.18. Wheatley RR, Kelley MA, Peacock N, Delgado J: Women’s narratives onquality in prenatal care: a multicultural perspective. Qual Health Res 2008,18(11):1586–1598.19. Hildingsson I, Thomas JE: Women’s perspectives on maternity services inSweden: processes, problems, and solutions. J Midwifery Womens Health2007, 52(2):126–133.20. Vause S, Maresh M: Indicators of quality of antenatal care: a pilot study.Br J Obstet Gynaecol 1999, 106(3):197–205.21. Boller C, Wyss K, Mtasiwa D, Tanner M: Quality and comparison ofantenatal care in public and private providers in the United Republic ofTanzania. Bull World Health Organ 2003, 81(2):116–122.22. Wong ST, Korenbrot CC, Stewart AL: Consumer assessment of the qualityof interpersonal processes of prenatal care among ethnically diverselow-income women: development of a new measure. Womens HealthIssues 2004, 14(4):118–129.23. Vinagre MH, Neves J: The influence of service quality and patients’emotions on satisfaction. Int J Health Care Qual Assur 2008, 21(1):87–103.24. Gotlieb JB, Grewal D, Brown SW: Consumer satisfaction and perceivedquality: complementary or divergent constructs? J Appl Psychol 1994,79(6):875.25. Handler A, Rosenberg D, Raube K, Lyons S: Prenatal care characteristicsand African-American women’s satisfaction with care in a managed careorganization. Womens Health Issues 2003, 13(3):93–103.26. Lawrence JM, Ershoff D, Mendez C, Petitti DB: Satisfaction with pregnancyand newborn care: development and results of a survey in a healthmaintenance organization. Am J Manag Care 1999, 5(11):1407–1413.27. Omar MA, Schiffman RF, Bingham CR: Development and testing of thepatient expectations and satisfaction with prenatal care instrument. ResNurs Health 2001, 24(3):218–229.28. Clement S, Sikorski J, Wilson J, Das S, Smeeton N: Women’s satisfactionwith traditional and reduced antenatal visit schedules. Midwifery 1996,12(3):120–128.29. Seguin L, Therrien R, Champagne F, Larouche D: The components ofwomen’s satisfaction with maternity care. Birth 1989, 16(3):109–113.30. Erci B, Ivanov L: The relationship between women’s satisfaction withprenatal care service and the characteristics of the pregnant womenand the service. Eur J Contracept Reprod Health Care 2004, 9(1):16–28.31. Ivanov LL, Flynn BC: Utilization and satisfaction with prenatal careservices. West J Nurs Res 1999, 21(3):372–386.32. Ivanov LL, Champion VL: Development of a Russian satisfaction withprenatal care scale. J Nurs Meas 2000, 8(2):117–129.33. Donabedian A: Evaluating the quality of medical care. Milbank Mem FundQ 1966, 44(Suppl 3):206.34. Donabedian A: The quality of care. How can it be assessed? JAMA 1988,260(12):1743–1748.35. Aday LA, Andersen R: A framework for the study of access to medicalcare. Health Serv Res 1974, 9(3):208–220.36. Andersen RM: Revisiting the behavioral model and access to medicalcare: does it matter? J Health Soc Behav 1995, 36(1):1–10.37. Campbell SM, Roland MO, Buetow SA: Defining quality of care. Soc Sci Med2000, 51(11):1611–1625.38. Bennett I, Switzer J, Aguirre A, Evans K, Barg F: ‘Breaking it down’:patient-clinician communication and prenatal care among African Americanwomen of low and higher literacy. Ann Fam Med 2006, 4(4):334–340.39. Moore ML, Ketner M, Walsh K, Wagoner S: Listening to women at risk forpreterm birth. MCN Am J Matern Child Nurs 2004, 29(6):391–397.40. Tandon SD, Parillo KM, Keefer M: Hispanic women’s perceptions ofpatient-centeredness during prenatal care: a mixed-method. Birth-IssuesPerinatal Care 2005, 32(4):312–317.41. Bloom KC, Bednarzyk MS, Devitt DL, Renault RA, Teaman V, Van Loock DM:Barriers to prenatal care for homeless pregnant women. J Obstet GynecolNeonatal Nurs 2004, 33(4):428–435.42. Sword W: Prenatal care use among women of low income: a matter of“taking care of self”. Qual Health Res 2003, 13(3):319–332.43. Chew-Graham CA, Sharp D, Chamberlain E, Folkes L, Turner KM: Disclosureof symptoms of postnatal depression, the perspectives of healthprofessionals and women: a qualitative study. BMC Fam Pract 2009, 10:7.44. Al-Qutob R, Mawajdeh S, Bin RF: The assessment of reproductive healthservices: a conceptual framework for prenatal care. Health Care WomenInt 1996, 17(5):423–434.45. Langer A, Nigenda G, Romero M, Rojas G, Kuchaisit C, Al-Osimi M, for theWHO Antenatal Care Trial Research