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
Access is defined as "the potential ability of women to enter prenatal care services and maintain care for herself and fetus 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. As women reported,
"It's actually quite convenient 'cause I can walk there [from work] on the nice days. ... It's close to my husband's work as well"(W03-04) and, in contrast,
"We're spending over $60 a month just for parking [for prenatal care]. It would really make a difference if there were some options in that respect." (W04-04)
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 organize their lives and get to appointments and follow through on stuff. So I think to have some flexibility around sort of how you, how you offer them care is, is really important and I must say we're probably way more flexible with our prenatal patients and our new moms. ... It doesn't matter if they show up late, it doesn't matter if they miss three appointments in a row. You know they're not penalized for that because you're really trying to sort of 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)
Women, in particular, commented on the value of having prenatal care providers available to them outside of scheduled appointment times. 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. One woman commented:
I think being able to call and get somebody to call you back in about 10 or 15 minutes has been really great. I think that - I don't know that I wouldn't have had as healthy a pregnancy - but I think I would've felt a little bit more stressed out about certain things. (W01-06)
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:
The rooms are good because you looked around and you saw everything that your future was going to be and you had access to pamphlets, you had any questions you'd have anything. Everything was there for you. Everything - you were completely surrounded. ... It's there and that's the greatest I think. Everything is available to you. (W04-01)
Physical setting
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 recognized the importance of privacy. One health care professional compared differences in privacy in two different settings in 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 come into the back room, people aren't really seeing you, whereas in our last clinic there was a lot of movement in and out, and you could see people getting their blood pressure done and all that. And you know, that's okay for some people, but it's, you know, it's not okay for everyone. ... Not everyone wants to have their belly measured in front of a hundred people. (PCP02-05)
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. The aesthetics of the physical space also were identified as contributing to quality care. As one woman stated:
I like how this whole building obviously, it's different colours. It makes it a good atmosphere. It's very clean. ... You get an overall happy feeling when you'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 different colours and stuff like that. (W05-05)
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, as captured in this quote:
She's got a very nice chaise lounge rather than an examining table, and then she has a little desk. ... So it's pretty comfy. And then there's a separate room for pelvic exams. Yeah, the whole place is kind of upholstered and furnished. It does not feel clinical. There is a minimum of rubber gloves and paper, and cold metal stirrups and whatnot. (W01-07)
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. As one participant commented:
I would say that it's [the environment] a positive one because she [the receptionist] greets me with a smile, and again, non-judgmental, even if she's really, really busy, she doesn't act like she's flustered or stressed out. I think that's really important because people's energies can impact another person. And it could ruin your day. So if she had a bad day, it could ruin my day too because she just yelled at me or something like that. (W01-08)
For some women, knowing that their prenatal care provider had clinical experience and was not new to providing prenatal care engendered a sense of confidence in their abilities, as conveyed in the following remark:
They definitely exude a kind of a relaxation and a confidence about what they're doing. All the tests they do, they make them seem so easy. I think they've been doing it so long, they know exactly where the baby is. They know exactly how to get a heart rate. ... You know that they know what they're doing, so it's relaxing to just go in and let them do their thing and know that everything's fine. (W02-05)
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 they [prenatal care providers] have a lot of experience, especially because they have children of their own. (W02-08)
Health professionals also spoke more about the contribution of clinical expertise to quality prenatal care. One family physician noted this as a special consideration when transferring care:
I have one obstetrician/gynaecologist in particular that I refer to who I worked with during my training, who I have a relationship of trust with. So I can say with confidence to the people who I'm sending on, "I trust this woman, she's great, she's clinically sound, she will take really good care of you." (PCP03-04)
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-medicalization of pregnancy; and women-centredness.
