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Women's and care providers' perspectives of quality prenatal care: a qualitative descriptive study Sword, Wendy; Heaman, Maureen I; Brooks, Sandy; Tough, Suzanne; Janssen, Patricia A; Young, David; Kingston, Dawn; Helewa, Michael E; Akhtar-Danesh, Noori; Hutton, Eileen Apr 13, 2012

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RESEARCH ARTICLE Open AccessWomen’s and care providers’ perspectives ofquality prenatal care: a qualitative descriptive studyWendy Sword1*, Maureen I Heaman2, Sandy Brooks3, Suzanne Tough4, Patricia A Janssen5, David Young6,Dawn Kingston7, Michael E Helewa8, Noori Akhtar-Danesh9 and Eileen Hutton10AbstractBackground: Much attention has been given to the adequacy of prenatal care use in promoting healthy outcomes forwomen and their infants. Adequacy of use takes into account the timing of initiation of prenatal care and the numberof visits. However, there is emerging evidence that the quality of prenatal care may be more important than adequacyof use. The purpose of our study was to explore women’s and care providers’ perspectives of quality prenatal care toinform the development of items for a new instrument, the Quality of Prenatal Care Questionnaire. We report on thederivation of themes resulting from this first step of questionnaire development.Methods: A qualitative descriptive approach was used. Semi-structured interviews were conducted with 40pregnant women and 40 prenatal care providers recruited from five urban centres across Canada. Data wereanalyzed using inductive open and then pattern coding. The final step of analysis used a deductive approach toassign the emergent themes to broader categories reflective of the study’s conceptual framework.Results: The three main categories informed by Donabedian’s model of quality health care were structure of care,clinical care processes, and interpersonal care processes. Structure of care themes included access, physical setting, andstaff and care provider characteristics. Themes under clinical care processes were health promotion and illnessprevention, screening and assessment, information sharing, continuity of care, non-medicalization of pregnancy, andwomen-centredness. Interpersonal care processes themes were respectful attitude, emotional support, approachableinteraction style, and taking time. A recurrent theme woven throughout the data reflected the importance of ameaningful relationship between a woman and her prenatal care provider that was characterized by trust.Conclusions: While certain aspects of structure of care were identified as being key dimensions of quality prenatalcare, clinical and interpersonal care processes emerged as being most essential to quality care. These processes areimportant as they have a role in mitigating adverse outcomes, promoting involvement of women in their owncare, and keeping women engaged in care. The findings suggest key considerations for the planning, delivery, andevaluation of prenatal care. Most notably, care should be woman-centred and embrace shared decision making asan essential element.BackgroundPrenatal care has become one of the most widely usedpreventive health care services in developed countries[1,2]. Broadly defined, it encompasses “the detection,treatment, or prevention of adverse maternal, fetal, andinfant outcomes as well as interventions to address psy-chosocial stress, detrimental health behaviors such assubstance abuse, and adverse socioeconomic conditions”(p.116) [1]. Much attention has been given to the ade-quacy of prenatal care use in mitigating poor outcomesfor women and their infants. Adequacy of utilization hasbeen conceptualized as consisting of two dimensions:the timing of initiation of prenatal care and the numberof prenatal visits, taking gestational age at entry intocare and at delivery into consideration [3]. As noted byKotelchuck [3], adequacy does not take into account thecontent or quality of care that is delivered but ratherfocuses only on quantifying its use.* Correspondence: sword@mcmaster.ca1School of Nursing and Department of Clinical Epidemiology andBiostatistics, Faculty of Health Sciences, McMaster University, 1280 MainStreet West, Hamilton, Ontario L8S 4K1, CanadaFull list of author information is available at the end of the articleSword et al. BMC Pregnancy and Childbirth 2012, 12:29http://www.biomedcentral.com/1471-2393/12/29© 2012 Sword et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.There is emerging evidence that the quality of prenatalcare, i.e., what is actually done during the giving andreceiving of care, may be more important than thequantity of care. Ricketts, Murray, and Schwalberg [4],for instance, found that providing enhanced prenatalcare to high-risk women that specifically addressed life-style and psychosocial characteristics was effective inresolving risk factors and, subsequently, low birth weightrisk. In another study an association was found betweenthe health promotion content of prenatal care receivedat a low-risk clinic and healthy behaviours in pregnancy,including reduced substance use [5]. Evaluations of Cen-tering Pregnancy©, a group model of prenatal care thatallows more time with care providers than traditionalcare and is relationship-centered, suggest its potentialeffectiveness in reducing negative birth outcomes [6]. Arandomized controlled trial of Centering Pregnancy©demonstrated improvements in gestational age, maternalpsychosocial function, breastfeeding initiation, and satis-faction with care [7].In light of this evidence that suggests the importance ofquality of care and evidence that reducing the frequencyof prenatal visits for low-risk healthy women does notadversely affect maternal or neonatal outcomes, the needfor the usual 14 to 16 visits recommended by some pro-fessional organizations has been questioned [8]. In fact, arecommended schedule of fewer visits for such womenwas proposed over 20 years ago by an expert panel of theU.S Public Health Service’s Low Birth Weight PreventionWork Group [9]. This recommendation was based on theassumption that high quality care is offered [10].There is no agreement, however, as to what constitutesquality prenatal care. The list of nine indicators of qualityprenatal care developed by a working group of the RoyalCollege of Obstetricians and Gynaecologists reflect verydefined medical aspects of care (e.g., Rhesus antibodyscreening, detection of and use of external cephalic ver-sion for breech presentation, steroid administration inpreterm delivery) [11]. Adherence to evidence-based clin-ical practice guidelines that are both applicable to thepopulation of childbearing women and to midwiferypractice has been suggested as a strategy to maintainquality in antenatal care delivered by midwives [12]. Kirk-ham, Harris, and Grzybowski [13] similarly proposed thatprenatal care should be based on “the best available evi-dence” but added that this evidence should be integrated“into a model of informed, shared decision making”(p. 1307). While noting that medical procedures areimportant, Alexander and Kotelchuck [1] suggested thatparameters for assessing quality of prenatal care shouldtake into account the provision of health education,assessment of the need for and referral to ancillary ser-vices (e.g., nutrition support, social services), and the nat-ure of patient-provider-system interactions.Given the wide variation in opinions about the essentialelements of quality prenatal care, the inconsistency inapproaches to assessing quality of prenatal care in thepublished literature is not surprising. Research in thisarea has largely been atheoretical, few studies have con-sidered women’s perspectives, and much of the focus hasbeen on medical or clinical aspects of care to the exclu-sion of interpersonal processes. Moreover, studies seek-ing to examine the relationships between quality ofprenatal care and perinatal outcomes have been hinderedby the lack of a theoretically-grounded and psychometri-cally-tested instrument. To fill this gap we conductedresearch with the aim of developing and testing aninstrument to measure quality of prenatal care, the Qual-ity of Prenatal Care Questionnaire. As a first step ininstrument development, semi-structured interviewswere conducted with women and prenatal care providersto ascertain their views of quality care. Understandingwhat patients value is particularly critical in a prenatalcare context as engagement of women in care is impor-tant for early initiation and continuation of care over arelatively short time period for health promotion, preven-tion of adverse outcomes, and early identification of andintervention for health risks [14]. Additionally, there isevidence that engagement in prenatal care is predictive offuture use of preventive health services, including well-child care [15].The purpose of this article is to describe women’s andprenatal care providers’ perspectives of quality prenatalcare. In doing so, the research adds to our understandingof specific dimensions of prenatal care that ultimatelymight contribute to healthy outcomes for women andtheir infant. We received ethics approval for this studyfrom Hamilton Health Sciences/McMaster UniversityFaculty of Health Sciences Research Ethics Board and theethics committee responsible for the conduct of researchat each participating site.MethodsA qualitative descriptive exploratory design was used tounderstand women’s and care providers’ perspectives ofquality prenatal care. As noted by Sandelowski [16], quali-tative description is especially useful in obtaining straightdescriptive answers to questions of special relevance topractitioners and policy makers. The conceptual frame-work that guided the study was derived from Donabedian’s[17] systems-based model of quality health care. It encom-passes three aspects of care: structure, processes, and out-comes. Structure refers to attributes of the setting inwhich health care is delivered and received; the domainsof care structure include physical setting and staff charac-teristics [17,18]. Process of care refers to what is actuallydone in the delivery and receipt of care and incorporatestwo key components: clinical care and interpersonal careSword et al. BMC Pregnancy and Childbirth 2012, 12:29http://www.biomedcentral.com/1471-2393/12/29Page 2 of 18processes [17,18]. Clinical care refers to the application ofmedical and other sciences and technology to achieve thebest health result whereas interpersonal care describes thesocial and psychological interactions between health careprofessional and users of the health care system [17,18].Outcomes, including patient satisfaction, are a conse-quence rather than a component of care and may bedirectly or indirectly influenced by the structure and pro-cesses of care [17,18].Sample and recruitmentStudy participants were recruited from five urban centresacross Canada: Vancouver, Calgary, Winnipeg, Hamilton,and Halifax. Each of these centres offers a range of prena-tal care services to diverse populations. Purposeful maxi-mum variation sampling was used to select informantsthat would provide a broad range of perspectives, therebycreating in-depth understanding of important dimensionsof quality prenatal care [19,20]. Women were eligible toparticipate in the study if they were in the late third tri-mester of pregnancy (≥ 32 weeks), ≥ 16 years of age, andable to read and write English. We aimed for variation inage, parity, medical risk status, socioeconomic status, eth-nicity, and urban vs. rural residence. Women wererecruited from a variety of settings offering prenatal ser-vices (e.g., maternity clinics, hospital prebirth registrationclinics, public health programs). Staff at each settingassisted in identifying potential study participants;women deemed eligible were given a study informationletter and, if interested, gave signed permission to havetheir names forwarded to the site research assistant. Theresearch assistant subsequently contacted women tofurther explain the study, answer questions, and arrangedata collection with consenting individuals.Prenatal care providers, including obstetricians, familyphysicians, midwives and nurses, were eligible to partici-pate if they had practiced in obstetrics/maternity care fora minimum of 2 years. We tried to ensure diversity incharacteristics such as profession, length of time in prac-tice, type of practice (solo vs. group), and place of prac-tice (urban vs. rural setting). The research coordinatorsent a letter of invitation to care providers identified bystudy team members and followed-up with a telephonecall to determine their interest in participating. Snowballsampling was then used as these individuals were askedto suggest other potential study participants.Data collectionA semi-structured interview was conducted by a trainedresearch assistant with each study participant at a loca-tion of their choice. Signed informed consent wasobtained prior to the start of data collection. An inter-view guide informed by Donabedian’s [17] model wasused. The guide included an opening question, “Whatdoes quality prenatal care mean to you?” Then a numberof questions were posed asking about structural aspects,clinical care processes, and interpersonal care processesperceived to contribute to quality care. Probes for eachquestion were identified to promote consistency in datacollection across study sites and participants. Womentook part in a face-to-face interview late in the third tri-mester of pregnancy and a second interview was con-ducted by telephone approximately 4 weeks after theyhad given birth. This follow-up interview was an oppor-tunity to obtain additional perspectives about quality pre-natal care as women were in a position to reflect andcomment on their care experience having had their baby.It also provided an opportunity to validate the themesemerging from the initial interviews. Care providers par-ticipated in a single face-to-face interview. All interviewswere digitally recorded and transcribed verbatim. A briefsociodemographic questionnaire was administered at theend of the interview to collect background informationon study participants. Women were given a $20 gift cardin appreciation for their time and contribution to thestudy.Data analysisThe qualitative data were managed and analyzed usingNVivo 7. We began the analysis using an inductiveapproach. The transcripts initially were read in full, withanalysis then proceeding using open coding techniqueswhereby each meaningful segment of text was assigned aconceptual code [21,22]. A research assistant had responsi-bility for the coding and met with the principal and co-principal investigators after coding the first few interviewsto develop a preliminary coding scheme, which subse-quently was applied to the remaining interviews. Throughcomparative analysis, the same codes were assigned todata with common characteristics [22]. As the open codesbecame saturated, the analysis evolved to pattern codingwhereby specific dimensions of quality prenatal care wereidentified [21]. Finally, a deductive approach was used toassign the emergent themes to broader categories thatreflected Donebedian’s model [17] and its further elabora-tion by Campbell, Roland, and Buetow [18]. The researchassistant and principal investigator met periodicallythroughout the coding process to discuss and revise thecoding scheme and the synthesis of codes at a higher level.The quantitative background data were entered into andanalyzed using SPSS 17. Descriptive statistics were used tosummarize the data collected from all women and prenatalcare providers.A number of strategies were used to ensure rigor of thequalitative analysis. In addition to the involvement of theprincipal investigator in coding, the emergent codingscheme was discussed with the co-principal investigator.Data were reorganized as the coding scheme progressedSword et al. BMC Pregnancy and Childbirth 2012, 12:29http://www.biomedcentral.com/1471-2393/12/29Page 3 of 18and all themes were firmly grounded in the data [23,24].Memos were kept about coding decisions along withcopies of evolving coding schemes [25]. Having womenvalidate the emergent themes further enhanced the trust-worthiness of interpretation of the interview data.ResultsWe recruited eight pregnant women and eight prenatalcare providers from each of the five study sites, for a totalof 80 participants. The sociodemographic characteristicsof women who participated in the study are shown inTable 1. Five women (12.5%) reported they had experi-enced a pregnancy complication and eight (20%) had aphysical or mental chronic health problem. Twenty-fourwomen (60.0%) had seen an obstetrician for prenatalcare, 21 (52.5%) had seen a family physician, and seven(17.5%) had seen a midwife; 30.0% (n = 12) reportedreceiving care from more than one type of provider.Twenty-seven of the women (67.5%) who took part in aprenatal interview participated in a follow-up interview at4 weeks postpartum. Of the prenatal care providers inter-viewed, 14 (35.0%) were midwives, 12 (30.0%) were familyphysicians, eight (20%) were obstetricians, and six (15.0%)were nurses/nurse practitioners. The majority (78.0%) ofcare providers was practicing full-time and most werefemale (80.0%). The mean number of years in practicewas 16.1 years (SD 11.8).Table 2 summarizes the themes that emerged from thedata analysis and their relationship to the predeterminedcategories that are reflective of Donabedian’s model [17].An additional theme, meaningful relationship, was woventhroughout the interviews and cut across the three cate-gories. While each group of informants emphasized dif-ferent elements of quality prenatal care, the groups weresimilar in their overall views of what constitutes qualitycare. Therefore the data from both pregnant women andcare providers were combined for the analysis. In pre-senting the findings, we use quotes for illustrative pur-poses. The source of each quote is indentified, with “W”and “PCP“ being used along with study site and partici-pant numbers for women and prenatal care providers,respectively.Structure of careStructure of care reflects the attributes of the care set-ting that contribute to the quality of care. The themesinclude access, physical setting, and staff and care provi-der characteristics.AccessAccess is defined as “the potential ability of women toenter prenatal care services and maintain care for herselfand fetus during the perinatal period” (p. 220) [26].According to study participants access includes beingable to begin prenatal care as early as possible with ahealth care provider of the woman’s choice. Access alsoencompasses having care available in locations that areconvenient to women’s homes or places of work, closeto bus routes, and with adequate free or inexpensiveTable 1 Characteristics of women study participants (n = 40)CharacteristicAge in years (mean ± SD) 30.4 (6.5)n (%)Marital statusMarried 25 (62.5)Common-law/living with a partner 11 (27.5)Separated/widowed/divorced -Single (never married) 4 (10.0)Annual household incomeNo income 1 (2.5)< $10,000 -$10,000-19,999 4 (10.0)$20,000-39,999 3 (7.5)$40,000-59,999 10 (25.0)$60,000-79,999 3 (7.5)≥ $80,000 19 (47.5)Country of birthCanada 32 (80.0)Other 8 (20.0)Language spoken at homeEnglish 36 (90.0)Other 4 (10.0)Highest level of educationSome high school 2 (5.0)Completed high school 8 (20.0)Some community college/technical school 2 (5.0)Completed college/technical school -Some university 5 (12.5)University degree 23 (57.5)Table 2 Quality of care categories and themesCategories1 ThemesStructure of care AccessPhysical settingStaff and care provider characteristicsClinical care processes Health promotion and illness preventionScreening and assessmentSharing of informationContinuity of careNon-medicalization of pregnancyWomen-centrednessInterpersonal care processes Respectful attitudeEmotional supportApproachable interaction styleTaking time1 Based on Donabedian’s model of quality careSword et al. BMC Pregnancy and Childbirth 2012, 12:29http://www.biomedcentral.com/1471-2393/12/29Page 4 of 18parking. As women reported, “It’s actually quite conve-nient ‘cause I can walk there [from work] on the nicedays. ... It’s close to my husband’s work as well"(W03-04)and, in contrast, “We’re spending over $60 a month justfor parking [for prenatal care]. It would really make adifference if there were some options in that respect.”