Group: Conceptual bases andmethodology for the evaluation of women’s and providers’ perceptionof the quality of antenatal care in the WHO Antenatal Care RandomisedControlled Trial. Paediatr Perinat Epidemiol 1998, 12(Suppl 2):98–115.46. Streiner DL, Norman GR: Health measurement scales: a practical guide to theirdevelopment and use. 3rd edition. Oxford: Oxford University Press; 2003.47. Pett MA, Lackey NR, Sullivan J: Making sense of factor analysis: the use offactor analysis for instrument development in health care research. ThousandOaks, CA: Sage Publications; 2003.48. Sword W, Heaman MI, Brooks S, Tough S, Janssen PA, Young D, Kingston D,Helewa ME, Akhtar-Danesh N, Hutton E: Women’s and care providers’perspectives of quality prenatal care: a qualitative descriptive study. BMCPregnancy Childbirth 2012, 12:29.49. Feinstein AR: Clinimetrics. New Haven: New Haven: Yale University Press; 1987.50. Marx RG, Bombardier C, Hogg-Johnson S, Wright JG: Clinimetric andpsychometric strategies for development of a health measurement scale.J Clin Epidemiol 1999, 52(2):105–111.51. Dillman DA, Smyth JD, Christian LM: Internet, mail, and mixed-mode surveys:the tailored design method. 3rd edition. Hoboken, N.J: John Wiley & Sons Inc;2009.Heaman et al. BMC Pregnancy and Childbirth 2014, 14:188 Page 15 of 16http://www.biomedcentral.com/1471-2393/14/18852. Waltz CF, Strickland OL, Lenz ER: Measurement in nursing and healthresearch. New York: New York: Springer Pub; 2005.53. DeVellis RF: Scale development : theory and applications. Thousand Oaks, CA:Sage Publications, Inc.; 2003.54. Comrey AL, Lee HB: A first course in factor analysis. 2nd edition. Hillsdale, NJ:Lawrence Erlbaum; 1992.55. Pedhazur EJ, Schmelkin LP: Measurement, design, and analysis: an integratedapproach. Hillsdale, N.J.: Lawrence Erlbaum Associates; 1991.56. Strickland OL: Using factor analysis for validity assessment: practicalconsiderations. J Nurs Meas 2003, 11(3):203–205.57. Mishel MH: Methodological studies: instrument development. InAdvanced designs in nursing research. 2nd edition. Edited by Brink PJ, WoodMJ. Thousand Oaks, CA: Sage Publications; 1998:235–282.58. Polit DF, Beck CF: Nursing research: principles and methods. 8th edition.Philadelphia: Lippincott Williams & Wilkins; 2004.59. Nunnally JC, Bernstein IH: Psychometric theory. 3rd edition. New York:McGraw-Hill; 1994.60. Walter SD, Eliasziw M, Donner A: Sample size and optimal designs forreliability studies. Stat Med 1998, 17(1):101–110.61. U.S.Preventive Services Task Force: U.S. Preventive services task forcegrade definitions. 2012, http://www.uspreventiveservicestaskforce.org/uspstf/grades.htm.62. Donabedian A: The Lichfield lecture. Quality assurance in health care:consumers’ role. Qual Health Care 1992, 1(4):247–251.63. Lees C: Measuring the patient experience. Nurse Res 2011, 19(1):25–28.64. Novick G: Women’s experience of prenatal care: an integrative review.J Midwifery Womens Health 2009, 54(3):226–237.65. Heaman M, O’Brien B: Prenatal care provider. In What mothers say: theCanadian maternity experiences survey. Edited by Public Health Agency ofCanada. Ottawa: Public Health Agency of Canada; 2009:37–41.66. Tough SC, Johnston DW, Siever JE, Jorgenson G, Slocombe L, Lane C, ClarkeM: Does supplementary prenatal nursing and home visitation supportimprove resource use in a universal health care system? A randomizedcontrolled trial in Canada. Birth-Issues Perinatal Care 2006, 33(3):183–194.67. Carifio J, Perla R: Ten common misunderstandings, misconceptions,persistent myths and urban legends about Likert scales and Likertresponse formats and their antidotes. J Soc Sci 2007, 3(3):106–116.68. Carifio J, Perla R: Resolving the 50-year debate around using and misuingLikert scales. Med Educ 2008, 42:1150–1151.69. Rosenberg KD: Benefits and limitations of prenatal care. JAMA 1998,280(24):2072.doi:10.1186/1471-2393-14-188Cite this article as: Heaman et al.: Quality of prenatal care questionnaire:instrument development and testing. BMC Pregnancy and Childbirth2014 14:188.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitHeaman et al. BMC Pregnancy and Childbirth 2014, 14:188 Page 16 of 16http://www.biomedcentral.com/1471-2393/14/188

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.52383.1-0223411/manifest

Comment

Related Items