Quality of Prenatal Care Questionnaire: Instrument Development and Testing

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Quality of prenatal care questionnaire: Instrument development and testing
Article in BMC Pregnancy and Childbirth · June 2014

DOI: 10.1186/1471-2393-14-188 · Source: PubMed
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Heaman et al. BMC Pregnancy and Childbirth 2014, 14:188
http://www.biomedcentral.com/1471-2393/14/188
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
Background: Utilization indices exist to measure quantity of prenatal care, but currently there is no published
instrument 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 QPCQ
were generated through interviews with 40 pregnant women and 40 health care providers and a review of
prenatal care guidelines, followed by assessment of content validity and rating of importance of items. The
preliminary 100-item QPCQ was administered to 422 postpartum women to conduct item reduction using exploratory
factor analysis. The final 46-item version of the QPCQ was then administered to another 422 postpartum women to
establish 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 were
validated by confirmatory factor analysis. Construct validity was also demonstrated using a hypothesis testing
approach; there was a significant positive association between women’s ratings of the quality of prenatal care and their
satisfaction 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 the
Prenatal 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 stability
testing confirmed that women’s ratings of their quality of prenatal care did not change as a result of giving birth or
between 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 measure
to compare quality of care across geographic regions, populations, and service delivery models, and to assess the
relationship between quality of care and maternal and infant health outcomes.
Keywords: Prenatal care, Quality of care, Measurement, Instrument, Reliability, Validity, Psychometric testing
Background research has frequently relied on prenatal care utilization

The evidence for the effectiveness of prenatal care remains indices to study the association between adequacy of pre-
equivocal, despite its widespread use [1,2], and substantial natal care and pregnancy outcomes [4-6]; however these
amounts of health care resources “continue to be ex- indices focus solely on quantifying the use of care and do
pended on a tradition of care that has not proven itself not adequately assess the content or quality of care [1].
equal to the perinatal health issues of today” [3]. Previous Several studies have highlighted the potential importance
of content and quality of care [7-14]. In fact, the “role of
* Correspondence: Maureen.Heaman@umanitoba.ca adequate utilization has more recently been downplayed
†
Equal contributors
1
College of Nursing and Departments of Community Health Sciences and and greater credence has been given to the importance of
Obstetrics, Gynecology and Reproductive Sciences, College of Medicine, the content, comprehensiveness, and quality of prenatal
Faculty of Health Sciences, University of Manitoba, 89 Curry Place, Winnipeg care” [1].
R3T 2N2, Manitoba, Canada
Full list of author information is available at the end of the article
© 2014 Heaman et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Heaman et al. BMC Pregnancy and Childbirth 2014, 14:188 Page 2 of 16
The content and quality of prenatal care have been commonly used were Donabedian’s [33,34] model of qual-
measured in different ways. For example, Beeckman and ity and Aday and Andersen’s [35,36] theoretical frame-
colleagues recently developed the Content and Timing work for the study of access to medical care. The latter
of Care in Pregnancy (CTP) tool to assess women’s model is primarily focused on health service utilization is-
receipt of recommended content based on recommenda- sues. There is a need to develop a theoretically-grounded
tions in national and international guidelines [8]. Partici- measure of prenatal care quality that is distinct from satis-
pants recorded the timing and content of prenatal care faction measures in order to better evaluate the relation-
using diaries. These investigators concluded the content ship between quality of prenatal care and pregnancy
items need further refinement prior to larger scale testing outcomes. The conceptual framework guiding this re-
of the new measure [8]. Content has also been measured search was Donabedian’s systems-based model of quality
in studies that examined the effect of adherence to recom- health care [34]. The framework encompasses a three-part
mended prenatal care content, assessed from medical re- approach to quality assessment, in which “good structure
cords, on pregnancy outcomes [9-11]. Other studies have increases the likelihood of good process, and good process
investigated the impact of enhanced or augmented pre- increases the likelihood of a good outcome” [34]. Struc-
natal services [12,13,15] or new models of care, such as ture includes attributes of the setting in which care is
group prenatal care [16], on outcomes. The quality of provided, such as material and human resources and
prenatal care has been evaluated using focus groups to ex- organizational structure [34]. The process component re-
plore quality as experienced by women [17-19], develop- flects the actual care given. There are two processes of
ing audit indicators of quality of prenatal care [20], or care: clinical or technical, and interpersonal [37]. Accord-
using checklists, observations and exit interviews [21]. ing to Donabedian, the goodness of technical performance
Wong and colleagues developed an instrument to meas- should be judged in comparison with best practice, while
ure the quality of interpersonal processes of care [22], but interpersonal process is the vehicle by which technical
this instrument measures only one dimension of quality. care is implemented and includes information exchange,
To date, research on the effectiveness of prenatal care has privacy, informed choice, and sensitivity [34].
been hindered by the lack of an instrument that compre- In keeping with the findings of qualitative studies that
hensively measures quality of prenatal care. demonstrated the value women place on the interper-
Assessment of prenatal care has focused primarily on sonal processes of prenatal care (including communica-
women’s satisfaction, but often without clear distinction tion, decision-making and interpersonal style), recent
between the constructs of satisfaction and quality of attention has been focused on the conceptualization of
care. Research to empirically test the relationships be- these processes, their measurement, and their impact on
tween these variables provides evidence that perceived women’s satisfaction and perception of quality of care
quality affects satisfaction with health care, and that [7,22]. Research has demonstrated that ineffective com-
quality of care and consumer satisfaction are distinct munication is a barrier to prenatal care utilization [38-40].