Women and prenatal care providers identified the importance of health promotion advice to encourage a healthy lifestyle. A family physician talked about taking time to address smoking in pregnancy as follows:
If they're smoking I spend quite a bit of time addressing the concerns about smoking because I really try and emphasize the positives of them not smoking when they're pregnant and then hopefully then towards the end push the need to be a non-smoker afterwards. (PCP05-04)
Counseling about nutrition and appropriate weight gain was identified as an essential component of quality prenatal care. An obstetrician described her approach to this as follows:
I think I do far more nutritional counseling than most people do because I do watch their weight gain and I do try to get them to do 3-day food diaries and to try to help them to bring the weight under control or the weight gain under control if it's getting a bit out of control. So I have Canada's Food Guide that I tell them to take and I consult nutritionists if necessary. (PCP05-05)
Women commented favourably on the impact of receiving health promotion advice. One study participant remarked on the insight she gained from her prenatal care provider asking her to record her food intake:
Well, definitely you have to eat properly. ... I know I didn't know the proper amounts of different things you need during the day. ... They had one that was a check list. And you could check off every time you ate this and how much of this you ate, which I found really helpful 'cause you don't realize what you're not getting until you have this thing in front of you. So it definitely helped me out. (W05-05)
For other participants, their care provider's advice encouraged them to maintain a healthy lifestyle. As another woman explained:
Well, it [advice] encourages me to keep doing what I'm doing. Like move around instead of getting lazy or giving up or anything. ... Like no matter how lazy I am, to still get off the couch and get some exercise. Also 'cause that's what's keeping them healthy is the exercise and the nutrition and everything. So just the encouraging me to do extra things and just keep going with my regular life is the major thing. (W04-08)
Health care providers commented more frequently than women on the need to pay attention to known risk factors during pregnancy as an illness prevention strategy. The factors most commonly discussed were preexisting health problems, health-risk behaviours, and social risks to health. One obstetrician described his approach to risk assessment as follows:
I ask her if she has any known medical problems and then, I must say, I coach a little bit because many people don't know what a medical problem is and I usually name diabetes, heart disease, kidney disease. If she's ever had tuberculosis, epilepsy, rheumatic fever, 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 attending to preexisting health conditions and as one participant remarked, "That's an important part of the prenatal care". (W04-06)
Some care providers spoke about assessing social risks to health and linking women to appropriate resources in their communities. As a family physician stated:
They [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 fetal development were progressing normally. As one woman commented, "Every time they check me really good so I'm satisfied that my baby is doing good so and even I'm doing good. They check my blood pressure, my diabetes, my protein and everything." (W02-03)
Prenatal care providers highlighted the importance of following guidelines for screening in pregnancy to ensure better outcomes for mothers and babies. An obstetrician noted:
The things I really think improve outcome are screening tests for HIV, screening for Rh disease. Rubella immunization, we still do it. And syphilis, although it's low probability of picking something up, it makes a big difference when you do. The screening ultrasound, whether or not that's making a big difference in the outcome, I know, is a little debatable. We try and follow up on those guidelines.... So we do a fairly structured, follow all those guidelines for screening for group B strep. I think those things are really important in changing outcomes. (PCP02-01)
Health care providers also discussed the importance of screening and assessment related to psychosocial health as reflected in the following comment made by an obstetrician:
... assessment of how the woman's doing with relation to her pregnancy and in relation to her life and are there any arising medical conditions that might impact on her pregnancy? Or social conditions. ... It may be that if she's under undue stress that there may, that there may be ramifications in terms of how she's coping with the pregnancy or how she's going to cope with it once the baby's delivered. Her risk of postpartum depression is likely to be increased by increased life stressors during the pregnancy and in the postpartum period. So I think it's important for me to know about that. ... I can be supportive and at least I know that that woman's at risk so that if she starts to go downhill I can identify it and get perinatal psych involved for example. (PCP05-05)
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. One midwife, for instance, discussed hypertension and the importance of medication in its treatment:
Hypertension might actually be managed to improve outcomes. ... Because the way in which we manage hypertension now is quite different than the way in which it was approached say 30 years ago and so we don't see the same sort of things. I mean we don't see eclamptic women. I can't remember when the last time was I saw somebody seizing because of their high blood pressure, right. We medicate people differently, we treat them differently, and I think their outcomes are likely to be better. (PCP04-01)