(W04-04)Ease of scheduling appointments and office or clinichours that are flexible enough to accommodate women’spersonal lives were identified as dimensions of quality care.A family physician spoke about this flexibility as follows:Families come and mothers-to-be come in all sorts ofabilities to organize their lives and get to appoint-ments and follow through on stuff. So I think to havesome flexibility around sort of how you, how you offerthem care is, is really important and I must say we’reprobably way more flexible with our prenatalpatients and our new moms. ... It doesn’t matter ifthey show up late, it doesn’t matter if they miss threeappointments in a row. You know they’re not pena-lized for that because you’re really trying to sort ofhold on to that relationship and, and build on it asopposed to sending them the little letter about onemore no show you’re out of here. (PCP04-08)Women, in particular, commented on the value ofhaving prenatal care providers available to them outsideof scheduled appointment times. They identified thatthey often had concerns or questions they felt eitherwere too serious to wait until their next prenatal carevisit or did not warrant a visit. Having telephone accessto the care provider or staff and having phone messagesreturned promptly were identified as important in redu-cing anxiety and feeling cared for. One woman com-mented:I think being able to call and get somebody to callyou back in about 10 or 15 minutes has been reallygreat. I think that - I don’t know that I wouldn’thave had as healthy a pregnancy - but I think Iwould’ve felt a little bit more stressed out about cer-tain things. (W01-06)Women extended the notion of access to includeaccess to educational resources. Ready availability of avariety of pregnancy-related educational materials suchas books, pamphlets, and videos was another importantcomponent of quality care as reflected in this statement:The rooms are good because you looked around andyou saw everything that your future was going to beand you had access to pamphlets, you had any ques-tions you’d have anything. Everything was there foryou. Everything - you were completely surrounded. ...It’s there and that’s the greatest I think. Everything isavailable to you. (W04-01)Physical settingWomen described several physical features of the settingin which they received prenatal care that contribute toits quality, including cleanliness, aesthetics, and privacy.They noted that the latter was particularly vital whenproviding urine samples and communicating with theirprenatal care providers. One woman remarked on theimportance of discussions that cannot be overheard byothers as follows:Privacy ... I wouldn’t want to be sitting in the waitingroom listening to a doctor speak with a patient. Soit’s reassuring to me to know that if I can’t hear himtalking to someone then nobody can hear him talkingto me. (W05-01)Prenatal care providers similarly recognized theimportance of privacy. One health care professionalcompared differences in privacy in two different settingsin which she had worked:Compared to our old clinic, which was very small,very crowded, there is a lot of privacy in this clinic,which I think is important. You know, once you comeinto the back room, people aren’t really seeing you,whereas in our last clinic there was a lot of move-ment in and out, and you could see people gettingtheir blood pressure done and all that. And youknow, that’s okay for some people, but it’s, you know,it’s not okay for everyone. ... Not everyone wants tohave their belly measured in front of a hundred peo-ple. (PCP02-05)Having the right type of seating was important as itwas noted that pregnant women often have back pro-blems and thus find it difficult to find comfortable seat-ing. The aesthetics of the physical space also wereidentified as contributing to quality care. As one womanstated:I like how this whole building obviously, it’s differentcolours. It makes it a good atmosphere. It’s veryclean. ... You get an overall happy feeling whenyou’re there. You’re not sitting in a dark office,gloomy feeling. It’s bright and everything’s bright,makes you feel happy, I find, so I like the differentcolours and stuff like that. (W05-05)Women desired a “welcoming“ environment and oftendescribed family physicians’ or obstetricians’ offices asSword et al. BMC Pregnancy and Childbirth 2012, 12:29http://www.biomedcentral.com/1471-2393/12/29Page 5 of 18“medical“ and “clinical“ whereas those of midwives weredescribed in more favourable terms, as captured in thisquote:She’s got a very nice chaise lounge rather than anexamining table, and then she has a little desk. ... Soit’s pretty comfy. And then there’s a separate roomfor pelvic exams. Yeah, the whole place is kind ofupholstered and furnished. It does not feel clinical.There is a minimum of rubber gloves and paper, andcold metal stirrups and whatnot. (W01-07)Staff and care provider characteristicsWomen discussed how the characteristics of staff whowork in prenatal care settings contribute to its quality,including the temperament and personality of officestaff. Staff who were pleasant, greeted patients by name,and were efficient had a positive impact on how womenviewed their care. As one participant commented:I would say that it’s [the environment] a positive onebecause she [the receptionist] greets me with a smile,and again, non-judgmental, even if she’s really, reallybusy, she doesn’t act like she’s flustered or stressedout. I think that’s really important because people’senergies can impact another person. And it couldruin your day. So if she had a bad day, it could ruinmy day too because she just yelled at me or some-thing like that. (W01-08)For some women, knowing that their prenatal careprovider had clinical experience and was not new toproviding prenatal care engendered a sense of confi-dence in their abilities, as conveyed in the followingremark:They definitely exude a kind of a relaxation and aconfidence about what they’re doing. All the teststhey do, they make them seem so easy. I think they’vebeen doing it so long, they know exactly where thebaby is. They know exactly how to get a heart rate. ...You know that they know what they’re doing, so it’srelaxing to just go in and let them do their thing andknow that everything’s fine. (W02-05)Many women suggested that a prenatal care provider’sclinical expertise is enhanced by having personal knowl-edge of pregnancy and childbirth. One participantexplained:I feel like I can relate with them, and they have somekind of vast experience. ... You always feel more com-fortable with the person with more experience. And Ifeel that they [prenatal care providers] have a lot ofexperience, especially because they have children oftheir own. (W02-08)Health professionals also spoke more about the contri-bution of clinical expertise to quality prenatal care. Onefamily physician noted this as a special considerationwhen transferring care:I have one obstetrician/gynaecologist in particularthat I refer to who I worked with during my training,who I have a relationship of trust with. So I can saywith confidence to the people who I’m sending on, “Itrust this woman, she’s great, she’s clinically sound,she will take really good care of you.” (PCP03-04)Clinical care processesClinical care processes denote the application of clinicalmedicine and knowledge-based care [18]. We expandedthis definition to include a patient-oriented approach tocare with active involvement of women in their ownprenatal care. The themes for clinical care processes are:health promotion and illness prevention; screening andassessment; information sharing; continuity of care;non-medicalization of pregnancy; and women-centredness.Health promotion and illness preventionWomen and prenatal care providers identified theimportance of health promotion advice to encourage ahealthy lifestyle. A family physician talked about takingtime to address smoking in pregnancy as follows:If they’re smoking I spend quite a bit of time addres-sing the concerns about smoking because I really tryand emphasize the positives of them not smokingwhen they’re pregnant and then hopefully thentowards the end push the need to be a non-smokerafterwards. (PCP05-04)Counseling about nutrition and appropriate weightgain was identified as an essential component of qualityprenatal care. An obstetrician described her approach tothis as follows:I think I do far more nutritional counseling thanmost people do because I do watch their weight gainand I do try to get them to do 3-day food diaries andto try to help them to bring the weight under controlor the weight gain under control if it’s getting a bitout of control. So I have Canada’s Food Guide that Itell them to take and I consult nutritionists if neces-sary. (PCP05-05)Sword et al. BMC Pregnancy and Childbirth 2012, 12:29http://www.biomedcentral.com/1471-2393/12/29Page 6 of 18Women commented favourably on the impact ofreceiving health promotion advice. One study partici-pant remarked on the insight she gained from her pre-natal care provider asking her to record her food intake:Well, definitely you have to eat properly. ... I know Ididn’t know the proper amounts of different thingsyou need during the day. ... They had one that was acheck list. And you could check off every time you atethis and how much of this you ate, which I foundreally helpful ‘cause you don’t realize what you’re notgetting until you have this thing in front of you. So itdefinitely helped me out. (W05-05)For other participants, their care provider’s adviceencouraged them to maintain a healthy lifestyle. Asanother woman explained:Well, it [advice] encourages me to keep doing whatI’m doing. Like move around instead of getting lazyor giving up or anything. ... Like no matter how lazyI am, to still get off the couch and get some exercise.Also ‘cause that’s what’s keeping them healthy is theexercise and the nutrition and everything. So just theencouraging me to do extra things and just keepgoing with my regular life is the major thing. (W04-08)Health care providers commented more frequentlythan women on the need to pay attention to known riskfactors during pregnancy as an illness prevention strat-egy. The factors most commonly discussed were preex-isting health problems, health-risk behaviours, and socialrisks to health. One obstetrician described his approachto risk assessment as follows:I ask her if she has any known medical problems andthen, I must say, I coach a little bit because manypeople don’t know what a medical problem is and Iusually name diabetes, heart disease, kidney disease.If she’s ever had tuberculosis, epilepsy, rheumaticfever, hepatitis.... I ask her if she smokes, if she drinks,if she’s ever had street drugs. (PCP05- 03)Women similarly noted the importance of attendingto preexisting health conditions and as one participantremarked, “That’s an important part of the prenatalcare”. (W04-06)Some care providers spoke about assessing social risksto health and linking women to appropriate resources intheir communities. As a family physician stated:They [women] might bring up that they’ve got someanxiety or whatever. And I just like to make sure Idelve into that because you uncover things like physi-cal violence and financial issues. ... I think if youtake the time to ask those, like a few questions abouthow things are going in life, and get a sense of wherepeople live and how they’re