constructs [23,24]. Quality is defined as a judgment or Care provider characteristics, such as lack of perceived
evaluation of several dimensions specific to the service concern and respect, being task focused and conveying an
being delivered, whereas satisfaction is an affective or authoritarian approach, also deter use of prenatal care
emotional response to a specific consumer experience [40-42]. These characteristics also can be a barrier to
[23,24]. Satisfaction measures tend to include compo- women disclosing health concerns [43]. Thus interper-
nents that are considered elements of quality, such as sonal processes are important in keeping women engaged
structure of service delivery (wait time, continuity of in prenatal care and, ultimately, in enhancing outcomes.
care, physical environment) and process of care (advice The development of an instrument to measure quality
received, explanations given by care provider, technical of prenatal care can be informed by multiple sources, in-
quality of care) [25-27]. These instruments have limita- cluding the available research evidence regarding effective
tions in that they do not discriminate between quantity clinical practices and the perspectives of care providers
and quality of care [28], generally lack psychometric and women [21,37]. Because quality of care is determined
evaluation [27], and do not adequately tap varying di- by the structure of service delivery and service-giving
mensions of the uniqueness of prenatal care [27]. Finally, processes [34,44], it encompasses content dimensions
satisfaction measures are insensitive, as most women re- through its attention to the technical (e.g., physical exami-
port high levels of satisfaction with prenatal care [25,26], nations and tests) and interpersonal (e.g., health promo-
particularly when measured after delivery [29]. tion counseling) aspects of care. Care providers are best
Approaches to the assessment of quality of prenatal positioned to comment on clinical aspects of care [21], in-
care have been largely atheoretical. Among the few stud- cluding that which is knowledge-based but does not ne-
ies that have based their selection of measures on a the- cessarily have scientific evidence of effectiveness [37]. Few
oretical framework [21,30-32], the two frameworks most studies have considered the perspectives of pregnant
women in the development of measurement instruments care. The items for the initial questionnaire were gener-
[26,27], and only one tool incorporated both women’s and ated from two sources. The first source was a qualitative
health care providers’ perspectives [45]. descriptive study involving in-depth semi-structured inter-
views with 40 pregnant women and 40 prenatal care pro-
Purpose and aims of the study viders from five urban centers across Canada (Vancouver,
The development of a valid and reliable instrument to Calgary, Winnipeg, Hamilton, and Halifax), conducted be-
measure prenatal care quality is a critical scientific foun- tween April and November 2008. The qualitative descrip-
dation for research to monitor the provision and benefits tive study is described in detail elsewhere [48]. In keeping
of prenatal health care services. Donabedian states that with Donabedian’s suggestion that the goodness of clinical
consumers make an indispensable contribution to defin- or technical performance should be judged in comparison
ing and evaluating the quality of care [15]. The purpose with best practice [34], the second source of items was a
of this study was to develop and test a new instrument, review of the evidence from 15 international guidelines
the Quality of Prenatal Care Questionnaire (QPCQ), to that inform the provision of prenatal care. Table 1 pre-
be completed by consumers (women receiving prenatal sents a list of the prenatal care guidelines reviewed.
care). Specific aims were:
Rating importance of items
1. To generate items for the QPCQ; A clinimetric or “clinical sensibility” approach was used to
2. To conduct content and face validity assessment and select which of the 206 items in the QPCQ would be
exploratory factor analysis of the QPCQ to retained for the next step of instrument development [49].
determine final items; and This approach relied on the judgments of patients and cli-
3. To conduct psychometric testing of the final version nicians rather than on mathematical (psychometric) tech-
of the QPCQ. niques to determine which items to include [50]. The
sample of 40 women and 40 health care providers who
Methods participated in the qualitative descriptive study [48] were
This study addressed the development, validation, and mailed a copy of the 206-item instrument along with a
evaluation of a research instrument. Guided by the cover letter and self-addressed, stamped envelope for re-
methodological frameworks for developing measurement turn in June and July of 2009. Four randomly generated
scales described by Streiner and Norman [46] and Pett, versions of the list of QPCQ items were prepared to avoid
Lackey and Sullivan [47], the study consisted of five response fatigue toward the end of rating all the items. To
phases implemented over the course of 4 years. Refer to maximize response rate, a modification of Dillman’s tai-
Figure 1 for a flow chart of the five phases. Phase One lored design method was utilized, including a reminder
was development of an instrument to measure quality of letter and second mailing of surveys to respondents [51].
prenatal care, and included item generation, content val- In the cover letter, participants were given the following
idity, rating of importance of items, and item presenta- instructions: “When you rate the items, we are not asking
tion. Phase Two consisted of face validation and you to reflect on your own experiences with prenatal care.
pretesting. Phase Three was item reduction using factor Rather, we would like you to rate how important you think
analysis. Phase Four involved instrument evaluation, that each item is in the care provided by health care profes-
is, psychometric testing to establish its construct validity, sionals to pregnant women using a 7-point rating scale
internal consistency reliability, and test-retest reliability. from 1 (not very important) to 7 (extremely important).”
Phase Five involved temporal stability testing. Ethical ap- Data for this phase were entered into Microsoft Excel. A
proval for this study was received from Hamilton Health mean rating score was generated for each item.
