Women's and Care Providers' Views of Quality Prenatal Care
Women's and Care Providers' Views of Quality Prenatal Care
A qualitative descriptive exploratory design was used to understand women's and care providers' perspectives of quality prenatal care. As noted by Sandelowski, 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's systems-based model of quality health care. It encompasses three aspects of care: structure, processes, and outcomes. Structure refers to attributes of the setting in which health care is delivered and received; the domains of care structure include physical setting and staff characteristics. Process of care refers to what is actually done in the delivery and receipt of care and incorporates two key components: clinical care and interpersonal care processes. Clinical care refers to the application of medical and other sciences and technology to achieve the best health result whereas interpersonal care describes the social and psychological interactions between health care professional and users of the health care system. 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.
Study participants were recruited from five urban centres across Canada: Vancouver, Calgary, Winnipeg, Hamilton, and Halifax. Each of these centres offers a range of prenatal care services to diverse populations. Purposeful maximum variation sampling was used to select informants that would provide a broad range of perspectives, thereby creating in-depth understanding of important dimensions of quality prenatal care. 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. We aimed for variation in age, parity, medical risk status, socioeconomic status, ethnicity, and urban vs. rural residence. Women were recruited from a variety of settings offering prenatal services (e.g., maternity clinics, hospital prebirth registration clinics, public health programs). 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. The research assistant subsequently contacted women to further explain the study, answer questions, and arrange data collection with consenting individuals.
Prenatal care providers, including obstetricians, family physicians, midwives and nurses, were eligible to participate if they had practiced in obstetrics/maternity care for a minimum of 2 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). The research coordinator sent a letter of invitation to care providers identified by study team members and followed-up with a telephone call to determine their interest in participating. Snowball sampling was then used as these individuals were asked to suggest other potential study participants.
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's 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 4 weeks after they had given birth. This follow-up interview was an opportunity to obtain additional perspectives about quality prenatal care as women were in a position to reflect and comment on their care experience having had their baby. It also provided an opportunity to validate the themes emerging from the initial interviews. 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 analyzed 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. A research assistant had responsibility for the coding and met with the principal and co-principal investigators after coding the first few interviews to develop a preliminary coding scheme, which subsequently was applied to the remaining interviews. Through comparative analysis, the same codes were assigned to data with common characteristics. As the open codes became saturated, the analysis evolved to pattern coding whereby specific dimensions of quality prenatal care were identified. Finally, a deductive approach was used to assign the emergent themes to broader categories that reflected Donebedian's model and its further elaboration by Campbell, Roland, and Buetow. The research assistant and principal investigator met periodically throughout the coding process to discuss and revise the coding scheme and the synthesis of codes at a higher level. The quantitative background data were entered into and analyzed using SPSS 17. Descriptive statistics were used to summarize the data collected from all women and prenatal care providers.
A number of strategies were used to ensure rigor of the qualitative analysis. In addition to the involvement of the principal investigator in coding, the emergent coding scheme was discussed with the co-principal investigator. Data were reorganized as the coding scheme progressed and all themes were firmly grounded in the data. Memos were kept about coding decisions along with copies of evolving coding schemes. Having women validate the emergent themes further enhanced the trustworthiness of interpretation of the interview data.
Methods
A qualitative descriptive exploratory design was used to understand women's and care providers' perspectives of quality prenatal care. As noted by Sandelowski, 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's systems-based model of quality health care. It encompasses three aspects of care: structure, processes, and outcomes. Structure refers to attributes of the setting in which health care is delivered and received; the domains of care structure include physical setting and staff characteristics. Process of care refers to what is actually done in the delivery and receipt of care and incorporates two key components: clinical care and interpersonal care processes. Clinical care refers to the application of medical and other sciences and technology to achieve the best health result whereas interpersonal care describes the social and psychological interactions between health care professional and users of the health care system. 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.
Sample and Recruitment
Study participants were recruited from five urban centres across Canada: Vancouver, Calgary, Winnipeg, Hamilton, and Halifax. Each of these centres offers a range of prenatal care services to diverse populations. Purposeful maximum variation sampling was used to select informants that would provide a broad range of perspectives, thereby creating in-depth understanding of important dimensions of quality prenatal care. 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. We aimed for variation in age, parity, medical risk status, socioeconomic status, ethnicity, and urban vs. rural residence. Women were recruited from a variety of settings offering prenatal services (e.g., maternity clinics, hospital prebirth registration clinics, public health programs). 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. The research assistant subsequently contacted women to further explain the study, answer questions, and arrange data collection with consenting individuals.
Prenatal care providers, including obstetricians, family physicians, midwives and nurses, were eligible to participate if they had practiced in obstetrics/maternity care for a minimum of 2 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). The research coordinator sent a letter of invitation to care providers identified by study team members and followed-up with a telephone call to determine their interest in participating. Snowball sampling was then used as these individuals were asked to suggest other potential study participants.
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's 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 4 weeks after they had given birth. This follow-up interview was an opportunity to obtain additional perspectives about quality prenatal care as women were in a position to reflect and comment on their care experience having had their baby. It also provided an opportunity to validate the themes emerging from the initial interviews. 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 analyzed 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. A research assistant had responsibility for the coding and met with the principal and co-principal investigators after coding the first few interviews to develop a preliminary coding scheme, which subsequently was applied to the remaining interviews. Through comparative analysis, the same codes were assigned to data with common characteristics. As the open codes became saturated, the analysis evolved to pattern coding whereby specific dimensions of quality prenatal care were identified. Finally, a deductive approach was used to assign the emergent themes to broader categories that reflected Donebedian's model and its further elaboration by Campbell, Roland, and Buetow. The research assistant and principal investigator met periodically throughout the coding process to discuss and revise the coding scheme and the synthesis of codes at a higher level. The quantitative background data were entered into and analyzed using SPSS 17. Descriptive statistics were used to summarize the data collected from all women and prenatal care providers.
A number of strategies were used to ensure rigor of the qualitative analysis. In addition to the involvement of the principal investigator in coding, the emergent coding scheme was discussed with the co-principal investigator. Data were reorganized as the coding scheme progressed and all themes were firmly grounded in the data. Memos were kept about coding decisions along with copies of evolving coding schemes. Having women validate the emergent themes further enhanced the trustworthiness of interpretation of the interview data.