Women's and Care Providers' Views of Quality Prenatal Care
Women's and Care Providers' Views of Quality Prenatal Care
Prenatal care has become one of the most widely used preventive health care services in developed countries. Broadly defined, it encompasses "the detection, treatment, or prevention of adverse maternal, fetal, and infant outcomes as well as interventions to address psychosocial stress, detrimental health behaviors such as substance abuse, and adverse socioeconomic conditions." Much attention has been given to the adequacy of prenatal care use in mitigating poor outcomes for women and their infants. Adequacy of utilization has been conceptualized as consisting of two dimensions: the timing of initiation of prenatal care and the number of prenatal visits, taking gestational age at entry into care and at delivery into consideration. As noted by Kotelchuck, adequacy does not take into account the content or quality of care that is delivered but rather focuses only on quantifying its use.
There is emerging evidence that the quality of prenatal care, i.e., what is actually done during the giving and receiving of care, may be more important than the quantity of care. Ricketts, Murray, and Schwalberg, for instance, found that providing enhanced prenatal care to high-risk women that specifically addressed lifestyle and psychosocial characteristics was effective in resolving risk factors and, subsequently, low birth weight risk. In another study an association was found between the health promotion content of prenatal care received at a low-risk clinic and healthy behaviours in pregnancy, including reduced substance use. Evaluations of Centering Pregnancy, a group model of prenatal care that allows more time with care providers than traditional care and is relationship-centered, suggest its potential effectiveness in reducing negative birth outcomes. A randomized controlled trial of Centering Pregnancy demonstrated improvements in gestational age, maternal psychosocial function, breastfeeding initiation, and satisfaction with care.
In light of this evidence that suggests the importance of quality of care and evidence that reducing the frequency of prenatal visits for low-risk healthy women does not adversely affect maternal or neonatal outcomes, the need for the usual 14 to 16 visits recommended by some professional organizations has been questioned. In fact, a recommended schedule of fewer visits for such women was proposed over 20 years ago by an expert panel of the U.S Public Health Service's Low Birth Weight Prevention Work Group. This recommendation was based on the assumption that high quality care is offered.
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). 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. Kirkham, Harris, and Grzybowski similarly proposed that prenatal care should be based on "the best available evidence" but added that this evidence should be integrated "into a model of informed, shared decision making" (p. 1307). While noting that medical procedures are important, Alexander and Kotelchuck suggested that parameters for assessing quality of prenatal care should take into account the provision of health education, assessment of the need for and referral to ancillary services (e.g., nutrition support, social services), and the nature of patient-provider-system interactions.
Given the wide variation in opinions about the essential elements of quality prenatal care, the inconsistency in approaches to assessing quality of prenatal care in the published literature is not surprising. Research in this area has largely been atheoretical, few studies have considered women's perspectives, and much of the focus has been on medical or clinical aspects of care to the exclusion of interpersonal processes. Moreover, studies seeking to examine the relationships between quality of prenatal care and perinatal outcomes have been hindered by the lack of a theoretically-grounded and psychometrically-tested instrument. To fill this gap we conducted research with the aim of developing and testing an instrument to measure quality of prenatal care, the Quality of Prenatal Care Questionnaire. As a first step in instrument development, semi-structured interviews were conducted with women and prenatal care providers to ascertain their views of quality care. Understanding what patients value is particularly critical in a prenatal care context as engagement of women in care is important for early initiation and continuation of care over a relatively short time period for health promotion, prevention of adverse outcomes, and early identification of and intervention for health risks. Additionally, there is evidence that engagement in prenatal care is predictive of future use of preventive health services, including well-child care.
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.
Background
Prenatal care has become one of the most widely used preventive health care services in developed countries. Broadly defined, it encompasses "the detection, treatment, or prevention of adverse maternal, fetal, and infant outcomes as well as interventions to address psychosocial stress, detrimental health behaviors such as substance abuse, and adverse socioeconomic conditions." Much attention has been given to the adequacy of prenatal care use in mitigating poor outcomes for women and their infants. Adequacy of utilization has been conceptualized as consisting of two dimensions: the timing of initiation of prenatal care and the number of prenatal visits, taking gestational age at entry into care and at delivery into consideration. As noted by Kotelchuck, adequacy does not take into account the content or quality of care that is delivered but rather focuses only on quantifying its use.
There is emerging evidence that the quality of prenatal care, i.e., what is actually done during the giving and receiving of care, may be more important than the quantity of care. Ricketts, Murray, and Schwalberg, for instance, found that providing enhanced prenatal care to high-risk women that specifically addressed lifestyle and psychosocial characteristics was effective in resolving risk factors and, subsequently, low birth weight risk. In another study an association was found between the health promotion content of prenatal care received at a low-risk clinic and healthy behaviours in pregnancy, including reduced substance use. Evaluations of Centering Pregnancy, a group model of prenatal care that allows more time with care providers than traditional care and is relationship-centered, suggest its potential effectiveness in reducing negative birth outcomes. A randomized controlled trial of Centering Pregnancy demonstrated improvements in gestational age, maternal psychosocial function, breastfeeding initiation, and satisfaction with care.
In light of this evidence that suggests the importance of quality of care and evidence that reducing the frequency of prenatal visits for low-risk healthy women does not adversely affect maternal or neonatal outcomes, the need for the usual 14 to 16 visits recommended by some professional organizations has been questioned. In fact, a recommended schedule of fewer visits for such women was proposed over 20 years ago by an expert panel of the U.S Public Health Service's Low Birth Weight Prevention Work Group. This recommendation was based on the assumption that high quality care is offered.
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). 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. Kirkham, Harris, and Grzybowski similarly proposed that prenatal care should be based on "the best available evidence" but added that this evidence should be integrated "into a model of informed, shared decision making" (p. 1307). While noting that medical procedures are important, Alexander and Kotelchuck suggested that parameters for assessing quality of prenatal care should take into account the provision of health education, assessment of the need for and referral to ancillary services (e.g., nutrition support, social services), and the nature of patient-provider-system interactions.
Given the wide variation in opinions about the essential elements of quality prenatal care, the inconsistency in approaches to assessing quality of prenatal care in the published literature is not surprising. Research in this area has largely been atheoretical, few studies have considered women's perspectives, and much of the focus has been on medical or clinical aspects of care to the exclusion of interpersonal processes. Moreover, studies seeking to examine the relationships between quality of prenatal care and perinatal outcomes have been hindered by the lack of a theoretically-grounded and psychometrically-tested instrument. To fill this gap we conducted research with the aim of developing and testing an instrument to measure quality of prenatal care, the Quality of Prenatal Care Questionnaire. As a first step in instrument development, semi-structured interviews were conducted with women and prenatal care providers to ascertain their views of quality care. Understanding what patients value is particularly critical in a prenatal care context as engagement of women in care is important for early initiation and continuation of care over a relatively short time period for health promotion, prevention of adverse outcomes, and early identification of and intervention for health risks. Additionally, there is evidence that engagement in prenatal care is predictive of future use of preventive health services, including well-child care.
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.