Background
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.
Methods
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).
Data collection
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.
Data analysis
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
Results
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; 3