The sharing of information by health care 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 like more prepared, and just feels good to know everything that's going on. (W02-06)
As suggested by the remark about "no secret codes", it is important that information be conveyed in a way that women can understand. Another woman commented:
Like I understand what she's talking about when she talks to me. And I think she tries to make it that way. I don't leave, ever leave and kind of go, "What did she say? What is she talking about?" You know? So that's been good. (W01-03)
One woman expressed how much she appreciated being given information about every aspect of her prenatal care visit:
The nurse will let you know whether your urine was good or if there was a problem. And then she'll check your blood pressure ... she'll give you the number, and then she'll explain what it is, whether it's good or not. And then she weighs you and then she tells you first what it is, and then how much you've gained or lost or anything like that. She is very, very specific and detailed about letting you know how you're doing that way. ... It makes me feel involved. It makes me feel confident. It makes me feel like they actually care and they pay attention to what's going on. (W02-06)
Women expressed the value of health care providers sharing information in an open and honest manner, even when delivering potentially distressing news. One woman described her experience as follows:
They also have a way of breaking it [information] down so that it makes sense to people who don't have medical degrees and help you to understand the ramifications. For example ... the last appointment I had with my endocrinologist, which was a week and a day ago. And we were talking specifically about the ramifications of a larger baby. And he didn't beat around the bush. He just told me upright what they were. First trimester, second and third trimester. So, that was kind of nice as well ... because then we know what we're dealing with, with this larger size baby and because then we're more prepared. (W04-04)
Health care providers also commented on honesty as an element of quality care. As one obstetrician stated, "I try to build confidence in our relationship. I am completely straight forward. Nothing is dressed up." (PCP05-05)
Continuity of care
Many women explained that receiving care from the same health care 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 asked if she felt continuity of care was an important feature of quality prenatal care, one woman responded:
Yes, I think it would be because you, you build the relationship. They know.... They're from there from the beginning. Right when it's like a little kidney bean instead of two little babies, right? So, you're gradually growing the baby together rather than half way through you're getting to know the doctors again. (W04-08)
Some women commented specifically on the importance of receiving prenatal care from a health care provider with whom they had developed a relationship, as exemplified 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. So like going in to see her - it's sort of like going in to see someone you've known forever. It's, "Hey, how's it going?" You know, you have your little chit-chat first and then you get into what's going on. Whereas when you're go see someone new, it's kind of - I don't know if you're going to be embarrassed about things, or you're kind of shy about talking about certain things. (W01-03)
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. In reflecting on her transfer of care from a family physician to a midwife, one study woman observed:
Transition wise it would be helpful if there was a bit more of a flow. Like something where you know the GP understands ... she just kind of said you've got to go find care and I was like okay and then I sort of felt like, well, am I supposed to put them in touch or do they talk? Or is there like my medical history? Is that relevant to the pregnancy? ... At one point of course my midwife had to request some of my relevant medical files. Like had I had rubella shots etcetera. Things like that. (W01-01)
Non-medicalization of pregnancy
A recurring theme in the study was the importance of not treating pregnancy as a disease or medical condition, but rather as a normal process. When asked about her impressions of prenatal care, one woman responded:
I just thought there'd be more, it would be more medicalized, which I'm glad it's not, actually. You know?'Cause you want to feel like a normal person, too, even though you're pregnant. You don't want to feel like a patient. (W02-04)
Several women expressed a preference for receiving care from a midwife because it felt less medically-oriented than care provided by physicians. One woman contrasted her experiences as follows:
From the first appointment that we had with our midwife I always said I just loved that it didn't feel as medical and as clinical. Like it didn't feel like I was sick when I went to see her. And when I went to see my family doctor, although I didn't actually feel like I was sick, I just felt like I was going in there for like a medical condition. Whereas with my midwife it was just sort of this experience we were all kind of having. And it sounds a little cheesy and hokey but that's kind of how I felt. (W03-04)
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)
One physician similarly commented, "The traditional visit is the doctor and the patient and their partner.... It kind of medicalizes their pregnancy, which for the most part isn't really necessary." (PCP01-06)
Women-centredness
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 recipients [
27].
