Prenatal care has become one of the most widely used preventive healthcare services in developed countries.1,2 Broadly defined, it encompasses “the detection, treatment, or prevention of adverse maternal, foetal, and infant outcomes as well as interventions to address psychosocial stress, detrimental health behaviors such as substance abuse, and adverse socioeconomic conditions” (p.116).1 There is no agreement, however, as to what constitutes quality prenatal care. The list of nine indicators of quality prenatal care developed by a working group of the Royal College of Obstetricians and Gynaecologists reflect very defined medical aspects of care (e.g., Rhesus antibody screening, detection of and use of external cephalic version for breech presentation, steroid administration in preterm delivery).11 Adherence to evidence-based clinical practice guidelines that are both applicable to the population of childbearing women and to midwifery practice has been suggested as a strategy to maintain quality in antenatal care delivered by midwives.12
There is evidence that engagement in prenatal care is predictive of future use of preventive health services, including things like well-child care.15
The purpose of this article is to describe women’s and prenatal care providers’ perspectives of quality prenatal care. In doing so, the research adds to our understanding of specific dimensions of prenatal care that ultimately might contribute to healthy outcomes for women and their infant. We received ethics approval for this study from Hamilton Health Sciences/McMaster University Faculty of Health Sciences Research Ethics Board and the ethics committee responsible for the conduct of research at each participating site.
A qualitative descriptive exploratory design was used to understand women’s and care providers’ perspectives of quality prenatal care. As noted by Sandelowski,16 qualitative description is especially useful in obtaining straight descriptive answers to questions of special relevance to practitioners and policy makers. The conceptual framework that guided the study was derived from Donabedian’s17 systems-based model of quality healthcare. It encompasses three aspects of care: structure, processes, and outcomes. Structure refers to attributes of the setting in which healthcare is delivered and received, and the domains of care structure include physical setting and staff characteristics.17,18 Outcomes, including patient satisfaction, are a consequence rather than a component of care and may be directly or indirectly influenced by the structure and processes of care.17,18
Sample and recruitment
Study participants were recruited from five urban centres across Canada: Vancouver, Calgary, Winnipeg, Hamilton, and Halifax. Purposeful maximum variation sampling was used to select informants that would provide a broad range of perspectives, thereby creating an in-depth understanding of important dimensions of quality prenatal care.19,20 Women were eligible to participate in the study if they were in the late third trimester of pregnancy (≥32 weeks), ≥16 years of age, and able to read and write English. Women were recruited from a variety of settings offering prenatal services (e.g., maternity clinics, hospital prebirth registration clinics, public health programmes). Staff at each setting assisted in identifying potential study participants; women deemed eligible were given a study information letter and, if interested, gave signed permission to have their names forwarded to the site research assistant. Prenatal care providers, including obstetricians, family physicians, midwives and nurses, were eligible to participate if they had practised in obstetrics/maternity care for a minimum of two years. We tried to ensure diversity in characteristics such as profession, length of time in practice, type of practice (solo vs. group), and place of practice (urban vs. rural setting).
A semi-structured interview was conducted by a trained research assistant with each study participant at a location of their choice. Signed informed consent was obtained prior to the start of data collection. An interview guide informed by Donabedian’s17 model was used. The guide included an opening question, “What does quality prenatal care mean to you?” Then a number of questions were posed asking about structural aspects, clinical care processes, and interpersonal care processes perceived to contribute to quality care. Probes for each question were identified to promote consistency in data collection across study sites and participants. Women took part in a face-to-face interview late in the third trimester of pregnancy and a second interview was conducted by telephone approximately four weeks after they had given birth. Care providers participated in a single face-to-face interview. All interviews were digitally recorded and transcribed verbatim. A brief sociodemographic questionnaire was administered at the end of the interview to collect background information on study participants. Women were given a $20 gift card in appreciation for their time and contribution to the study.