living, you do pick up ona lot of those extra things. ... And we can give themplaces where they can go get support for that ... mak-ing sure you get social workers involved appropri-ately, especially if you’re a woman at risk of physicalviolence. (PCP02-05)Screening and assessmentBoth women and health care providers discussed thevalue of screening and assessment as part of quality pre-natal care. Women talked primarily about tests andmeasurements that provided reassurance the pregnancyand fetal development were progressing normally. Asone woman commented, “Every time they check mereally good so I’m satisfied that my baby is doing good soand even I’m doing good. They check my blood pressure,my diabetes, my protein and everything.” (W02-03)Prenatal care providers highlighted the importance offollowing guidelines for screening in pregnancy toensure better outcomes for mothers and babies. Anobstetrician noted:The things I really think improve outcome are screen-ing tests for HIV, screening for Rh disease. Rubellaimmunization, we still do it. And syphilis, althoughit’s low probability of picking something up, it makesa big difference when you do. The screening ultra-sound, whether or not that’s making a big differencein the outcome, I know, is a little debatable. We tryand follow up on those guidelines.... So we do a fairlystructured, follow all those guidelines for screeningfor group B strep. I think those things are reallyimportant in changing outcomes. (PCP02-01)Health care providers also discussed the importance ofscreening and assessment related to psychosocial healthas reflected in the following comment made by anobstetrician:... assessment of how the woman’s doing with relationto her pregnancy and in relation to her life and arethere any arising medical conditions that mightimpact on her pregnancy? Or social conditions. ... Itmay be that if she’s under undue stress that theremay, that there may be ramifications in terms ofhow she’s coping with the pregnancy or how she’sgoing to cope with it once the baby’s delivered. Herrisk of postpartum depression is likely to be increasedby increased life stressors during the pregnancy andin the postpartum period. So I think it’s importantSword et al. BMC Pregnancy and Childbirth 2012, 12:29http://www.biomedcentral.com/1471-2393/12/29Page 7 of 18for me to know about that. ... I can be supportive andat least I know that that woman’s at risk so that ifshe starts to go downhill I can identify it and getperinatal psych involved for example. (PCP05-05)Screening and assessment were identified as beingessential as a first step in ensuring women receiveappropriate care not only for mental health problemsbut also for physical health concerns that develop dur-ing pregnancy. One midwife, for instance, discussedhypertension and the importance of medication in itstreatment:Hypertension might actually be managed to improveoutcomes. ... Because the way in which we managehypertension now is quite different than the way inwhich it was approached say 30 years ago and so wedon’t see the same sort of things. I mean we don’t seeeclamptic women. I can’t remember when the lasttime was I saw somebody seizing because of theirhigh blood pressure, right. We medicate people differ-ently, we treat them differently, and I think their out-comes are likely to be better. (PCP04-01)Sharing of informationThe sharing of information by health care providers wasidentified as a key aspect of quality prenatal care, parti-cularly by women. When asked what aspects of prenatalcare were important to her, one woman replied:I believe it’s the way they involve you, and the waythey tell you everything that’s going on. So there’s nosecrets, there’s no mysteries, there’s no secret codes oranything like that that you don’t understand. ... Itmakes you feel like you are totally in the loop andyou know just as much as the doctors know. ... And itmakes you more confident, and like more prepared,and just feels good to know everything that’s goingon. (W02-06)As suggested by the remark about “no secret codes“, itis important that information be conveyed in a way thatwomen can understand. Another woman commented:Like I understand what she’s talking about when shetalks to me. And I think she tries to make it thatway. I don’t leave, ever leave and kind of go, “Whatdid she say? What is she talking about?” You know?So that’s been good. (W01-03)One woman expressed how much she appreciatedbeing given information about every aspect of her pre-natal care visit:The nurse will let you know whether your urine wasgood or if there was a problem. And then she’ll checkyour blood pressure ... she’ll give you the number,and then she’ll explain what it is, whether it’s goodor not. And then she weighs you and then she tellsyou first what it is, and then how much you’vegained or lost or anything like that. She is very, veryspecific and detailed about letting you know howyou’re doing that way. ... It makes me feel involved. Itmakes me feel confident. It makes me feel like theyactually care and they pay attention to what’s goingon. (W02-06)Women expressed the value of health care providerssharing information in an open and honest manner,even when delivering potentially distressing news. Onewoman described her experience as follows:They also have a way of breaking it [information]down so that it makes sense to people who don’thave medical degrees and help you to understand theramifications. For example ... the last appointment Ihad with my endocrinologist, which was a week anda day ago. And we were talking specifically about theramifications of a larger baby. And he didn’t beataround the bush. He just told me upright what theywere. First trimester, second and third trimester. So,that was kind of nice as well ... because then weknow what we’re dealing with, with this larger sizebaby and because then we’re more prepared. (W04-04)Health care providers also commented on honesty asan element of quality care. As one obstetrician stated, “Itry to build confidence in our relationship. I am comple-tely straight forward. Nothing is dressed up.” (PCP05-05)Continuity of careMany women explained that receiving care from thesame health care provider throughout the pregnancywas a feature of quality care. Some noted that thisallowed the health care provider to be familiar with andeffectively monitor their pregnancies. One woman whoexperienced several care providers explained:I see almost six doctors. ... Every week I saw differentdoctors. ... When you go and see different doctorsmaybe they didn’t know our progress. ... When youhave some problem it’s necessary to clarify all this forall new doctors. ... It’s better to see one specific doctorall the time because they see everything, our progressand otherwise if I saw every doctor, every differentdoctor - it’s not good I think. You get to know thembetter. And if you have issues from one, you know,Sword et al. BMC Pregnancy and Childbirth 2012, 12:29http://www.biomedcentral.com/1471-2393/12/29Page 8 of 18week to the next, you can say, “Well, how are yourfeet today?"or “How are your hands today?” and “Doyou have any other symptoms?” ... It’s all about justcontinuity and rapport, relationship. (W02-01)Other women elaborated on how having a consistentcare provider throughout the pregnancy contributed tothe development of a positive relationship. When askedif she felt continuity of care was an important feature ofquality prenatal care, one woman responded:Yes, I think it would be because you, you build therelationship. They know.... They’re from there fromthe beginning. Right when it’s like a little kidneybean instead of two little babies, right? So, you’regradually growing the baby together rather than halfway through you’re getting to know the doctors again.(W04-08)Some women commented specifically on the impor-tance of receiving prenatal care from a health care pro-vider with whom they had developed a relationship, asexemplified in the following remark:I think it’s more of a personal thing with the doctor.Like my regular doctor, I’ve had since I was eight. Solike going in to see her - it’s sort of like going in tosee someone you’ve known forever. It’s, “Hey, how’s itgoing?” You know, you have your little chit-chat firstand then you get into what’s going on. Whereas whenyou’re go see someone new, it’s kind of - I don’t knowif you’re going to be embarrassed about things, oryou’re kind of shy about talking about certain things.(W01-03)When women had different prenatal care providersduring their pregnancies, they identified a smooth tran-sition between care providers and timely, efficient shar-ing of information as important factors in continuity oftheir care. In reflecting on her transfer of care from afamily physician to a midwife, one study womanobserved:Transition wise it would be helpful if there was a bitmore of a flow. Like something where you know theGP understands ... she just kind of said you’ve got togo find care and I was like okay and then I sort offelt like, well, am I supposed to put them in touch ordo they talk? Or is there like my medical history? Isthat relevant to the pregnancy? ... At one point ofcourse my midwife had to request some of my rele-vant medical files. Like had I had rubella shots etce-tera. Things like that. (W01-01)Non-medicalization of pregnancyA recurring theme in the study was the importance ofnot treating pregnancy as a disease or medical condi-tion, but rather as a normal process. When asked abouther impressions of prenatal care, one woman responded:I just thought there’d be more, it would be moremedicalized, which I’m glad it’s not, actually. Youknow?’Cause you want to feel like a normal person,too, even though you’re pregnant. You don’t want tofeel like a patient. (W02-04)Several women expressed a preference for receivingcare from a midwife because it felt less medically-oriented than care provided by physicians. One womancontrasted her experiences as follows:From the first appointment that we had with ourmidwife I always said I just loved that it didn’t feelas medical and as clinical. Like it didn’t feel like Iwas sick when I went to see her. And when I went tosee my family doctor, although I didn’t actually feellike I was sick, I just felt like I was going in there forlike a medical condition. Whereas with my midwifeit was just sort of this experience we were all kind ofhaving. And it sounds a little cheesy and hokey butthat’s kind of how I felt. (W03-04)Some health care providers, particularly midwives, alsoidentified the importance of not treating pregnancy as amedical condition. A midwife emphatically stated:Pregnancy - pregnancy is not a disease [banging ontable]. Pregnancy is a normal physiological state.Women become pregnant and you shouldn’t make apathology out of it. It’s not an indication to stopwork. Pregnancy is a condition of moderation. Youwant to exercise, you exercise. If you are a skier, skibut maybe stay off the black double diamonds anddo the nice blues and do something that you’re com-fortable with. Don’t get over tired and I think thatthat’s fine. But a lot of people try to make pregnancya disease and it really isn’t. (PCP05-03)One physician similarly commented, “The traditionalvisit is the doctor and the patient and their partner.... Itkind of medicalizes their pregnancy, which for the mostpart isn’t really necessary.” (PCP01-06)Women-centrednessWomen-centredness emerged as a salient attribute ofquality prenatal care from the perspective of bothwomen and health care professionals. Key principles ofwomen-centred care are that it situates care withinSword et al. BMC Pregnancy and Childbirth 2012, 12:29http://www.biomedcentral.com/1471-2393/12/29Page 9 of 18women’s life contexts, acknowledges the social determi-nants of health, and positions women as active partnersin their care rather than as passive recipients [27].It was evident that women valued a high level of per-sonalization in their prenatal care. They wanted theirprenatal care providers to pay attention not only totheir pregnancies but also to the psychosocial aspects oftheir lives. Health professionals similarly noted theimportance of “practicing comprehensively“. As one mid-wife stated:I try to focus not only on the medical stuff, but thesocial and to some extent cultural. I try to focus andnot just think only about the pregnancy, which Ithink is a little bit different about the way we prac-tice compared to someone who’s practicing high risk.... We like to think of ourselves as taking care of theentire patient and not just focusing on the pregnancy.(PCP02-05)Some prenatal care providers spoke specifically aboutthe need to attend to priorities created by women’s lifecircumstances as reflected in this family physician’scomment:I obviously am supportive of health promotion andeducation but I’m cautious that it doesn’t underminethe sense of the woman being an adult and havingother priorities in her life ... one size doesn’t fit all. ...We tailor the education and health promotion to suitthe woman’s particular chapter in the life she’s inright now. For example, a woman is leading a deva-stated life. Isn’t quite sure where she’s going to sleepat night. Now is not a good time to talk about quit-ting smoking. Her priority is safety and things likethat. (PCP03-03)Consideration of women’s life circumstances extendedto allowing women to choose to include significantothers, such as partners or other family members, intheir prenatal care. This was conveyed in the followingstatement:Both of the doctors that I’ve seen have been reallygreat about ... encouraging the father to come to, orwhoever, a parent or a friend to come. And actually,what was nice, the first time or the second time thatI had an appointment with the doctor who will deli-ver me, she knew my fiancé was in the waiting room.And she said, “Oh, bring him in here because, he’s apart of this and I want to meet him. He should be apart of this experience as well.” So that was nice.Having doctors who ... treated it as more of a familyexperience. (W01-05)The involvement of women as active partners in theircare was recognized as an essential feature of qualityprenatal care by most study participants. A midwifedescribed how involving women can foster positivehealth promoting behaviours and outcomes:And the medical course of events becomes not some-thing that happens to a woman, but something thatshe is part of making happen and having happen. ...I think if a person does feel very involved in theirown prenatal care ... that does encourage their moti-vation to be as healthy as possible. And that couldcertainly make for more positive outcomes. (PCP01-05)The main aspects of women as active partnersincluded giving them responsibility for routine aspectsof care. Another midwife commented on how this canengender a sense of control:We have a little set up where they check their urine.The cups are there right at the bathroom and thescale is right there. When you do that you’re sayingto women, “We totally trust you.”... If you’re not col-our blind you can read a urine strip, it’s a no brainerand when they take their own blood pressure. So theytake charge for their body and they hand over to usto measure the baby and check that well being. AndI really like that model. I think it sends a message.(PCP01-03)Women concurred that such involvement gave them asense of control, as reflected in this statement:You weigh yourself, and you check your own urine asfar as just protein and sugar. ... And just let themknow the colour of the strip, and let them know whatyou weigh. So you are kind of monitoring yourself alittle bit, which is nicer because you feel in control.(W02-07)Women’s active involvement in their own care alsoincluded meaningful participation in decision making. Inone woman’s words:Straight off the bat, seeing her just to confirm mypregnancy, she was very reassuring about takingcharge of the medication that I was on, should I stayon it, should I go off it, and sort of consulting withme and what I felt comfortable with as well as hermedical opinion. And that was really, really helpful,that I was involved in the decision making but Iknew that she knew what she was talking about.(W04-06)Sword et al. BMC Pregnancy and Childbirth 2012, 12:29http://www.biomedcentral.com/1471-2393/12/29Page 10 of 18Health care providers agreed that giving women infor-mation and allowing them to make informed decisionswas important. As a midwife remarked:The goal of that [informed consent], the women, thefamilies, feel like they’re making really thorough deci-sions for themselves. That puts them in charge of theirown care. ... We try hard not to direct care, except intimes when we feel we have more information thanthey can have, just because we are care providers. So ofcourse there are times when we will say, “You knowwhat? I think you really need to have an ultrasound forgrowth”, and that’s going to really make me more com-fortable. But for the really routine stuff, it’s importantthat women can feel they direct that themselves, andalso feel ownership over it. (PCP01-04)Another midwife explained how involving women indecision making throughout their care engenders trustin a care provider when s/he needs to be more directive:Trust needs to be built, because here I am bringingsomebody in saying, “You have some responsibility inyour care. I’ll help you make decisions and I’ll give youthe education you need. And of course I see myself ashaving played a huge role because I’m the care provi-der, but you have a responsibility to go home and readand educate yourself about whatever it is I’m talkingabout. And then we’ll make the decision together. Butyou’re the one who’s really making it in the end. You’rerunning the show.” And so in order for them to actuallytrust themselves to do that, they have to trust me first,that I’m going to be able to say to them, “Well, I hearyou that you want to have a home birth with your tri-plets that are all breech but actually that’s probably, inmy opinion, not the best idea.” (PCP01-08)Interpersonal care processesInterpersonal care processes reflect the psychosocialaspects of interactions between prenatal care providersand the women to whom they provide care. The themesare respectful attitude, emotional support, approachableinteraction style, and taking time.Respectful attitudeAccording to study participants quality prenatal careinvolves a respectful regard for women as care recipi-ents. Women expressed a desire for care providers whoare non-judgmental and who therefore are easy to talkto. In one woman’s words:She’s very easy to talk to. Just like talking to a friendmore like, she doesn’t seem to judge you or anything.It’s easy for me to open up especially when I hadtroubles talking to doctors. Well I thought I had trou-bles talking to doctors. (W03-01)Several women specifically noted the importance oftheir prenatal care providers not minimizing their con-cerns or making them feel foolish when asking ques-tions. One woman described her experience as follows:I guess one of my worries was that, you know, some-times because this woman [care provider] sees somany pregnant people that she might kind of down-play my concerns. And I think that would make mefeel uncomfortable and reluctant to share some of myfeelings. And that hasn’t been the case, and I defi-nitely felt like I can call or bring up these concernsand to not feel stupid about it. So that’s been, Ithink, good at relieving my stress about the wholeexperience. (W01-05)When asked what characteristics were important in aprenatal care provider to enhance quality of care, healthcare professionals also discussed the importance ofbeing non-judgmental. As one obstetrician responded,“The big one’s non-judgmental. So you have to be ableto, you know, care for them whatever they bring in. Andyou get really good at not letting your jaw drop whenthey tell you things."(PCP03-05)Many participants noted the importance of womenfeeling respected and valued at all times. A very youngmother shared, “Oh they treated me good. Like they werereally respectful and they, I don’t know, they were neverrude or treated me bad just because of my age. I justlike to feel like everybody else, like to feel respected.”