Sciences/McMaster University Faculty of Health Sciences
Research Ethics Board, the University of Manitoba Educa- Item presentation
tion/Nursing Research Ethics Board, the University of Once the most important items were selected for inclu-
Calgary Conjoint Health Research Ethics Board, the IWK sion in the QPCQ, the research team discussed and
Health Centre Research Ethics Board, and the University made decisions regarding instrument format, printed
of British Columbia Clinical Research Ethics Board. layout, wording of instructions to the subjects, wording
and structuring of the items, and response format [47].
Phase one: item generation, content validation, rating of Our intent was to develop an instrument suitable for
importance of items, and item presentation self-administration to pregnant or postpartum women.
Item generation
The first step of the instrument development process was Phase two: face validation and pretesting
to generate a comprehensive list of items to represent the Once the newly formed instrument had been drafted, it
various components of the construct quality of prenatal was assessed for face validity and pretested. Face validity
Figure 1 Flow chart of five phases of development and testing of the QPCQ.
refers to the appearance of the instrument to a layper- difficult to read or confusing. The length of time to
son, and whether the instrument appears to measure the complete the QPCQ was recorded. Women were then
construct [52]. Pretesting was used to ensure that items asked a series of questions by the research assistant
were clearly written and were being interpreted correctly about the clarity of the instructions and the items,
[46]. Research assistants administered the 111- item ver- whether the items appear to be related to the construct
sion of the QPCQ to 11 pregnant women in two sites of quality of prenatal care, suggestions for alternate
(Winnipeg and Hamilton) between November and wording, items that should be added or removed, and
December 2009 in a location of the participants’ choice the overall appearance of the instrument. The feedback
(e.g., prenatal care facility, own home). Women were regarding the quality of prenatal care instrument was
instructed to respond to each item as if they were actu- discussed by the researchers and revisions were made
ally participating in a study, but to mark items that were accordingly.
Table 1 Prenatal care guidelines reviewed to generate items for the QPCQ based on “A” grade evidence
Organization name Guideline title Publication date
The American College of Obstetricians and Gynecologists & Guidelines for Perinatal Care (6th edition) October 2007
American Academy of Pediatrics
The American College of Obstetricians and Gynecologists Committee Opinion-Psychological Risk Factors: Perinatal Screening August 2006
and Intervention
The Society of Obstetricians and Gynaecologists of Canada Healthy Beginnings: Guidelines for Care During Pregnancy December 1998
and Childbirth
Fetal Health Surveillance: Antepartum and Intrapartum September 2007
Consensus Guideline
Public Health Agency of Canada Family-Centered Maternity & Newborn Care: National Guidelines 2000
National Institute for Health and Clinical Excellence Antenatal Care: Routine care for healthy pregnant women March 2008
The Royal Australian and New Zealand College of Obstetricians and childbirth responsibilities July 2007
Obstetricians and Gynaecologists
Prenatal screening for trisomy 21, trisomy 18 and neural tube defects July 2007
Mineral and vitamin supplementation in pregnancy July 2008
Antenatal screening tests June 2008
Diagnosis of Gestational Diabetes Mellitus June 2008
Guidelines for the use of Rhd immunoglobulin in Obstetrics March 2007
in Australia
Royal College of Obstetricians and Gynaecologists Clinical Standards: Advice on Planning the Service in Obstetrics July 2002
and Gynaecology
World Health Organization What is the effectiveness of antenatal care? (Supplement) December 2005
New WHO antenatal care model 2002
Phase three: item reduction using exploratory factor analysis Recruitment and data collection procedure
The purpose of this step was to further reduce the num- Nursing staff of the postpartum units were asked to
ber of items in the QPCQ by eliminating any that were identify women who met the inclusion criteria and de-
redundant or not congruent with the overall construct termine their willingness to learn more about the study.
being measured. We aimed to recruit a convenience Women were then approached by the site research as-
sample of at least 400 women (approximately 80 women sistant (Vancouver, Calgary, Winnipeg, Halifax) or the
per study site) to participate in the item reduction step. research coordinator (Hamilton), who provided a verbal
A sample size of 400 women was determined to be suffi- explanation and written information about the study.
cient as Devillis [53] suggests that a sample size of 200 is Signed, informed consent was obtained from those who
adequate in most cases of factor analysis, while Comrey agreed to participate. Participants completed the QPCQ
and Lee state that a sample size of 300 is good and 500 and a brief demographic form, and received a $20 gift
is very good [54]. certificate in appreciation for their time and contribution
to the study. Data collection for Phase Three was con-
Setting and sample ducted between March and June 2010.