The qualitative data were managed and analysed using NVivo 7. We began the analysis using an inductive approach. The transcripts initially were read in full, with analysis then proceeding using open coding techniques whereby each meaningful segment of text was assigned a conceptual code.21,22 Through comparative analysis, the same codes were assigned to data with common characteristics.22 As the open codes became saturated, the analysis evolved to pattern coding whereby specific dimensions of quality prenatal care were identified.21 Finally, a deductive approach was used to assign the emergent themes to broader categories that reflected Donebedian’s model17 and its further elaboration by Campbell, Roland, and Buetow.18 The quantitative background data were entered into and analysed using SPSS.17 Descriptive statistics were used to summarise the data collected from all women and prenatal care providers.
Data were reorganised as the coding scheme progressed and all themes were firmly grounded in the data.23,24 Memos were kept about coding decisions along with copies of evolving coding schemes.25
We recruited eight pregnant women and eight prenatal care providers from each of the five study sites, for a total of 80 participants. Five women (12.5%) reported they had experienced a pregnancy complication and eight (20%) had a physical or mental chronic health problem. Twenty-four women (60.0%) had seen an obstetrician for prenatal care, 21 (52.5%) had seen a family physician, and seven (17.5%) had seen a midwife; 30.0% (n = 12) reported receiving care from more than one type of provider. Of the prenatal care providers interviewed, 14 (35.0%) were midwives, 12 (30.0%) were family physicians, eight (20%) were obstetricians, and six (15.0%) were nurses/nurse practitioners. The majority (78.0%) of care providers was practising full-time and most were female (80.0%). The mean number of years in practice was 16.1 years (SD 11.8).
In presenting the findings, we use quotes for illustrative purposes. The source of each quote is identified, with “W” and “PCP” being used along with study site and participant numbers for women and prenatal care providers, respectively.
Structure of care
Structure of care reflects the attributes of the care setting that contribute to the quality of care. The themes include access, physical setting, and staff and care provider characteristics.
Access is defined as “the potential ability of women to enter prenatal care services and maintain care for herself and foetus during the perinatal period” (p. 220).26 According to study, participants’ access includes being able to begin prenatal care as early as possible with a health care provider of the woman’s choice. Access also encompasses having care available in locations that are convenient to women’s homes or places of work, close to bus routes, and with adequate free or inexpensive parking.
Ease of scheduling appointments and office or clinic hours that are flexible enough to accommodate women’s personal 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 of abilities to organise their lives and get to appointments and follow through on stuff. So I think to have some flexibility around how you offer them care is really important, and I must say we’re probably way more flexible with our prenatal patients and our new mums. … It doesn’t matter if they show up late, it doesn’t matter if they miss three appointments in a row. They’re not penalised for that, because you’re really trying to hold on to that relationship and, and build on it as opposed to sending them the little letter about ‘one more no-show, you’re out of here’.” (PCP04-08)
They identified that they often had concerns or questions they felt either were too serious to wait until their next prenatal care visit or did not warrant a visit. Having telephone access to the care provider or staff and having phone messages returned promptly were identified as important in reducing anxiety and feeling cared for. Women extended the notion of access to include access to educational resources. Ready availability of a variety of pregnancy-related educational materials such as books, pamphlets, and videos was another important component of quality care as reflected in this statement.
Women described several physical features of the setting in which they received prenatal care that contribute to its quality, including cleanliness, aesthetics, and privacy. They noted that the latter was particularly vital when providing urine samples and communicating with their prenatal care providers. One woman remarked on the importance of discussions that cannot be overheard by others as follows:
“Privacy … I wouldn’t want to be sitting in the waiting room listening to a doctor speak with a patient. So it’s reassuring to me to know that if I can’t hear him talking to someone then nobody can hear him talking to me.” (W05-01)
Prenatal care providers similarly recognised the importance of privacy.
Having the right type of seating was important as it was noted that pregnant women often have back problems and thus find it difficult to find comfortable seating.Women desired a “welcoming” environment and often described family physicians’ or obstetricians’ offices as “medical” and “clinical” whereas those of midwives were described in more favourable terms.
Staff and care provider characteristics
Women discussed how the characteristics of staff who work in prenatal care settings contribute to its quality, including the temperament and personality of office staff. Staff who were pleasant, greeted patients by name, and were efficient had a positive impact on how women viewed their care.
