RESEARCH ARTICLE Open Access Quality Of Prenatal Care .

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Heaman et al. BMC Pregnancy and Childbirth 2014, 8RESEARCH ARTICLEOpen AccessQuality of prenatal care questionnaire: instrumentdevelopment and testingMaureen I Heaman1*†, Wendy A Sword2†, Noori Akhtar-Danesh2, Amanda Bradford3, Suzanne Tough4,Patricia A Janssen5, David C Young6, Dawn A Kingston7, Eileen K Hutton8 and Michael E Helewa9AbstractBackground: Utilization indices exist to measure quantity of prenatal care, but currently there is no publishedinstrument to assess quality of prenatal care. The purpose of this study was to develop and test a new instrument,the Quality of Prenatal Care Questionnaire (QPCQ).Methods: Data for this instrument development study were collected in five Canadian cities. Items for the QPCQwere generated through interviews with 40 pregnant women and 40 health care providers and a review ofprenatal care guidelines, followed by assessment of content validity and rating of importance of items. Thepreliminary 100-item QPCQ was administered to 422 postpartum women to conduct item reduction using exploratoryfactor analysis. The final 46-item version of the QPCQ was then administered to another 422 postpartum women toestablish its construct validity, and internal consistency and test-retest reliability.Results: Exploratory factor analysis reduced the QPCQ to 46 items, factored into 6 subscales, which subsequently werevalidated by confirmatory factor analysis. Construct validity was also demonstrated using a hypothesis testingapproach; there was a significant positive association between women’s ratings of the quality of prenatal care and theirsatisfaction with care (r 0.81). Convergent validity was demonstrated by a significant positive correlation (r 0.63)between the “Support and Respect” subscale of the QPCQ and the “Respectfulness/Emotional Support” subscale of thePrenatal Interpersonal Processes of Care instrument. The overall QPCQ had acceptable internal consistency reliability(Cronbach’s alpha 0.96), as did each of the subscales. The test-retest reliability result (Intra-class correlation coefficient 0.88) indicated stability of the instrument on repeat administration approximately one week later. Temporal stabilitytesting confirmed that women’s ratings of their quality of prenatal care did not change as a result of giving birth orbetween the early postpartum period and 4 to 6 weeks postpartum.Conclusion: The QPCQ is a valid and reliable instrument that will be useful in future research as an outcome measureto compare quality of care across geographic regions, populations, and service delivery models, and to assess therelationship between quality of care and maternal and infant health outcomes.Keywords: Prenatal care, Quality of care, Measurement, Instrument, Reliability, Validity, Psychometric testingBackgroundThe evidence for the effectiveness of prenatal care remainsequivocal, despite its widespread use [1,2], and substantialamounts of health care resources “continue to be expended on a tradition of care that has not proven itselfequal to the perinatal health issues of today” [3]. Previous* Correspondence: Maureen.Heaman@umanitoba.ca†Equal contributors1College of Nursing and Departments of Community Health Sciences andObstetrics, Gynecology and Reproductive Sciences, College of Medicine,Faculty of Health Sciences, University of Manitoba, 89 Curry Place, WinnipegR3T 2N2, Manitoba, CanadaFull list of author information is available at the end of the articleresearch has frequently relied on prenatal care utilizationindices to study the association between adequacy of prenatal care and pregnancy outcomes [4-6]; however theseindices focus solely on quantifying the use of care and donot adequately assess the content or quality of care [1].Several studies have highlighted the potential importanceof content and quality of care [7-14]. In fact, the “role ofadequate utilization has more recently been downplayedand greater credence has been given to the importance ofthe content, comprehensiveness, and quality of prenatalcare” [1]. 2014 Heaman et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited. The Creative Commons Public DomainDedication waiver ) applies to the data made available in this article,unless otherwise stated.