Subjects were recruited from hospitals providing obstet-
rical services in each study site. These hospitals included Data analysis
BC Women’s Hospital, Vancouver, BC; Foothills Exploratory factor analysis was conducted using SPSS
Hospital, Calgary, AB; St. Boniface General Hospital and Version 18.0. Exploratory factor analysis is used when
Health Sciences Centre Women’s Hospital, Winnipeg, the researcher does not know how many factors are
MB; St. Joseph’s Healthcare, Hamilton, ON; and IWK needed to explain the interrelationships among a set of
Health Centre, Halifax, NS. Women were eligible to par- items, indicators, or characteristics [47]. This analytic
ticipate if they had given birth to a singleton live infant, approach involves a series of structure-analyzing proce-
were 16 years of age or older, had at least 3 prenatal care dures to identify the interrelationships among a large set
visits, and could read and write English. We excluded of observed variables and group the variables into di-
women with a known psychiatric disorder that pre- mensions or factors that have similar characteristics
cluded participation in data collection, and women who [47]. First, a correlation matrix was constructed to
had a stillbirth or early neonatal death because it would summarize the interrelationships among the items in the
be inappropriate to collect data from these women dur- scale [47]. The matrix was examined to identify any
ing the grieving process. items that were either too highly correlated (r ≥ 0.80) or
not correlated sufficiently with one another (r <0.30), significantly more likely to be satisfied with their care.
and these items were dropped from the analysis. Ex- We hypothesized that women who rated the quality of
ploratory factor analysis was then used to explore the their prenatal care higher would have higher ratings of
underlying dimensions of the construct of interest [47], satisfaction with prenatal care. The Pearson correlation
since the conceptual framework did not clearly specify between the total QPCQ score and the satisfaction sub-
a set number of subconcepts or process of care dimen- scale score of the Patient Expectations and Satisfaction
sions [55,56]. Principal axis factoring was used to extract with Prenatal Care instrument (PESPC) [27] was esti-
the factors, followed by oblique rotation using the direct mated. The PESPC is a 41-item self-administered
oblimin procedure [55]. We chose oblique rotation questionnaire designed to measure pregnant women’s
because we did not expect the dimensions to be orthog- expectations and satisfaction with the prenatal care they
onal, i.e., uncorrelated with one another. A factor pat- anticipated and received. The PESPC is structurally
tern matrix was generated, which contained the loadings valid, and the satisfaction subscale demonstrates an ac-
that represented the unique relationship of each item ceptable level of internal consistency (Cronbach’s alpha
to a factor, after controlling for the correlation among of 0.94). The third approach was to test the convergent
the factors [47]. Items with weak loadings (less than validity principle, whereby different measures of the
0.40) or that did not load reasonably on any factor were same construct should correlate highly with each other
deleted. [52]. Although there is no other instrument that mea-
sures quality prenatal care in all its dimensions, one in-
Phase four: validity and reliability testing strument has been developed to measure the quality of
Phase Four involved administering the newly designed interpersonal processes of prenatal care, known as the
46-item QPCQ to women to establish its construct val- Prenatal Interpersonal Processes of Care (PIPC) [22].
idity, internal consistency reliability, and test-retest reli- The PIPC has seven subscales and 30 items that reflect
ability. Similarly to the previous phase, participants were three underlying dimensions: Communication, Patient-
recruited from hospital postpartum units in each study Centered Decision Making, and Interpersonal Style. The
site using the same eligibility/ineligibility criteria and re- majority of the seven subscales have acceptable internal
cruitment procedure. Study participants were asked to consistency reliability (ranging from 0.66 to 0.85) and
complete a brief demographic questionnaire, the 46-item preliminary evidence of construct validity has been
QPCQ, the Patient Expectations and Satisfaction with established. It was anticipated that one or more of the
Prenatal Care Instrument (PESPC) [27], and the Prenatal PIPC subscales (such as respectfulness/emotional sup-
Interpersonal Processes of Care (PIPC) instrument [22]. port) would measure similar constructs as one or more
Women were given a second copy of the QPCQ to be of the QPCQ subscales, and if so, the Pearson correl-
completed 1 week later and returned in a stamped self- ation between the subscales would be estimated.
addressed envelope. Each participant received a $20 gift
certificate in appreciation for their time and contribution Reliability
to the study. Data collection for Phase Four was con- Reliability of an instrument is the degree of consistency
ducted between September and December 2010. with which it measures the attribute it is intended to
measure [58]. Both internal consistency reliability and
Construct validity test-retest reliability of the QPCQ were assessed.
Validity testing of an instrument is on an ongoing Internal consistency is based on the average correl-
process to determine whether there is sufficient evidence ation among items within a test [59] and assesses homo-
to support that it accurately measures the construct it geneity or the extent to which all items measure the
was designed to measure, and the degree to which it per- same construct [58]. Cronbach’s alpha was used to assess
forms according to theoretical predictions [57]. First, the extent to which performance of any one item on the
confirmatory factor analysis was conducted, using the instrument was a good indicator of performance of any
Amos version 7 statistical analysis program, to test the other item on the same instrument [57], and was calcu-
utility of the underlying dimensions of the construct that lated for both the overall scale and each of the subscales.
were previously identified though exploratory factor ana- A Cronbach’s alpha coefficient of at least 0.70 is consid-
lysis [47]. A second approach to determining construct ered acceptable, while 0.80 or greater is desirable
validity was through hypothesis testing. According to [46,59]. In addition, item-to-total scale correlation coeffi-
Donabedian, patient satisfaction is one of the desired cients for the instrument subscales were examined, as
outcomes of quality of care [34]. Although different defi- well as whether the Cronbach’s alpha increased if any of
nitions of quality were used, a randomized controlled the items were deleted.
trial [12] and a cross-sectional study [7] found that The test-retest method is a test of stability to deter-
women who received “high quality” prenatal care were mine whether the same results are obtained on repeat
administration of the instrument to the same sample. As create a blueprint to establish the specific scope and em-
mentioned previously, women participating in this phase phasis of our instrument to measure quality of prenatal
of the study were given a second copy of the QPCQ to care, including the major domains to be assessed [52].