Many women suggested that a prenatal care provider’s clinical expertise is enhanced by having personal knowledge of pregnancy and childbirth. One participant explained:
“I feel like I can relate with them, and they have some kind of vast experience. … You always feel more comfortable with the person with more experience. And I feel that [prenatal care providers] have a lot of experience, especially because they have children of their own.” (W02-08)
Clinical care processes
Clinical care processes denote the application of clinical medicine and knowledge-based care.18 We expanded this definition to include a patient-oriented approach to care with active involvement of women in their own prenatal care. The themes for clinical care processes are: health promotion and illness prevention; screening and assessment; information sharing; continuity of care; non-medicalisation of pregnancy; and women-centredness.
Health promotion and illness prevention
Women and prenatal care providers identified the importance of health promotion advice to encourage a healthy lifestyle. Counseling about nutrition and appropriate weight gain was identified as an essential component of quality prenatal care.
Some care providers spoke about assessing social risks to health and linking women to appropriate resources in their communities. As a family physician stated:
“[Women] might bring up that they’ve got some anxiety or whatever. And I just like to make sure I delve into that, because you uncover things like physical violence and financial issues. … I think if you take the time to ask those, like a few questions about how things are going in life, and get a sense of where people live and how they’re living, you do pick up on a lot of those extra things. … And we can give them places where they can go get support for that … making sure you get social workers involved appropriately, especially if you’re a woman at risk of physical violence.” (PCP02-05)
Screening and assessment
Both women and health care providers discussed the value of screening and assessment as part of quality prenatal care. Women talked primarily about tests and measurements that provided reassurance the pregnancy and foetal development were progressing normally.
Prenatal care providers highlighted the importance of following guidelines for screening in pregnancy to ensure better outcomes for mothers and babies. Healthcare providers also discussed the importance of screening and assessment related to psychosocial health. Screening and assessment were identified as being essential as a first step in ensuring women receive appropriate care, not only for mental health problems, but also for physical health concerns that develop during pregnancy.
Sharing of information
The sharing of information by healthcare providers was identified as a key aspect of quality prenatal care, particularly by women. When asked what aspects of prenatal care were important to her, one woman replied:
“I believe it’s the way they involve you, and the way they tell you everything that’s going on. So there’s no secrets, there’s no mysteries, there’s no secret codes or anything like that that you don’t understand. … It makes you feel like you are totally in the loop and you know just as much as the doctors know. … And it makes you more confident, and more prepared, and just feels good to know everything that’s going on.” (W02-06)
Continuity of care
Many women explained that receiving care from the same healthcare provider throughout the pregnancy was a feature of quality care. Some noted that this allowed the health care provider to be familiar with and effectively monitor their pregnancies. One woman who experienced several care providers explained:
“I see almost six doctors. … Every week I saw different doctors. … When you go and see different doctors maybe they didn’t know our progress. … When you have some problem it’s necessary to clarify all this for all new doctors. … It’s better to see one specific doctor all the time, because they see everything, our progress and otherwise if I saw every doctor, every different doctor – it’s not good, I think. You get to know them better. And if you have issues from one, you know, week to the next, you can say, ‘Well, how are your feet today?’ or ‘How are your hands today?’ and ‘Do you have any other symptoms?’ … It’s all about just continuity and rapport, relationship. (W02-01)
Other women elaborated on how having a consistent care provider throughout the pregnancy contributed to the development of a positive relationship. When women had different prenatal care providers during their pregnancies, they identified a smooth transition between care providers and timely, efficient sharing of information as important factors in continuity of their care.
Non-medicalisation of pregnancy
A recurring theme in the study was the importance of not treating pregnancy as a disease or medical condition, but as a normal process.