Heaman et al. BMC Pregnancy and Childbirth 2014, 8The content and quality of prenatal care have beenmeasured in different ways. For example, Beeckman andcolleagues recently developed the Content and Timingof Care in Pregnancy (CTP) tool to assess women’sreceipt of recommended content based on recommendations in national and international guidelines [8]. Participants recorded the timing and content of prenatal careusing diaries. These investigators concluded the contentitems need further refinement prior to larger scale testingof the new measure [8]. Content has also been measuredin studies that examined the effect of adherence to recommended prenatal care content, assessed from medical records, on pregnancy outcomes [9-11]. Other studies haveinvestigated the impact of enhanced or augmented prenatal services [12,13,15] or new models of care, such asgroup prenatal care [16], on outcomes. The quality ofprenatal care has been evaluated using focus groups to explore quality as experienced by women [17-19], developing audit indicators of quality of prenatal care [20], orusing checklists, observations and exit interviews [21].Wong and colleagues developed an instrument to measure the quality of interpersonal processes of care [22], butthis instrument measures only one dimension of quality.To date, research on the effectiveness of prenatal care hasbeen hindered by the lack of an instrument that comprehensively measures quality of prenatal care.Assessment of prenatal care has focused primarily onwomen’s satisfaction, but often without clear distinctionbetween the constructs of satisfaction and quality ofcare. Research to empirically test the relationships between these variables provides evidence that perceivedquality affects satisfaction with health care, and thatquality of care and consumer satisfaction are distinctconstructs [23,24]. Quality is defined as a judgment orevaluation of several dimensions specific to the servicebeing delivered, whereas satisfaction is an affective oremotional response to a specific consumer experience[23,24]. Satisfaction measures tend to include components that are considered elements of quality, such asstructure of service delivery (wait time, continuity ofcare, physical environment) and process of care (advicereceived, explanations given by care provider, technicalquality of care) [25-27]. These instruments have limitations in that they do not discriminate between quantityand quality of care [28], generally lack psychometricevaluation [27], and do not adequately tap varying dimensions of the uniqueness of prenatal care [27]. Finally,satisfaction measures are insensitive, as most women report high levels of satisfaction with prenatal care [25,26],particularly when measured after delivery [29].Approaches to the assessment of quality of prenatalcare have been largely atheoretical. Among the few studies that have based their selection of measures on a theoretical framework [21,30-32], the two frameworks mostPage 2 of 16commonly used were Donabedian’s [33,34] model of quality and Aday and Andersen’s [35,36] theoretical framework for the study of access to medical care. The lattermodel is primarily focused on health service utilization issues. There is a need to develop a theoretically-groundedmeasure of prenatal care quality that is distinct from satisfaction measures in order to better evaluate the relationship between quality of prenatal care and pregnancyoutcomes. The conceptual framework guiding this research was Donabedian’s systems-based model of qualityhealth care [34]. The framework encompasses a three-partapproach to quality assessment, in which “good structureincreases the likelihood of good process, and good processincreases the likelihood of a good outcome” [34]. Structure includes attributes of the setting in which care isprovided, such as material and human resources andorganizational structure [34]. The process component reflects the actual care given. There are two processes ofcare: clinical or technical, and interpersonal [37]. According to Donabedian, the goodness of technical performanceshould be judged in comparison with best practice, whileinterpersonal process is the vehicle by which technicalcare is implemented and includes information exchange,privacy, informed choice, and sensitivity [34].In keeping with the findings of qualitative studies thatdemonstrated the value women place on the interpersonal processes of prenatal care (including communication, decision-making and interpersonal style), recentattention has been focused on the conceptualization ofthese processes, their measurement, and their impact onwomen’s satisfaction and perception of quality of care[7,22]. Research has demonstrated that ineffective communication is a barrier to prenatal care utilization [38-40].Care provider characteristics, such as lack of perceivedconcern and respect, being task focused and conveying anauthoritarian approach, also deter use of prenatal care[40-42]. These characteristics also can be a barrier towomen disclosing health concerns [43]. Thus interpersonal processes are important in keeping women engagedin prenatal care and, ultimately, in enhancing outcomes.The development of an instrument to measure qualityof prenatal care can be informed by multiple sources, including the available research evidence regarding effectiveclinical practices and the perspectives of care providersand women [21,37]. Because quality of care is determinedby the structure of service delivery and service-givingprocesses [34,44], it encompasses content dimensionsthrough its attention to the technical (e.g., physical examinations and tests) and interpersonal (e.g., health promotion counseling) aspects of care. Care providers are bestpositioned to comment on clinical aspects of care [21], including that which is knowledge-based but does not necessarily have scientific evidence of effectiveness [37]. Fewstudies have considered the perspectives of pregnant