be completed one week later and returned by mail. This The Co-Principal Investigators (MIH & WAS) generated
time interval is within the recommended retest interval an initial list of 210 items for the preliminary version of
of 2 to 14 days [46]. For each participant who returned the Quality of Prenatal Care Questionnaire (QPCQ).
the second questionnaire, their scores on the QPCQ Several of the items were generated from the interview
were summed for time one and time two, and the level data that informed the development of themes. These
of agreement between the two sets of scores was deter- themes were organized into three main categories in-
mined using the intra-class correlation coefficient (ICC). formed by the structure and process components of
Reliability coefficients above 0.70 are considered accept- Donabedian’s [34] model of quality health care. Structure
able [58]. For the sample size calculation, the minimal of care themes included access to care, staff and provider
acceptable level of ICC was set at 0.75 and the upper characteristics, and the physical setting. Themes under
limit of ICC at 0.85, with α = 0.05 and β = 0.20. Using clinical care processes included screening and assess-
the method suggested by Walter, Eliasziw and Donner ment, health promotion and illness prevention, continu-
[60], a minimum sample size of 79 subjects was needed. ity of care, information sharing, women-centeredness,
and non-medicalization of pregnancy. Themes concern-
Phase five: temporal stability testing ing interpersonal care processes included emotional sup-
This phase was conducted to assess whether or not port, approachable interaction style, taking time, and
women’s responses to the QPCQ were stable between respectful attitude [48]. Items generated from the guide-
late pregnancy and the postpartum period, in order to line review reflected components of prenatal care rated
determine whether or not the birth experience and out- as having a high certainty of net benefit (i.e., “A” grade
come might have influenced women’s recall of quality of evidence) [61]). The research team then met to review
care and their responses to the questionnaire. This infor- and discuss the list of 210 items, and as the content ex-
mation is needed to inform timing of administration of perts, assessed the content validity of the QPCQ by
the questionnaire in future research. evaluating each item for its relevance and clarity, and for
For this phase of the study, we collected data from 234 any repetition of items. Four items judged to duplicate
women in four of the study sites. Women were asked to other items were removed.
provide background information and complete a package Ratings of the importance of the 206 items for the
of questionnaires shortly before they gave birth (after QPCQ were received from 56 participants (70% response
36 weeks gestation) (Time 1), again during their postpar- rate). The overall top 100 items that were rated as most
tum hospital stay (Time 2), and then again 4 to 6 weeks important were retained for the next version of the in-
after the baby was born (Time 3). Data collection was strument; these items had a mean rating of 5.7 or higher
conducted between January and July 2011. Mean scores on a scale of 1 to 7. In order to ensure that the perspec-
on the total QPCQ and each of the subscales were cal- tives of women and health care providers were equally
culated. At first, we used a randomized block design represented, we also added any items ranked in the top
(RBD) analysis of variance to evaluate the differences be- 50 from either women or providers that were not in the
tween the three time points. RBD was used to adjust for overall top 100. Because there was generally good con-
the correlations between time points for the same indi- gruence between women and providers in rating the im-
viduals. However, because of an imbalance in the num- portance of items, this resulted in only 3 items with high
ber of participants at different time points and to use ratings from health care providers and 2 items from
the most information available in the data, we followed women being added to the top 100 items. Six items de-
RBD with conducting a paired t-test between each two rived from A-level evidence but not in the top 100 items
time points (i.e., Time 1 and Time 2, Time 1 and Time were also retained. These steps resulted in a QPCQ with
3, Time 2 and Time 3). The intra-class correlation coef- 111 items.
ficient (ICC) was used to examine stability of the QPCQ When constructing the QPCQ, the research team de-
total score and subscale scores across the three time cided that each item would be rated using a Likert scale
periods. with five response categories consisting of “Strongly
Disagree” (1), “Disagree” (2), “Neither Agree Nor Dis-
Results agree” (3), “Agree” (4) and “Strongly Agree” (5). All
Phase one: item generation, content validation, rating of points on the scale were labeled to prevent the tendency
importance of items, and item presentation for respondents to endorse labeled points more often
Results from the qualitative descriptive study [48] and when only some are labeled [46]. A selection of items
the review of prenatal care guidelines were used to was “reversed” to reduce responder bias that may occur
when all items are written as positive [46]. The 111 make decisions about their prenatal care and how
items were then formatted into the initial version of the their prenatal care providers prepare and give
QPCQ with the following instructions: “This question- women options for their birth experience.
naire asks about the prenatal care you received from a 3. Sufficient Time: The 4 items within this factor focus
physician, midwife, or other health care providers during on the time prenatal care providers spend
your pregnancy. You might have seen more than one addressing women’s questions and the time spent in
health care provider for your care but please think of the an appointment.
prenatal care you received overall when completing this 4. Approachability: The 4 items in this factor address
questionnaire. Please read each statement carefully and the health care provider’s approachability (e.g.,
indicate how much you agree or disagree with it by circ- woman was afraid to ask questions, felt like she was
ling the appropriate number.” wasting prenatal care provider’s time).