Several women expressed a preference for receiving care from a midwife, because it felt less medically-oriented than care provided by physicians. Some health care providers, particularly midwives, also identified the importance of not treating pregnancy as a medical condition. A midwife emphatically stated:
“Pregnancy – pregnancy is not a disease [banging on table]. Pregnancy is a normal physiological state. Women become pregnant and you shouldn’t make a pathology out of it. It’s not an indication to stop work. Pregnancy is a condition of moderation. You want to exercise, you exercise. If you are a skier, ski but maybe stay off the black double diamonds and do the nice blues and do something that you’re comfortable with. Don’t get over tired and I think that that’s fine. But a lot of people try to make pregnancy a disease and it really isn’t.” (PCP05-03)
Women-centredness emerged as a salient attribute of quality prenatal care from the perspective of both women and health care professionals. Key principles of women-centred care are that it situates care within women’s life contexts, acknowledges the social determinants of health, and positions women as active partners in their care rather than as passive recipient.27
Some prenatal care providers spoke specifically about the need to attend to priorities created by women’s life circumstances as reflected in this family physician’s comment:
“… We tailor the education and health promotion to suit the woman’s particular chapter in the life she’s in right now. For example, a woman is leading a devastated life, isn’t quite sure where she’s going to sleep at night. Now is not a good time to talk about quitting smoking. Her priority is safety and things like that.” (PCP03-03)
Consideration of women’s life circumstances extended to allowing women to choose to include significant others, such as partners or other family members, in their prenatal care.
Health care providers were in agreement that giving women information and allowing them to make informed decisions was important. (PCP01-04)
Another midwife explained how involving women in decision making throughout their care engenders trust in a care provider when s/he needs to be more directive:
“Trust needs to be built, because here I am bringing somebody in saying, ‘You have some responsibility in your care. I’ll help you make decisions and I’ll give you the education you need. And of course I see myself as having played a huge role, because I’m the care provider, but you have a responsibility to go home and read and educate yourself about whatever it is I’m talking about. And then we’ll make the decision together. But you’re the one who’s really making it in the end. You’re running the show.’ And so, in order for them to actually trust themselves to do that, they have to trust me first, that I’m going to be able to say to them, ‘Well, I hear you that you want to have a home birth with your triplets that are all breech, but actually that’s probably, in my opinion, not the best idea.’” (PCP01-08)
Interpersonal care processes
Interpersonal care processes reflect the psychosocial aspects of interactions between prenatal care providers and the women to whom they provide care. The themes are respectful attitude, emotional support, approachable interaction style, and taking time.
According to study participants quality prenatal care involves a respectful regard for women as care recipients. Women expressed a desire for care providers who are non-judgmental and who therefore are easy to talk to. In one woman’s words:
“She’s very easy to talk to. Just like talking to a friend, she doesn’t seem to judge you or anything. It’s easy for me to open up, especially when I had troubles talking to doctors. Well, I thought I had troubles talking to doctors.” (W03-01)
Several women specifically noted the importance of their prenatal care providers not minimising their concerns or making them feel foolish when asking questions. One woman described her experience as follows:
“I guess one of my worries was that sometimes, because [the care provider] sees so many pregnant people, she might downplay my concerns. And I think that would make me feel uncomfortable and reluctant to share some of my feelings. And that hasn’t been the case, and I definitely felt like I can call or bring up these concerns and to not feel stupid about it. So that’s been, I think, good at relieving my stress about the whole experience.” (W01-05)
Some health care providers spoke of the importance of offering services in a culturally sensitive manner.
What emerged as one of the most essential features of quality prenatal care was the provision of emotional support, which is conveyed through behaviours such as listening, expression of caring and concern, acknowledgement of feelings, and reflective understanding.28 Women also spoke of needing to feel that they and their pregnancies were important to their care providers. For one study participant, this was conveyed through a family physician’s understanding of the significance to her of hearing the baby’s heart beat:
“I met a doctor there and he was just so warm and fantastic, and I was almost eight weeks pregnant and hadn’t heard the heart beat or anything yet. And he said, ‘Hey, let’s listen to the heart beat. Go grab your husband from the waiting room.’ And it was just incredible, because I thought, ‘Oh my god! We’re gonna hear the heart beat!’ And it’s your first pregnancy, and he went above and beyond. … He was just really warm and exactly what you want in a pre-natal care provider.” (W02-07)
Women wanted “to just feel cared for” and have reassurance from their prenatal care providers throughout their pregnancies that their babies’ development and pregnancies were progressing normally.