(W03-06) One midwife shared some thoughts aboutrespect saying:I don’t really know that it [quality care] has much todo with prenatal care but just care in general youknow? It’s about respect for people. ... It ’s aboutrespecting their intelligence, their understanding ofthe world. ... It’s about respecting their ability tomake good decisions about themselves and for them-selves. (PCP04-01)Included in this theme is acknowledgement of andrespect for cultural differences. Some health care provi-ders spoke of the importance of offering services in aculturally sensitive manner. A family physician stated:A significant number of our patients are from a dif-ferent culture than the care team - African or Asianor First Nations. I think we are reasonably successfulto provide care across that cultural divide. It hasmostly been my experience to work to do that, and ISword et al. BMC Pregnancy and Childbirth 2012, 12:29http://www.biomedcentral.com/1471-2393/12/29Page 11 of 18think it can be successful. But obviously, it takessome sensitivity. (PCP03-06)Emotional supportWhat emerged as one of the most essential features ofquality prenatal care was the provision of emotionalsupport, which is conveyed through behaviours such aslistening, expression of caring and concern, acknowl-edgement of feelings, and reflective understanding [28].Nearly every study participant, both women and healthcare providers, talked about its importance. One womandescribed an example of emotional support and theeffect it had on her as follows:The one where my blood sugar was higher was actu-ally really good in an odd way because I had gone inand I had my crazy morning at work already andwhen I got there I tried telling them and I just startedcrying. Apparently it’s the hormones so she [obstetri-cian] just stood up and gave me a big hug and I justfelt like laughing. It was kind of nice. (W01-01)Women also spoke of needing to feel that they andtheir pregnancies were important to their care providers.For one study participant, this was conveyed through afamily physician’s understanding of the significance toher of hearing the baby’s heart beat:I met a doctor there and he was just so warm andfantastic, and I was almost 8 weeks pregnant andhadn’t heard the heart beat or anything yet. And hesaid, “Hey, let’s listen to the heart beat. Go grab yourhusband from the waiting room.” And it was justincredible. Because I was like - “Oh my god! We’regonna hear the heart beat!” And it’s your first preg-nancy, and it was just like he went above andbeyond. ... He was just really warm and exactly whatyou want in a pre-natal care provider. (W02-07)Women wanted “to just feel cared for” and have reas-surance from their prenatal care providers throughouttheir pregnancies that their babies’ development andpregnancies were progressing normally. One womanexpressed:I think for me the most important aspects would beknowing that I’m okay. So knowing that my bloodpressure’s okay. And knowing that the baby’s heart-beat is - I can hear it, and it’s same as always. ...And knowing that, say for instance, the size of myuterus is the average size of everybody else’s uterus,right, so at this time of pregnancy. So I would justsay kind of being reassured that all my vitals, thebaby’s vitals are all fine. (W02-04)An additional feature of emotional support wasacknowledgement of women’s feelings and reassurancethat they were normal. One woman who did not receivethe emotional support anticipated from her midwifereflected on her disappointment as follows:I had thought that taking this route would give me abit - like an element of that emotional support - justthat little bit of emotional reassurance. ... I get theclinical reassurance regularly but the emotional reas-surance that no, you’re not crazy and you know thecrying or whatever’s happening is totally normal.You’ll be fine. That element has been a little bit lack-ing but that might have been a false expectation onmy part. (W01-01)Prenatal care providers similarly recognized that lis-tening and providing reassurance were key aspects oftheir roles. One family physician commented:I just try to alleviate stress and concern. People worrylots about everything and things that are out of theircontrol, so I try to just be laid back and make surethey know that things are okay. I’ll worry aboutthings that need to be, and just lay back and enjoyyourselves - look forward to the baby. I find prenatalcare very easy and very relaxing. Most patients, theyjust want to know that they’re doing well and thatthe baby is healthy. So you just have to reassurethem. (PCP03-08)Approachable interaction styleInteraction style refers to behaviours that characterizethe manner in which health care providers carry outtheir responsibilities [29]. Women expressed a prefer-ence for prenatal care providers who are positive andengaging as suggested by this comment: “This is my sec-ond go-around so we’ve had her for both pregnanciesand she’s very positive - always makes you feel very com-fortable and even uplifted during that visits, which isnice.” (W05-04). The use of humour was identified as aneffective strategy to engage women. One participant sta-ted:I think it [humour] just puts people at ease. Youknow if everything is very serious and to the point allthe time you get a little more tense. If you can laughabout things then you know it just puts you at ease.You’re a little more relaxed. (W04-07)Several women commented that it is important fortheir prenatal care providers to be calm and relaxed asthis reportedly helps to reassure women and to engen-der confidence in the care provider. Additionally, theseSword et al. BMC Pregnancy and Childbirth 2012, 12:29http://www.biomedcentral.com/1471-2393/12/29Page 12 of 18characteristics made care providers “approachable“ inthat women felt comfortable asking questions. Asanother woman expressed:I have an excellent relationship. I really like myobstetrician. ... She’s fairly laid back and she doesn’tmake me feel uncomfortable or nervous about askingall the questions that I have and I feel very confidentin her experience. (W05-07)Health care providers also acknowledged the need fora calm and relaxed demeanor. One obstetricianremarked:I find that when something bad is going on, it doesn’thelp things for you to be excited, and anxious, andworried, and what not - especially to verbalize thator show it to the patient, because that just makes itworse. So you have to be a little bit more that calm-ing voice, supportive, reliable and efficient - do whatyou have to do. But you know raising all the firealarms is just going to make it worse. (PCP03-08)Taking timeWomen placed considerable value on the amount oftime their health care providers spent with them duringprenatal visits. They identified the importance of careproviders taking time to address all their questions andconcerns. One woman recounted her experience as fol-lows:I really like that they take the time for me to just gothrough my list of questions. I don’t feel like I’mwasting their time or that it’s boring. I can just sitthere and go okay, “What about this? What aboutthat?” And they don’t mind that - that’s fine. So thatI would say is the best part of it - is that I have thetime to ask my questions. (W01-06)Women clearly did not want to feel rushed duringtheir appointments. When prenatal care providersappeared to be in a hurry, some women reported theydid not have adequate opportunity to formulate ques-tions, as captured in this remark:My expectation would be that of course, the doctorwould just ask, well they do ask, “Do you have anyquestions."And usually the answer is, “I don’t knowyet.” And as soon as you don’t answer within two sec-onds, okay, see you next week. Maybe it would benice if the doctor would like, at least wait ten secondsto give me a chance to formulate my question. ‘Causesometimes what I do, in the past, was have a list ofquestions and then go there. But then, um, they’renot happy because there’s like ten questions, which isusing up all their time. I feel a little bit guilty, havingtoo many questions. (W01-08)Several women expressed a desire for longer appoint-ments, especially at the beginning of their pregnancieswhen they had more questions or when important deci-sions had to be made. One participant commented:That first prenatal appointment, there is so much togo over. ... Like I said, the genetic screening, the var-ious blood tests ... all the prenatal testing that isdone now, there is just so much to give. And a lot ofprevention and sort of advice on what to avoid andwhat’s okay, and what’s not okay. I think a lot ofthat gets missed by the doctor because they don’thave time. (W01-02)A number of women identified a difference in theamount of time spent with midwives compared to thatspent with physicians. Many of the women stated a pre-ference for midwives because of the length of eachappointment. One woman noted:You can be comfortable to ask all the questions youneed to ask, and get the answers that you need toget, and now that they’ve [midwives] taken the timeto really think about, or do the research to find out,and make sure that they’re giving you the accurateanswers. And I have found myself with the [midwif-ery] team that I’m with right now, I’m not havingany problems with that. But earlier in my pregnancywith my family doctor, I did very much feel that theywere kind of rushing through it all because they’rejust so rushed on time and appointments. (W02-05)Some women had different experiences with theirfamily physicians in that they did not feel rushed duringtheir visits. As another woman remarked:Sometimes when I’ve had some concerns, and when Ithought about it later, I thought, “Oh my god.” ...Months down the road I think, “Oh that was so ridi-culous.” But he never said to me, “Oh, don’t give itanother thought. You’re crazy. Go home and relax.”He never says that. He always listens to me. Um,doesn’t rush me. (W04-02)Meaningful relationshipA recurrent theme throughout the interviews that cutacross all three categories reflects what may be the veryessence of quality prenatal care, a meaningful relation-ship between the care provider and the expectantSword et al. BMC Pregnancy and Childbirth 2012, 12:29http://www.biomedcentral.com/1471-2393/12/29Page 13 of 18mother. The relevance of the relationship to quality careis exemplified in this remark made by a woman whowas experiencing her sixth pregnancy:There have been things about each one [pregnancy]that have been different. And so to be able to comfor-tably discuss things with her [family physician]means everything. It means that the experience hasbeen positive when I feel safe talking to her, and Ifeel like I can trust her. I feel like it’s private, youknow, our conversation. I feel like she’s going to giveme an honest answer about things, that she’s going tobe fair in her presentation about different options.And so having that kind of relationship has beenreally important to me in terms of feeling like I’vehad incredible quality care. (W05-08)Other women similarly noted that a meaningful rela-tionship is characterized by trust and as one womancommented, a relationship based on trust can reduceanxiety and ultimately contribute to positive outcomes:I feel like I trust them, I feel comfortable and safewith them. I feel that they are both very well-trainedand very experienced. I think that my anxiety will belower because of the relationship that we have withthem and that’s got to have a positive outcome.