5. Availability: The 5 items in this factor include knowing
Phase two: face validation and pretesting how to contact the prenatal care provider and how
During the pretesting phase, the mean length of time for available the clinic/office staff or prenatal care provider
women to complete the 111-item version of the QPCQ are to respond to questions, concerns or needs.
ranged from 10 to 23 minutes, with a mean of 16 mi- 6. Support and Respect: This factor has 12 items
nutes. Women indicated that the QPCQ was easy to related to women being respected and supported by
complete, and only a few items were identified as poten- their prenatal care providers in regard to their
tially problematic. Based on this feedback, 11 items were concerns and decisions.
removed from the QPCQ, either because the item was
too vague (e.g., “My prenatal care provider was thor- We used the Flesch-Kincaid Grade Level test, available
ough”) or the item was not universally applicable to all in Microsoft Word, to assess the readability of the 46-
pregnant women (e.g., “My prenatal care provider took item QPCQ. This test rates text on a U. S. school grade
time to answer my partner’s/family member’s ques- level, which is similar to the Canadian grade level sys-
tions”). This resulted in a 100-item questionnaire. In tem. The QPCQ had a Flesch-Kincaid grade level score
addition, four items underwent wording changes to im- of 8.7, which means that women with a grade 9 educa-
prove their clarity or completeness (e.g., The item “I fully tion can read and understand the items in the QPCQ.
understood the reasons for tests my prenatal care pro-
vider (s) ordered for me” was changed to “I fully under- Phase four: validity and reliability testing
stood the reasons for blood work and other tests my The final sample for Phase Four consisted of 422 women.
prenatal care provider (s) ordered for me”). Demographic characteristics of the participants are sum-
marized in Table 2.
Phase three: item reduction using exploratory factor analysis Confirmatory factor analysis verified and confirmed
The final sample for Phase Three consisted of 422 par- the presence of six factors, and all 46 items were there-
ticipants. Demographic characteristics of the participants fore retained in the QPCQ. Refer to Table 3 for a list of
are summarized in Table 2; cases with missing data on the items loading on each factor. The factor (or sub-
each item were excluded from the analyses. Use of ex- scale) means and standard deviations are presented in
ploratory factor analysis extracted 5-, 6- and 7-factor so- Table 4. Each subscale mean score was calculated by first
lutions. The researchers examined the 3 solutions, and reversing the scores of any reverse scored items in the
selected the 6-factor solution because the items were subscale, then summing the scores for the items of the
judged to be the most relevant and grouped into factors subscale and dividing the sum by the number of items.
in the most meaningful way based on our clinical know- The QPCQ is a norm-referenced measure, in which an
ledge and experience. The 6-factor solution reduced the individual’s score takes on meaning when compared with
QPCQ to 46 items. These final factors or dimensions the scores of others (e.g., in the same sample) [46].
comprised the subscales of the QPCQ; the research team Higher scores on the QPCQ and its subscales reflect a
met to agree on the names to be assigned to each factor. higher rating of quality of prenatal care. The mean
The six factors are as follows: scores for the factors ranged from 3.84 to 4.37 out of a
total score of 5, indicating that women rated the quality
1. Information Sharing: The 9 items within this factor of their prenatal care toward the higher end of the con-
focus on how prenatal care providers answer tinuum. The factor “Anticipatory Guidance” had the
questions, keep information confidential, and ensure lowest mean rating, while “Information Sharing” had the
women understand reasons for tests and their results. highest mean rating.
2. Anticipatory Guidance: The 11 items in this factor A significant positive correlation between the QPCQ
focus on women being given enough information to total score and the satisfaction subscale score of the
Table 2 Demographic characteristics of participants in Table 2 Demographic characteristics of participants in

phases three, four, and five1 phases three, four, and five1 (Continued)
Characteristic Phase three Phase four Phase five Language Spoken Most Often at Home
Item Validity & Temporal English 352 (83.4) 352 (83.4) 205 (86.5)
reduction reliability stability
French 8 (1.9) 5 (1.2) 1 (0.4)
N = 422 N = 422 N = 234
n (%) n (%) n (%) Chinese 9 (2.1) 7 (1.7) 4 (1.7)
Recruitment Site Tagalog (Filipino) 3 (0.7) 13 (3.1) 2 (0.8)
Vancouver 82 (19.4) 64 (15.2) 9 (3.8) Other 32 (7.6) 24 (5.7) 13 (5.6)
Calgary 98 (23.2) 61 (14.5) 79 (33.8) Prenatal Care Provider**
Winnipeg 77 (18.3) 112 (26.5) 67 (28.6) Family physician 254 (60.0) 253 (60.0) 149 (62.9)
Hamilton 86 (20.4) 106 (25.1) 79 (33.8) Obstetrician 270 (64.0) 281 (66.6) 158 (66.7)
Halifax 79 (18.7) 79 (18.7) 0* Midwife 46 (11.0) 39 (9.2) 27 (11.4)
Marital Status Nurse practitioner 30 (7.0) 56 (13.3) 45 (19.0)