Approachable interaction style
Interaction style refers to behaviours that characterise the manner in which healthcare providers carry out their responsibilities.29 Several women commented that it is important for their prenatal care providers to be calm and relaxed as this reportedly helps to reassure women and to engender confidence in the care provider. Additionally, these characteristics made care providers “approachable” in that women felt comfortable asking questions. As another woman expressed:
“I have an excellent relationship. I really like my obstetrician. … She’s fairly laid back and she doesn’t make me feel uncomfortable or nervous about asking all the questions that I have and I feel very confident in her experience.” (W05-07)
Healthcare providers also acknowledged the need for a calm and relaxed demeanor.
When prenatal care providers appeared to be in a hurry, some women reported they did not have adequate opportunity to formulate questions, as captured in this remark:
“My expectation would be that of course, the doctor would just ask, well they do ask, ‘Do you have any questions?’And usually the answer is, ‘I don’t know yet.’ And as soon as you don’t answer within two seconds: ‘Okay, see you next week.’ Maybe it would be nice if the doctor would at least wait ten seconds to give me a chance to formulate my question. Sometimes what I do, in the past, was have a list of questions and then go there. But then they’re not happy because there’s ten questions, which is using up all their time. I feel a little bit guilty, having too many questions.” (W01-08)
A number of women identified a difference in the amount of time spent with midwives compared to that spent with physicians. Many of the women stated a preference for midwives because of the length of each appointment.
A recurrent theme throughout the interviews that cut across all three categories reflects what may be the very essence of quality prenatal care, a meaningful relationship between the care provider and the expectant mother.
Having a meaningful relationship with a care provider also contributes to women’s comfort in asking questions and becoming involved in directing their care. As one woman recounted:
“I didn’t know [the obstetrician] very well, so you’re walking in and it almost feels like a stranger, because it’s the reality – you’re meeting for the first time. … I didn’t say very much. … And then you start to build the relationship and that’s where the difference is. And he was a great man, to be honest with you. He comes up to me with a smile all the time so, and he knows me by my first name. It does help you build that relationship. … And seeing and having all that information [on warning signs] made me ask the questions that I needed to ask in order to have the proper information.” (W04-01)
Study participants, both women and care providers, acknowledged that a meaningful relationship makes it more likely that a woman will accept guidance and health-related advice. One family physician commented:
“You have to find the right time to talk about [smoking] too, and I think sometimes you have to develop a relationship first before you start saying ‘You know this and I know this, but is there any way we can help you reduce your smoking?’ Rather than walking in the room the first visit with your finger pointing, ‘I see you’re smoking, don’t you know that’s bad for your baby and do you want to have a healthy baby or do you want to have a baby with cancer and asthma?’… Not good bridge-building.” (PCP03-03)
The study findings provide information on the important elements of quality prenatal care as described by women and care providers, which reflect the structure of care, and clinical and interpersonal care processes. There has been much attention in the literature to access to prenatal care, which is one dimension of structure of care. Our findings along with those of other researchers30,31 suggest that convenience of care is a key consideration. This issue has been framed in the context of personal costs, including direct dollar costs (e.g., transportation costs) and costs of time (e.g., time away from work/school, travel time).32 Sensitivity to women’s life contexts or circumstances, an essential element of women-centred care, has been identified in other research41,44 as has women’s active involvement in decision making.30,45 Professional guidelines often refer to a woman’s right to informed choice. By way of example, the NICE guideline for antenatal care explicitly addresses informed decision making in stating that “pregnant women should be offered information based on the current available evidence together with support to enable them to make informed decisions about their care” (p. 12).36 Another key feature of women-centred care, personalised care, also has been noted in several studies.34,40,41 Consideration of each woman’s unique situation and needs provides opportunity for early intervention, particularly for risk factors associated with adverse life circumstances and socioeconomic conditions.
The interpersonal care processes revealed in our study as having a role in quality prenatal care included respectful attitude and emotional support. The importance of women being treated with respect has been noted in previous research.30,34,42 The other two dimensions of interpersonal care processes, approachable interaction style and taking time, have received little attention in the literature. The importance of an informal interaction style was identified in a study in which women described their appreciation of a clinician’s use of humour.41 If women are put at ease and feel relaxed, they are more likely to engage with care providers, share information, and participate in making decisions about their care. Enough time with a care provider was identified as a marker of patient-centred care in another study of quality of prenatal care,14 and Davey, Brown, and Bruinsma40 found that having adequate time with care provider increased overall care ratings of prenatal care.