It was evident that women valued a high level of personalization in their prenatal care. They wanted their prenatal care providers to pay attention not only to their pregnancies but also to the psychosocial aspects of their lives. Health professionals similarly noted the importance of "practicing comprehensively". As one midwife stated:
I try to focus not only on the medical stuff, but the social and to some extent cultural. I try to focus and not just think only about the pregnancy, which I think is a little bit different about the way we practice compared to someone who's practicing high risk. ... We like to think of ourselves as taking care of the entire patient and not just focusing on the pregnancy. (PCP02-05)
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:
I obviously am supportive of health promotion and education but I'm cautious that it doesn't undermine the sense of the woman being an adult and having other priorities in her life ... one size doesn't fit all. ... 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. This was conveyed in the following statement:
Both of the doctors that I've seen have been really great about ... encouraging the father to come to, or whoever, a parent or a friend to come. And actually, what was nice, the first time or the second time that I had an appointment with the doctor who will deliver me, she knew my fiancé was in the waiting room. And she said, "Oh, bring him in here because, he's a part of this and I want to meet him. He should be a part of this experience as well." So that was nice. Having doctors who ... treated it as more of a family experience. (W01-05)
The involvement of women as active partners in their care was recognized as an essential feature of quality prenatal care by most study participants. A midwife described how involving women can foster positive health promoting behaviours and outcomes:
And the medical course of events becomes not something that happens to a woman, but something that she is part of making happen and having happen. ... I think if a person does feel very involved in their own prenatal care ... that does encourage their motivation to be as healthy as possible. And that could certainly make for more positive outcomes. (PCP01-05)
The main aspects of women as active partners included giving them responsibility for routine aspects of care. Another midwife commented on how this can engender a sense of control:
We have a little set up where they check their urine. The cups are there right at the bathroom and the scale is right there. When you do that you're saying to women, "We totally trust you."... If you're not colour blind you can read a urine strip, it's a no brainer and when they take their own blood pressure. So they take charge for their body and they hand over to us to measure the baby and check that well being. And I really like that model. I think it sends a message. (PCP01-03)
Women concurred that such involvement gave them a sense of control, as reflected in this statement:
You weigh yourself, and you check your own urine as far as just protein and sugar. ... And just let them know the colour of the strip, and let them know what you weigh. So you are kind of monitoring yourself a little bit, which is nicer because you feel in control. (W02-07)
Women's active involvement in their own care also included meaningful participation in decision making. In one woman's words:
Straight off the bat, seeing her just to confirm my pregnancy, she was very reassuring about taking charge of the medication that I was on, should I stay on it, should I go off it, and sort of consulting with me and what I felt comfortable with as well as her medical opinion. And that was really, really helpful, that I was involved in the decision making but I knew that she knew what she was talking about. (W04-06)
Health care providers agreed that giving women information and allowing them to make informed decisions was important. As a midwife remarked:
The goal of that [informed consent], the women, the families, feel like they're making really thorough decisions for themselves. That puts them in charge of their own care. ... We try hard not to direct care, except in times when we feel we have more information than they can have, just because we are care providers. So of course there are times when we will say, "You know what? I think you really need to have an ultrasound for growth", and that's going to really make me more comfortable. But for the really routine stuff, it's important that women can feel they direct that themselves, and also feel ownership over it. (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.