Heaman et al. BMC Pregnancy and Childbirth 2014, 8women in the development of measurement instruments[26,27], and only one tool incorporated both women’s andhealth care providers’ perspectives [45].Purpose and aims of the studyThe development of a valid and reliable instrument tomeasure prenatal care quality is a critical scientific foundation for research to monitor the provision and benefitsof prenatal health care services. Donabedian states thatconsumers make an indispensable contribution to defining and evaluating the quality of care [15]. The purposeof this study was to develop and test a new instrument,the Quality of Prenatal Care Questionnaire (QPCQ), tobe completed by consumers (women receiving prenatalcare). Specific aims were:Page 3 of 16care. The items for the initial questionnaire were generated from two sources. The first source was a qualitativedescriptive study involving in-depth semi-structured interviews with 40 pregnant women and 40 prenatal care providers from five urban centers across Canada (Vancouver,Calgary, Winnipeg, Hamilton, and Halifax), conducted between April and November 2008. The qualitative descriptive study is described in detail elsewhere [48]. In keepingwith Donabedian’s suggestion that the goodness of clinicalor technical performance should be judged in comparisonwith best practice [34], the second source of items was areview of the evidence from 15 international guidelinesthat inform the provision of prenatal care. Table 1 presents a list of the prenatal care guidelines reviewed.Rating importance of items1. To generate items for the QPCQ;2. To conduct content and face validity assessment andexploratory factor analysis of the QPCQ todetermine final items; and3. To conduct psychometric testing of the final versionof the QPCQ.MethodsThis study addressed the development, validation, andevaluation of a research instrument. Guided by themethodological frameworks for developing measurementscales described by Streiner and Norman [46] and Pett,Lackey and Sullivan [47], the study consisted of fivephases implemented over the course of 4 years. Refer toFigure 1 for a flow chart of the five phases. Phase Onewas development of an instrument to measure quality ofprenatal care, and included item generation, content validity, rating of importance of items, and item presentation. Phase Two consisted of face validation andpretesting. Phase Three was item reduction using factoranalysis. Phase Four involved instrument evaluation, thatis, psychometric testing to establish its construct validity,internal consistency reliability, and test-retest reliability.Phase Five involved temporal stability testing. Ethical approval for this study was received from Hamilton HealthSciences/McMaster University Faculty of Health SciencesResearch Ethics Board, the University of Manitoba Education/Nursing Research Ethics Board, the University ofCalgary Conjoint Health Research Ethics Board, the IWKHealth Centre Research Ethics Board, and the Universityof British Columbia Clinical Research Ethics Board.Phase one: item generation, content validation, rating ofimportance of items, and item presentationItem generationThe first step of the instrument development process wasto generate a comprehensive list of items to represent thevarious components of the construct quality of prenatalA clinimetric or “clinical sensibility” approach was used toselect which of the 206 items in the QPCQ would beretained for the next step of instrument development [49].This approach relied on the judgments of patients and clinicians rather than on mathematical (psychometric) techniques to determine which items to include [50]. Thesample of 40 women and 40 health care providers whoparticipated in the qualitative descriptive study [48] weremailed a copy of the 206-item instrument along with acover letter and self-addressed, stamped envelope for return in June and July of 2009. Four randomly generatedversions of the list of QPCQ items were prepared to avoidresponse fatigue toward the end of rating all the items. Tomaximize response rate, a modification of Dillman’s tailored design method was utilized, including a reminderletter and second mailing of surveys to respondents [51].In the cover letter, participants were given the followinginstructions: “When you rate the items, we are not askingyou to reflect on your own experiences with prenatal care.Rather, we would like you to rate how important you thinkeach item is in the care provided by health care professionals to pregnant women using a 7-point rating scalefrom 1 (not very important) to 7 (extremely important).”Data for this phase were entered into Microsoft Excel. Amean rating score was generated for each item.Item presentationOnce the most important items were selected for inclusion in the QPCQ, the research team discussed andmade decisions regarding instrument format, printedlayout, wording of instructions to the subjects, wordingand structuring of the items, and response format [47].Our intent was to develop an instrument suitable forself-administration to pregnant or postpartum women.Phase two: face validation and pretestingOnce the newly formed instrument had been drafted, itwas assessed for face validity and pretested. Face validity