(W01-07)Having a meaningful relationship with a care provideralso contributes to women’s comfort in asking questionsand becoming involved in directing their care. As onewoman recounted:I didn’t know him [obstetrician] very well so you’rewalking in and it almost feels like a stranger becauseit’s the reality, you’re meeting for the first time. ... Ididn’t say very much. ... And then you start to buildthe relationship and that’s where the difference is.And he was a great man, to be honest with you. Hecomes up to me with a smile all the time so, and heknows me by my first name. It does help you buildthat relationship. ... And seeing and having all thatinformation [on warning signs] made me ask thequestions that I needed to ask in order to have theproper information. (W04-01)Health care providers recognized the centrality of ameaningful relationship with their prenatal clients toquality prenatal care. As one family physician remarked:What are the aims of our prenatal care? I think alsoit’s an unfolding process of a relationship. You knowit takes you know the relationship that grows anddevelops between client and caregiver as well as justmother becoming a mother and a family becoming afamily. Right? So and that, that’s part of prenatalcare and I think it’s integral actually to prenatalcare. (PCP01-01)Health professionals, too, associated such a relation-ship with trust, comfort, and a reduction in anxiety forthe women. Some care providers believed that the rela-tionship they had with a woman played a role in herengagement in prenatal care. A midwife explained:And so you build different relationships with differentpeople ‘cause some people are more forthcoming andthat kind of thing, and other people are just doingtheir thing, right? But that relationship. I meanthat’s why women keep coming back. ... We’ve gotpeople coming back who’ve had baby number fournow. So, they keep coming back and that means youbuilt the relationship. (PCP01-07)Study participants, both women and care providers,acknowledged that a meaningful relationship makes itmore likely that a woman will accept guidance andhealth-related advice. One family physician commented:You have to find the right time to talk about that[smoking] too, and I think sometimes you have todevelop a relationship first before you start sayingyou know this and I know this but is there any waywe can help you reduce your smoking? Rather thanwalking in the room the first visit with your fingerpointing, “I see you’re smoking, don’t you know that’sbad for your baby and do you want to have ahealthy baby or do you want to have a baby withcancer and asthma?”... Not a good bridge building.(PCP03-03)A meaningful relationship between woman and hercare provider therefore not only enhances the quality ofprenatal care but also can influence the extent to whichwomen adhere to professional recommendations.DiscussionThe study findings provide information on the impor-tant elements of quality prenatal care as described bywomen and care providers, which reflect the structureof care and clinical and interpersonal care processes.There has been much attention in the literature toaccess to prenatal care, which is one dimension of struc-ture of care. Our findings along with those of otherresearchers [30,31] suggest that convenience of care is akey consideration. This issue has been framed in thecontext of personal costs, including direct dollar costsSword et al. BMC Pregnancy and Childbirth 2012, 12:29http://www.biomedcentral.com/1471-2393/12/29Page 14 of 18(e.g., transportation costs) and costs of time (e.g., timeaway from work/school, travel time) [32]. We also deter-mined that appointment flexibility, ready access to careproviders by telephone, and access to educationalresources are important in the provision of quality care.Physical characteristics of the care setting deemed tobe important to quality prenatal care identified by studyparticipants have been reported in other studies. Forinstance, Proctor [30] found that cleanliness and home-like surroundings were quality indicators and in a studyof group prenatal care privacy was identified as an issueby some women [33]. Staff characteristics also werenoted to be elements of quality care. Women study par-ticipants commented on the importance of office staffwho are pleasant and other research suggests that rudetreatment by staff can negatively influence a woman’sdesire to return for appointments [34]. While bothwomen and care providers remarked on the importanceof a care provider’s clinical knowledge, women addition-ally valued the knowledge and understanding practi-tioners gained through personal experiences withpregnancy and childbirth.Clinical care processes and interpersonal care pro-cesses emerged as being most essential to quality care asdiscussions of these elements of care were far more pro-minent than discussions of structure of care in the inter-views with both women and prenatal care providers.Care providers spoke of screening and assessment, aclinical care process, in terms of guideline adherence toensure better perinatal outcomes. This perspective iscongruent with discussions of the role of evidence-basedcare and guidelines in promoting quality prenatal care[12,13]. For women, these medical aspects of care pro-vided reassurance about their health and their baby’shealth. Health promotion and illness prevention, includ-ing attention to risk factors, also emerged as compo-nents of quality care and are explicitly addressed inprenatal care guidelines [35-38].Some of the other clinical care processes identified inthe study have been identified previously in the researchliterature. For instance, the importance of sharing ofinformation is captured in findings that women appreci-ate being offered information by clinicians [30,39], beingkept well informed [40], and having their questionsanswered [41]. The importance of continuity of careprovider also has been highlighted in a number of stu-dies [30,39,42,43] and relates to women wanting clini-cians to know them and to remember them from onevisit to the next [40,42]. When women see more thanone care provider, we found that sharing of informationwas valued as it facilitated a smooth transition. Someprenatal care guidelines specifically address continuity ofcare [35-37].Sensitivity to women’s life contexts or circumstances,an essential element of women-centred care, has beenidentified in other research [41,44] as has women’sactive involvement in decision making [30,45]. Profes-sional guidelines often refer to a woman’s right toinformed choice. By way of example, the NICE guidelinefor antenatal care explicitly addresses informed decisionmaking in stating that “pregnant women should beoffered information based on the current available evi-dence together with support to enable them to makeinformed decisions about their care” (p. 12) [36].Another key feature of women-centred care, persona-lized care, also has been noted in several studies[34,40,41]. Consideration of each woman’s unique situa-tion and needs provides opportunity for early interven-tion, particularly for risk factors associated with adverselife circumstances and socioeconomic conditions.We additionally found that non-medicalization of awoman’s pregnancy was a feature of quality care. In astudy of group prenatal care, women appreciated that theirpregnancy-related changes and fears were normalized [33].Medicalization has transformed pregnancy and childbirthinto an illness where there is an assumption of risk to fetaland maternal health that becomes the focus of prenatalcare [46]. However, this orientation has been criticizedbecause it creates dependency on medical care, undermineswomen’s rights to autonomy, and minimizes the relevanceof women’s life contexts [46,47]. It therefore is not surpris-ing that non-medicalization of pregnancy emerged as acomponent of quality care as many elements of qualityidentified in our study respond to these criticisms.The interpersonal care processes revealed in our studyas having a role in quality prenatal care includedrespectful attitude and emotional support. The impor-tance of women being treated with respect has beennoted in previous research [30,34,42]. Interestingly, onlyone of the prenatal care guidelines reviewed explicitlyaddresses this issue by stating that women should betreated with consideration and respect, and that therelationship between a woman and her care providershould be characterized by mutual respect [48]. Listen-ing, which is an element of providing emotional support,has been highlighted as essential to quality care in otherstudies [14,30,44]. The value of clinicians who expresscaring is reinforced by a study that found ratings ofantenatal care were higher if care providers were sensi-tive and understanding and women’s concerns weretaken seriously [40]. Caring also is conveyed throughthe expression of concern for and assessment of awoman’s psychosocial well-being [49]. Importantly Shep-pard, Zambrana, and O’Malley [44] identified that lackof caring and insensitive behaviour can deter willingnessto follow advice and return visits.Sword et al. BMC Pregnancy and Childbirth 2012, 12:29http://www.biomedcentral.com/1471-2393/12/29Page 15 of 18The other two dimensions of interpersonal care pro-cesses, approachable interaction style and taking time,have received little attention in the literature. Theimportance of an informal interaction style was identi-fied in a study in which women described their appre-ciation of a clinician’s use of humour [41]. If women areput at ease and feel relaxed, they are more likely toengage with care providers, share information, and parti-cipate in making decisions about their care. Enoughtime with a care provider was identified as a marker ofpatient-centred care in another study of quality of pre-natal care [14], and Davey, Brown, and Bruinsma [40]found that having adequate time with care providerincreased overall care ratings of prenatal care.Having a meaningful relationship with a prenatal careprovider may be fundamental to quality care, and isinextricably linked with characteristics of the prenatalcare provider and clinical and interpersonal care pro-cesses. In an integrated review of the literature onwomen’s experiences of prenatal care, Novick [50] com-mented that the topic of relationships was discussed inthe majority of studies, which further highlights its cen-trality to quality care. The notion of trust in the careprovider was predominant in our participants’ referencesto a meaningful relationship. Trust has been identifiedas a key indicator of quality in the patient-provider rela-tionship, and having a trusting relationship with a careprovider increases the likelihood that professional advicewill be followed [44].The strengths of this study are its exploration