Married 281 (66.6) 284 (67.3) 168 (70.9) Site of Prenatal Care
Common-law 49 (11.6) 74 (17.5) 35 (14.8) Private office 211 (50.0) 165 (39.1) 73 (30.8)
Living with a partner 10 (2.4) 15 (3.6) 13 (5.5) Clinic 175 (41.5) 201 (47.6) 87 (36.7)
Single (never married) 30 (7.1) 45 (10.7) 16 (6.8) Outpatient department 28 (6.6) 42 (10.0) 47 (19.8)
of a hospital
Separated or divorced 2 (0.5) 1 (0.2) 2 (0.8)
Type of Delivery***
Household Income
Vaginal 289 (68.5) 318 (75.4) 154 (65.0)
Below $10,000 21 (5.0) 25 (5.9) 13 (5.5)
Planned C-section 62 (14.7) 47 (11.1) 12 (5.1)
$10,000 to $19,999 20 (4.7) 40 (9.5) 11 (4.6)
Unplanned C-section 71 (16.8) 55 (13.0) 28 (11.8)
$20,000 to $39,999 43 (10.2) 50 (11.8) 29 (12.2)
Parity***
$40,000 to $59,999 56 (13.3) 65 (15.4) 27 (11.4)
Primipara 169 (40.0) 157 (37.2) 113 (48.3)
$60,000 to $79,999 70 (16.6) 48 (11.4) 33 (13.9)
Multipara 239 (56.6) 248 (58.8) 103 (40.0)
$80,000 and above 199 (47.2) 179 (42.4) 114 (48.1)
Maternal Health
Highest Level of Education
Chronic health problem 49 (11.6) 37 (8.8) 37 (15.6)
Less than high school 35 (8.3) 34 (8.0) 16 (6.8)
Complication during 104 (24.6) 100 (23.7) 39 (16.7)
Completed high school 40 (9.5) 54 (12.8) 19 (8.0) pregnancy
Some community college 40 (9.5) 31 (7.3) 24 (10.1) Medical problem since 20 (4.7) 18 (4.3) 21 (8.9)
or technical school delivery
Completed community 93 (22.0) 92 (21.8) 41 (17.3) Infant***
college or technical school
Boy 224 (53.1) 194 (46.0) 87 (36.7)
Some university 39 (9.2) 39 (9.2) 20 (8.4)
Girl 198 (46.9) 227 (53.8) 106 (44.7)
Completed bachelor’s 122 (28.9) 107 (25.4) 77 (32.5)
degree Variable Mean (SD) Mean (SD) Mean (SD)
Graduate degree 52 (12.3) 63 (14.9) 36 (15.2) Maternal age (years) 30.2 (5.3) 30.2 (5.1) 29.7 (4.8)
Racial/Ethnic Background Gestational age at first 10.9 (9.0) 10.6 (5.8) 10.2 (5.4)
prenatal care visit (weeks)
White 316 (74.9) 291 (69.0) 174 (73.4)
Gestational age at 39.2 (1.4) 39.3 (2.0) 39.6 (1.2)
Aboriginal 14 (3.3) 23 (5.5) 17 (7.2) delivery (weeks)***
Black 13 (3.1) 4 (0.9) 3 (1.3) Birth weight of 3406.3 (544.3) 3465.9 (496.3) 3506.8 (472.2)
Chinese 18 (4.3) 15 (3.6) 9 (3.8) infant (grams)***
1
Missing responses were excluded from analyses.
Filipino 18 (4.3) 27 (6.4) 4 (1.7)
*Halifax did not participate in Phase Five of the study.
Latin American 8 (1.9) 5 (1.2) 5 (2.1) **Percentages reported for prenatal care providers do not add to 100 as
women were instructed to check off all that applied.
South Asian 13 (3.1) 7 (1.7) 6 (2.5) ***In Phase Five, responses for these items are reported for Time 2 participants
Other 18 (4.3) 40 (9.5) 16 (6.8) (n = 194 postpartum women).
Born in Canada
Yes 324 (76.8) 318 (75.4) 191 (80.6)
No 92 (21.8) 102 (24.2) 42 (17.7)
Table 3 Items loading on each factor, corrected item-total subscale correlations, and Cronbach’s alpha if item deleted
from subscale
Factor (Subscale) items Corrected item-total Cronbach’s alpha
subscale correlation if item deleted
from subscale
Factor 1: Information Sharing (9 items) Cronbach’s Alpha = .86
- I was given adequate information about prenatal tests and procedures .60 .84
- I was always given honest answers to my questions .56 .85
- Everyone involved in my prenatal care received the important information about me .45 .86
- I was screened adequately for potential problems with my pregnancy .47 .85
- The results of tests were explained to me in a way I could understand .67 .83
- My prenatal care provider(s) gave straightforward answers to my questions .70 .83
- My prenatal care provider(s) gave me enough information to make decisions for myself .67 .83
- My prenatal care provider(s) kept my information confidential .51 .85
- I fully understood the reasons for blood work and other tests my prenatal care provider(s) ordered for me .66 .83
Factor 2: Anticipatory Guidance (11 items) Cronbach’s Alpha = .85
- My prenatal care provider(s) gave me options for my birth experience .55 .83
- I was given enough information to meet my needs about breast-feeding .47 .84
- My prenatal care provider(s) prepared me for my birth experience .57 .83
- My prenatal care provider(s) spent time talking with me about my expectations for labor and delivery .61 .83
- I was given enough information about the safety of moderate exercise during pregnancy .46 .84
- I received adequate information about my diet during pregnancy .60 .83
- My prenatal care provider(s) was interested in how my pregnancy was affecting my life .58 .83
- I was linked to programs in the community that were helpful to me .41 .85
- I received adequate information about alcohol use during pregnancy .39 .85
- I was given adequate information about depression in pregnancy .58 .83
- My prenatal care provider(s) took time to ask about things that were important to me .66 .83
Factor 3: Sufficient Time (5 items) Cronbach’s Alpha = .81
- I had as much time with my prenatal care provider(s) as I needed .54 .79
- My prenatal care provider(s) was rushed .48 .84
- My prenatal care provider(s) always had time to answer my questions .70 .75
- My prenatal care provider(s) made time for me to talk .73 .73
- My prenatal care provider(s) took time to listen .68 .75