Heaman et al. BMC Pregnancy and Childbirth 2014, 8Page 4 of 16Figure 1 Flow chart of five phases of development and testing of the QPCQ.refers to the appearance of the instrument to a layperson, and whether the instrument appears to measure theconstruct [52]. Pretesting was used to ensure that itemswere clearly written and were being interpreted correctly[46]. Research assistants administered the 111- item version of the QPCQ to 11 pregnant women in two sites(Winnipeg and Hamilton) between November andDecember 2009 in a location of the participants’ choice(e.g., prenatal care facility, own home). Women wereinstructed to respond to each item as if they were actually participating in a study, but to mark items that weredifficult to read or confusing. The length of time tocomplete the QPCQ was recorded. Women were thenasked a series of questions by the research assistantabout the clarity of the instructions and the items,whether the items appear to be related to the constructof quality of prenatal care, suggestions for alternatewording, items that should be added or removed, andthe overall appearance of the instrument. The feedbackregarding the quality of prenatal care instrument wasdiscussed by the researchers and revisions were madeaccordingly.

Heaman et al. BMC Pregnancy and Childbirth 2014, 8Page 5 of 16Table 1 Prenatal care guidelines reviewed to generate items for the QPCQ based on “A” grade evidenceOrganization nameGuideline titlePublication dateThe American College of Obstetricians and Gynecologists & Guidelines for Perinatal Care (6th edition)American Academy of PediatricsOctober 2007The American College of Obstetricians and GynecologistsCommittee Opinion-Psychological Risk Factors: Perinatal Screeningand InterventionAugust 2006The Society of Obstetricians and Gynaecologists of CanadaHealthy Beginnings: Guidelines for Care During Pregnancyand ChildbirthDecember 1998Fetal Health Surveillance: Antepartum and IntrapartumConsensus GuidelineSeptember 2007Public Health Agency of CanadaFamily-Centered Maternity & Newborn Care: National Guidelines2000National Institute for Health and Clinical ExcellenceAntenatal Care: Routine care for healthy pregnant womenMarch 2008The Royal Australian and New Zealand College ofObstetricians and GynaecologistsObstetricians and childbirth responsibilitiesJuly 2007Prenatal screening for trisomy 21, trisomy 18 and neural tube defects July 2007Mineral and vitamin supplementation in pregnancyJuly 2008Antenatal screening testsJune 2008Diagnosis of Gestational Diabetes MellitusJune 2008Guidelines for the use of Rhd immunoglobulin in Obstetricsin AustraliaMarch 2007Royal College of Obstetricians and GynaecologistsClinical Standards: Advice on Planning the Service in Obstetricsand GynaecologyJuly 2002World Health OrganizationWhat is the effectiveness of antenatal care? (Supplement)December 2005New WHO antenatal care model2002Phase three: item reduction using exploratory factor analysisRecruitment and data collection procedureThe purpose of this step was to further reduce the number of items in the QPCQ by eliminating any that wereredundant or not congruent with the overall constructbeing measured. We aimed to recruit a conveniencesample of at least 400 women (approximately 80 womenper study site) to participate in the item reduction step.A sample size of 400 women was determined to be sufficient as Devillis [53] suggests that a sample size of 200 isadequate in most cases of factor analysis, while Comreyand Lee state that a sample size of 300 is good and 500is very good [54].Nursing staff of the postpartum units were asked toidentify women who met the inclusion criteria and determine their willingness to learn more about the study.Women were then approached by the site research assistant (Vancouver, Calgary, Winnipeg, Halifax) or theresearch coordinator (Hamilton), who provided a verbalexplanation and written information about the study.Signed, informed consent was

RESEARCH ARTICLE Open Access Quality of prenatal care questionnaire: instrument development and testing Maureen I Heaman1*†, Wendy A Sword2†, Noori Akhtar-Danesh2, Amanda Bradford3, Suzanne Tough4, Patricia A Janssen5, David C Young6, Dawn A Kingston7, Eileen K Hutton8 and Michael E Helewa9 Abstract

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