of qual-ity of prenatal care across different settings, populationsof women, and care providers. The large sample size of40 women and 40 care providers ensured that we cap-tured a broad range of perspectives and data saturationwas achieved. Interviewer training included orientationto the study and its conceptual framework as well aspractice interviews. Additionally, the transcripts of initialinterviews were reviewed by the principal investigatorand research coordinator, with feedback subsequentlydiscussed with each research assistant. Strategies wereput in place to ensure rigor of the analytic process andhence validity of the study findings. Study limitationsrelate mainly to the sample in that most of the womenhad been born in Canada, spoke English at home, andhad a university degree; however, these characteristicsdo reflect the majority of women in Canada who haverecently given birth [51]. Most of care providers werefemale, and there was an over-representation of mid-wives and an under-representation of obstetricians inthe sample.While intended to inform the development of itemsfor the Quality of Prenatal Care Questionnaire, thestudy findings also provide direction for the planningand delivery of prenatal care. As noted, the findingsreflect a number of the published prenatal care guide-lines and, in particular, resonate with the CanadianFamily-Centred Maternity and Newborn Care: NationalGuidelines [37]. These national guidelines recommendthat: pregnancy be considered a state of health; womenbe valued and respected; the relationship between awoman and her care provider be consultative and inter-active; and care providers facilitate informed decisionmaking. Our study findings also are congruent withother aspects of these guidelines that address the impor-tance of access to care, accommodation of a woman’spersonal support system, continuity of care, screeningand assessment, and health promotion counseling.Putting many of the elements of quality prenatal careinto practice requires clinician time. However, fee-for-service models are disincentives to spending time withpregnant women. Moreover, in Canada the relativelyfew family physicians who offer maternity care com-bined with the low number of registered midwives putspressure on obstetricians to provide care to both low-and high-risk pregnant women [52,53]. Collaborativemodels of care may be the answer not only to improvingaccess to primary maternity care in Canada but also toenhancing the quality of prenatal care women receive[54]. Increasing access to midwifery care, which inte-grates many of the essential components of quality carebecause it is women-centred, embraces shared decisionmaking, and incorporates emotional care [46], also mayserve to promote quality prenatal care.The findings of this study will be used to identify spe-cific items for the Quality of Prenatal Care Question-naire. Following the generation of a preliminary list ofitems, standard approaches to item reduction and valid-ity and reliability testing will be used. If determined tohave acceptable psychometric properties, the question-naire can be used in future studies designed to exploredifferent models of prenatal care and the ways in whichthey might enhance the quality of care women receive.Group prenatal care, as one alternative model, showspromise in delivering quality care and in influencingpositive outcomes [7,33]. The Quality of Prenatal CareQuestionnaire can be used in a variety of other studies.Research is needed to examine disparities in quality ofcare as studies have suggested it may vary for differentpopulations of women. Wheatley and colleagues [14],for instance, found that low-income primiparous womenhad numerous negative experiences related to specificmarkers of patient-centredness: listened carefully,explained things, showed respect, and spent enoughtime. Studies of the ways in which quality of prenatalcare varies by care provider also are warranted. Finally,research should examine the impact of quality care on abroad variety of maternal and infant outcomes and onfuture health service utilization. Preliminary evidenceSword et al. BMC Pregnancy and Childbirth 2012, 12:29http://www.biomedcentral.com/1471-2393/12/29Page 16 of 18suggests the importance of specific dimensions of qual-ity care, such as attention to lifestyle risk factors, ade-quate time with a care provider, and relationship-centredness, in improving maternal and infant health[4-7].ConclusionsQuality prenatal care is multidimensional and encom-passes structure of care, clinical care processes, andinterpersonal care processes. The study findings suggestthe need to focus on more than the biomedical aspectsof care and attend to elements of prenatal care that fos-ter a meaningful relationship between a woman and herprenatal care provider. The promotion of quality prena-tal care in clinical practice has implications for thetraining of current and future health professionals, thestructure of care delivery, provider reimbursement sche-dules, and policy development. While optimizing thequality of prenatal care is not without its challenges, aninvestment in quality care has the potential to enhancethe health of pregnant women and reduce the risk ofadverse perinatal outcomes.AcknowledgementsWe thank the research coordinator, Amanda Bradford-Janke, the siteresearch assistants, and our collaborators for their contributions to the study:Melanie Basso, Laurie Blahitka, Pat Gregory, Linda Tjaden, Jackie Barrett,Glenda Carson, and Kate Lively.The Canadian Institutes of Health Research (CIHR) provided funding for thisresearch (MOP - 84427). Dr. Maureen Heaman is supported by a CIHR Chairin Gender and Health. Dr. Dawn Kingston was a post-doctoral fellow fundedby this CIHR Chair.Author details1School of Nursing and Department of Clinical Epidemiology andBiostatistics, Faculty of Health Sciences, McMaster University, 1280 MainStreet West, Hamilton, Ontario L8S 4K1, Canada. 2Faculty of Nursing,University of Manitoba, 89 Curry Place, Winnipeg, Manitoba R3T 2N2,Canada. 3School of Nursing, Faculty of Health Sciences, McMaster University,1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada. 4Department ofPaediatrics and Community Health Sciences, Faculty of Medicine, Universityof Calgary and Alberta Centre for Child, Family and Community Research,2888 Shaganappi Trail NW, Calgary, Alberta T3B 6A8, Canada. 5School ofPopulation and Public Health, University of British Columbia, 2206 East Mall,Vancouver, British Columbia V6T 3Z1, Canada. 6IWK Health Centre andDepartment of Obstetrics and Gynecology, Faculty of Medicine, DalhousieUniversity, 5980 University Avenue, P.O. Box 9700, Halifax, Nova Scotia B3K6R8, Canada. 7Faculty of Nursing, University of Alberta, 5-258 EdmontonClinic Health Academy, 11405-87th Avenue, Edmonton, Alberta T6G 1C9,Canada. 8St. Boniface General Hospital and Department of Obstetrics,Gynecology and Reproductive Sciences, Faculty of Medicine, University ofManitoba, 409 Tache Avenue, Winnipeg, Manitoba R2H 2A6, Canada. 9Schoolof Nursing and Department of Clinical Epidemiology and Biostatistics,Faculty of Health Sciences, McMaster University, 1280 Main Street West,Hamilton, Ontario L8S 4K1, Canada. 10Department of Obstetrics andGynecology and Department of Clinical Epidemiology and Biostatistics,Faculty of Health Sciences, McMaster University, 1280 Main Street West,Hamilton, Ontario L8S 4K1, Canada.Authors’ contributionsWS and MIH wrote the grant application, directed the implementation ofthe study protocol, and had overall responsibility for the research. ST, PAJ,DY, DK, MEH, NAD, and EH contributed to the development of the studydesign and grant application. WS, MIH, ST, PAJ, and DY supervisedparticipant recruitment and data collection in their respective settings. WS,SB, and MIH analyzed the qualitative data. WS and SB drafted themanuscript. All authors provided feedback on the draft manuscript, and readand approved the final manuscript prepared by WS.Competing interestsThe authors declare that they have no competing interests.Received: 9 November 2011 Accepted: 13 April 2012Published: 13 April 2012References1. Alexander GR, Kotelchuck M: Assessing the role and effectiveness ofprenatal care: history, challenges, and directions for future research.Public Health Rep 2001, 116(4):306-316.2. Zanconato G, Msolomba R, Guarenti L, Franchi M: Antenatal care indeveloping countries: the need for a tailored model. Semin FetalNeonatal Med 2006, 11(1):15-20.3. 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Smeenk AD, ten Have HA: Medicalization and obstetric care: an analysisof developments in Dutch midwifery. Med Health Care Philos 2003,6(2):153-165.48. The Royal Australian and New Zealand College of Obstetricians andGynaecologists: Obstetrician and childbirth: responsibilites (C-Obs1). 2010[http://www.ranzcog.edu.au/the-ranzcog/policies-and-guidelines/college-statements/254-obstetricians-childbirth-responsibilities-c-obs1.html].49. Matthey S, White T, Phillips J, Taouk R, Chee TT, Barnett B: Acceptability ofroutine antenatal psychosocial assessments to women from English andnon-English speaking backgrounds. Arch Women’s Ment Health 2005,8(3):171-180.50. Novick G: Women’s experience of prenatal care: an integrative review. JMidwifery Womens Health 2009, 54(3):226-237.51. Public Health Agency of Canada: What Mothers Say: The CanadianMaternity Experiences Survey. 2009 [http://www.phac-aspc.gc.ca/rhs-ssg/pdf/survey-eng.pdf].52. British Columbia Centre of Excellence for Women’s Health: Solving thematernity care crisis. Making the way for midwifery’s contribution. 2003[http://www.bccewh.bc.ca/publications-resources/documents/solvingmaternitycarecrisis.pdf].53. Canadian Institute for Health Information: Giving birth in Canada:providers of maternity and infant care. Ottawa, Canada: Canadian Institutefor Health Information; 2004.54. Anderson M: Focus group report. Guidelines for model development.Discussion paper prepared for The Multidisciplinary CollaborativePrimary Maternity Care Project. Ottawa, Canada; 2005 [http://www.mcp2.ca/english/documents/FinalFocGrpRept22May05.pdf].Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2393/12/29/prepubdoi:10.1186/1471-2393-12-29Cite this article as: Sword et al.: Women’s and care providers’perspectives of quality prenatal care: a qualitative descriptive study. BMCPregnancy and Childbirth 2012 12:29.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/submitSword et al. BMC Pregnancy and Childbirth 2012, 12:29http://www.biomedcentral.com/1471-2393/12/29Page 18 of 18


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