Respectful attitude
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 more like, 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 minimizing 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, you know, sometimes because this woman [care provider] sees so many pregnant people that she might kind of 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)
When asked what characteristics were important in a prenatal care provider to enhance quality of care, health care professionals also discussed the importance of being non-judgmental. As one obstetrician responded, "The big one's non-judgmental. So you have to be able to, you know, care for them whatever they bring in. And you get really good at not letting your jaw drop when they tell you things."(PCP03-05)
Many participants noted the importance of women feeling respected and valued at all times. A very young mother shared, "Oh they treated me good. Like they were really respectful and they, I don't know, they were never rude or treated me bad just because of my age. I just like to feel like everybody else, like to feel respected." (W03-06) One midwife shared some thoughts about respect saying:
I don't really know that it [quality care] has much to do with prenatal care but just care in general you know? It's about respect for people. ... It's about respecting their intelligence, their understanding of the world. ... It's about respecting their ability to make good decisions about themselves and for themselves. (PCP04-01)
Included in this theme is acknowledgement of and respect for cultural differences. Some health care providers spoke of the importance of offering services in a culturally sensitive manner. A family physician stated:
A significant number of our patients are from a different culture than the care team - African or Asian or First Nations. I think we are reasonably successful to provide care across that cultural divide. It has mostly been my experience to work to do that, and I think it can be successful. But obviously, it takes some sensitivity. (PCP03-06)
Emotional support
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]. Nearly every study participant, both women and health care providers, talked about its importance. One woman described an example of emotional support and the effect it had on her as follows:
The one where my blood sugar was higher was actually really good in an odd way because I had gone in and I had my crazy morning at work already and when I got there I tried telling them and I just started crying. Apparently it's the hormones so she [obstetrician] just stood up and gave me a big hug and I just felt like laughing. It was kind of nice. (W01-01)
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 8 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 was like - "Oh my god! We're gonna hear the heart beat!" And it's your first pregnancy, and it was just like 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. One woman expressed:
I think for me the most important aspects would be knowing that I'm okay. So knowing that my blood pressure's okay. And knowing that the baby's heartbeat is - I can hear it, and it's same as always. ... And knowing that, say for instance, the size of my uterus is the average size of everybody else's uterus, right, so at this time of pregnancy. So I would just say kind of being reassured that all my vitals, the baby's vitals are all fine. (W02-04)
An additional feature of emotional support was acknowledgement of women's feelings and reassurance that they were normal. One woman who did not receive the emotional support anticipated from her midwife reflected on her disappointment as follows:
I had thought that taking this route would give me a bit - like an element of that emotional support - just that little bit of emotional reassurance. ... I get the clinical reassurance regularly but the emotional reassurance that no, you're not crazy and you know the crying or whatever's happening is totally normal. You'll be fine. That element has been a little bit lacking but that might have been a false expectation on my part. (W01-01)
Prenatal care providers similarly recognized that listening and providing reassurance were key aspects of their roles. One family physician commented:
I just try to alleviate stress and concern. People worry lots about everything and things that are out of their control, so I try to just be laid back and make sure they know that things are okay. I'll worry about things that need to be, and just lay back and enjoy yourselves - look forward to the baby. I find prenatal care very easy and very relaxing. Most patients, they just want to know that they're doing well and that the baby is healthy. So you just have to reassure them. (PCP03-08)
Approachable interaction style
Interaction style refers to behaviours that characterize the manner in which health care providers carry out their responsibilities [
29]. Women expressed a preference for prenatal care providers who are positive and engaging as suggested by this comment:
"This is my second go-around so we've had her for both pregnancies and she's very positive - always makes you feel very comfortable and even uplifted during that visits, which is nice." (W05-04). The use of humour was identified as an effective strategy to engage women. One participant stated:
I think it [humour] just puts people at ease. You know if everything is very serious and to the point all the time you get a little more tense. If you can laugh about 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 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)
Health care providers also acknowledged the need for a calm and relaxed demeanor. One obstetrician remarked:
I find that when something bad is going on, it doesn't help things for you to be excited, and anxious, and worried, and what not - especially to verbalize that or show it to the patient, because that just makes it worse. So you have to be a little bit more that calming voice, supportive, reliable and efficient - do what you have to do. But you know raising all the fire alarms is just going to make it worse. (PCP03-08)
Taking time
Women placed considerable value on the amount of time their health care providers spent with them during prenatal visits. They identified the importance of care providers taking time to address all their questions and concerns. One woman recounted her experience as follows:
I really like that they take the time for me to just go through my list of questions. I don't feel like I'm wasting their time or that it's boring. I can just sit there and go okay, "What about this? What about that?" And they don't mind that - that's fine. So that I would say is the best part of it - is that I have the time to ask my questions. (W01-06)
Women clearly did not want to feel rushed during their appointments. 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 like, at least wait ten seconds to give me a chance to formulate my question. 'Cause sometimes what I do, in the past, was have a list of questions and then go there. But then, um, they're not happy because there's like ten questions, which is using up all their time. I feel a little bit guilty, having too many questions. (W01-08)
Several women expressed a desire for longer appointments, especially at the beginning of their pregnancies when they had more questions or when important decisions had to be made. One participant commented:
That first prenatal appointment, there is so much to go over. ... Like I said, the genetic screening, the various blood tests ... all the prenatal testing that is done now, there is just so much to give. And a lot of prevention and sort of advice on what to avoid and what's okay, and what's not okay. I think a lot of that gets missed by the doctor because they don't have time. (W01-02)
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. One woman noted:
You can be comfortable to ask all the questions you need to ask, and get the answers that you need to get, and now that they've [midwives] taken the time to really think about, or do the research to find out, and make sure that they're giving you the accurate answers. And I have found myself with the [midwifery] team that I'm with right now, I'm not having any problems with that. But earlier in my pregnancy with my family doctor, I did very much feel that they were kind of rushing through it all because they're just so rushed on time and appointments. (W02-05)
Some women had different experiences with their family physicians in that they did not feel rushed during their visits. As another woman remarked:
Sometimes when I've had some concerns, and when I thought about it later, I thought, "Oh my god." ... Months down the road I think, "Oh that was so ridiculous." But he never said to me, "Oh, don't give it another 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 relationship
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. The relevance of the relationship to quality care is exemplified in this remark made by a woman who was experiencing her sixth pregnancy:
There have been things about each one [pregnancy] that have been different. And so to be able to comfortably discuss things with her [family physician] means everything. It means that the experience has been positive when I feel safe talking to her, and I feel like I can trust her. I feel like it's private, you know, our conversation. I feel like she's going to give me an honest answer about things, that she's going to be fair in her presentation about different options. And so having that kind of relationship has been really important to me in terms of feeling like I've had incredible quality care. (W05-08)
Other women similarly noted that a meaningful relationship is characterized by trust and as one woman commented, a relationship based on trust can reduce anxiety and ultimately contribute to positive outcomes:
I feel like I trust them, I feel comfortable and safe with them. I feel that they are both very well-trained and very experienced. I think that my anxiety will be lower because of the relationship that we have with them and that's got to have a positive outcome. (W01-07)
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 him [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)
Health care providers recognized the centrality of a meaningful relationship with their prenatal clients to quality prenatal care. As one family physician remarked:
What are the aims of our prenatal care? I think also it's an unfolding process of a relationship. You know it takes you know the relationship that grows and develops between client and caregiver as well as just mother becoming a mother and a family becoming a family. Right? So and that, that's part of prenatal care and I think it's integral actually to prenatal care. (PCP01-01)
Health professionals, too, associated such a relationship with trust, comfort, and a reduction in anxiety for the women. Some care providers believed that the relationship they had with a woman played a role in her engagement in prenatal care. A midwife explained:
And so you build different relationships with different people 'cause some people are more forthcoming and that kind of thing, and other people are just doing their thing, right? But that relationship. I mean that's why women keep coming back. ... We've got people coming back who've had baby number four now. So, they keep coming back and that means you built the relationship. (PCP01-07)
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 that [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 a good bridge building. (PCP03-03)
A meaningful relationship between woman and her care provider therefore not only enhances the quality of prenatal care but also can influence the extent to which women adhere to professional recommendations.