Having a meaningful relationship with a prenatal care provider may be fundamental to quality care, and is inextricably linked with characteristics of the prenatal care provider and clinical and interpersonal care processes. In an integrated review of the literature on women’s experiences of prenatal care, Novick50 commented that the topic of relationships was discussed in the majority of studies, which further highlights its centrality to quality care. The notion of trust in the care provider was predominant in our participants’ references to a meaningful relationship. Trust has been identified as a key indicator of quality in the patient-provider relationship, and having a trusting relationship with a care provider increases the likelihood that professional advice will be thoroughly followed.44
Quality prenatal care is multidimensional and encompasses structure of care, clinical care processes, and interpersonal care processes. The study findings suggest the need to focus on more than the biomedical aspects of care and attend to elements of prenatal care that foster a meaningful relationship between a woman and her prenatal care provider. The promotion of quality prenatal care in clinical practice has implications for the training of current and future health professionals, the structure of care delivery, provider reimbursement schedules, and policy development. While optimising the quality of prenatal care is not without its challenges, an investment in quality care has the potential to enhance the health of pregnant women and reduce the risk of adverse perinatal outcomes.
The Canadian Institutes of Health Research (CIHR) provided funding for this research (MOP – 84427). Dr. Maureen Heaman is supported by a CIHR Chair in Gender and Health. Dr. Dawn Kingston was a post-doctoral fellow funded by this CIHR Chair.
- Alexander GR, Kotelchuck M: Assessing the role and effectiveness of prenatal care: history, challenges, and directions for future research. Public Health Rep 2001, 116(4):306–316.
- Zanconato G, Msolomba R, Guarenti L, Franchi M: Antenatal care in developing countries: the need for a tailored model. Semin Fetal Neonatal Med 2006, 11(1):15–20.
- Kotelchuck M: An evaluation of the Kessner Adequacy of Prenatal Care Index and a proposed Adequacy of Prenatal Care Utilization Index. Am J Public Health 1994, 84(9):1414–1420.
- Ricketts SA, Murray EK, Schwalberg R: Reducing low birth weight by resolving risks: results from Colorado’s prenatal plus program. Am J Public Health 2005, 95(11):1952– 1957.
- Vonderheid SC, Norr KF, Handler AS: Prenatal health promotion content and health behaviors. West J Nurs Res 2007, 29(3):258–276.
- Massey Z, Rising SS, Ickovics J: Centering Pregnancy group prenatal care: promoting relationship-centered care. JOGNN 2006, 35(2):286–294.
- Ickovics JR, Kershaw TS, Westdahl C, Magriples U, Massey Z, Reynolds H, Rising SS: Group prenatal care and perinatal outcomes: a randomized controlled trial. Obstet Gynecol 2007, 110(2 Pt 1):330–339.
- Walker DS, McCully L, Vest V: Evidence-based prenatal care visits: when less is more. J Midwifery Womens Health 2001, 46(3):146–151.
- United States Public Health Service Expert Panel on the Content of Prenatal Care: Caring for our future: the content of prenatal care. Washington, DC: US Department of Health and Human Services; 1989.
- Walker DS, Rising SS: Revolutionizing prenatal care: new evidence-based prenatal care delivery models. JN Y State Nurses Assoc 2004, 35(2):18–21.
- Vause S, Maresh M: Indicators of quality of antenatal care: a pilot study. BJOG 1999, 106(3):197–205.
- Tillett J: Developing guidelines and maintaining quality in antenatal care. J Midwifery Womens Health 2009, 54(3):238–240.
- Kirkham C, Harris S, Grzybowski S: Evidence-based prenatal care: Part I. General prenatal care and counseling issues. Am Fam Physician 2005, 71(7):1307–1316.
Editorial note: This article and cited references have been truncated. Please read the full length article online for the complete list