Factor 4: Approachability (4 items) Cronbach’s Alpha = .73
- My prenatal care provider(s) was abrupt with me .50 .68
- I was rushed during my prenatal care visits .49 .69
- My prenatal care provider(s) made me feel like I was wasting their time .56 .65
- I was afraid to ask my prenatal care provider(s) questions .55 .65
Factor 5: Availability (5 items) Cronbach’s Alpha = .82
- I knew how to get in touch with my prenatal care provider(s) .54 .80
- Someone in my prenatal care provider(s)’s office always returned my calls .48 .82
- My prenatal care provider(s) was available when I had questions or concerns .63 .77
- I could always reach someone in the office/clinic if I needed something .71 .74
- I could reach my prenatal care provider(s) by phone when necessary .68 .75
Factor 6: Support and Respect (12 items) Cronbach’s Alpha = .93
- My prenatal care provider(s) respected me .63 .93
- My prenatal care provider(s) respected my knowledge and experience .63 .93
Table 3 Items loading on each factor, corrected item-total subscale correlations, and Cronbach’s alpha if item deleted
from subscale (Continued)
- My decisions were respected by my prenatal care provider(s) .73 .92
- My prenatal care provider(s) was patient .67 .93
- I was supported by my prenatal care provider(s) in doing what I felt was right for me .71 .92
- My prenatal care provider(s) supported me .75 .92
- My prenatal care provider(s) paid close attention when I was speaking .70 .92
- My concerns were taken seriously .71 .92
- I was in control of the decisions being made about my prenatal care .69 .92
- My prenatal care provider(s) supported my decisions .80 .92
- I was at ease with my prenatal care provider(s) .68 .93
- My values and beliefs were respected by my prenatal care provider(s) .69 .92
PESPC provided additional support for construct validity There were 234 participants at Time 1, 194 at Time 2,
(Pearson r = 0.81). Convergent validity was demonstrated and 158 at Time 3, demonstrating some attrition over
by a significant positive correlation (r = 0.63) between time. There were no statistically significant differences in
the “Support and Respect” subscale of the QPCQ and mean scores across time periods for the majority of the
the “Respectfulness/Emotional Support” subscale of the QPCQ subscales (Tables 6, 7, and 8). Although there
PIPC, and a significant positive correlation (r = 0.59) be- was a significant difference in mean score for the Antici-
tween the “Anticipatory Guidance” subscale of the QPCQ patory Guidance subscale between Time 1 and 2 (d =
and the “Empowerment/Self-care” subscale of the PIPC. 0.22) and between Time 1 and 3 (d = 0.17), and for the
Testing showed acceptable internal consistency reli- mean QPCQ score between Time 1 and 2 (d = 0.07), the
ability for the overall scale (Cronbach’s alpha = 0.96) and differences in mean scores were small and deemed not
for the six subscales (ranging from 0.73-0.93). Refer to to be clinically significant. The intra-class correlation co-
Table 3 for the results. Item-total scale correlation coef- efficient (ICC) was also used to examine stability of the
ficients were positive, and the Cronbach’s alpha did not QPCQ subscale scores across the three time periods,
increase if any of the items were deleted, with the excep- and varied from 0.67 to 0.76 (Table 9). The ICC for the
tion of one item, “My prenatal care provider was total QPCQ score was 0.81 (95% CI: 0.76-0.85).
rushed,” showing a slight increase.
Of the 422 participants, 182 women (43%) completed Discussion
the retest version of the QPCQ 5 to 14 days later and Measurement of the quality of prenatal care is an essen-
returned it by mail. The QPCQ demonstrated acceptable tial step in more fully evaluating its effectiveness. We
test-retest reliability (ICC = 0.88), indicating stability of have developed a new instrument, the Quality of Pre-
the instrument on repeat administration. natal Care Questionnaire (QPCQ), through a rigorous
process of item generation and psychometric testing.
Phase five: temporal stability testing The QPCQ was designed to be completed by women
Demographic characteristics of the participants in Phase who received prenatal care, consistent with growing ac-
Five (Time 1) are summarized in Table 2, and the sam- knowledgement of the value of the consumer’s viewpoint
ple size for each site and time period is shown in Table 5. in evaluating quality of health care [22,23,62,63]. The
final 46-item version of the QPCQ demonstrated con-
struct validity, as well as acceptable internal consistency
Table 4 QPCQ factor (or subscale) means and standard
deviations (SD) from phase four (N = 422)
and test-retest reliability. Having women complete the
QPCQ before delivery, during their postpartum hospital
Subscale Mean (SD)
stay, and again 4 to 6 weeks after delivery confirmed that
Factor 1 – Information Sharing 4.37 (0.50)
women’s ratings of their quality of prenatal care did not
Factor 2 – Anticipatory Guidance 3.84 (0.60) change as a result of giving birth or between the early
Factor 3 – Sufficient Time 4.16 (0.65) postpartum period and 4 to 6 weeks postpartum. These
Factor 4 – Approachability 4.22 (0.71) results suggest that the QCPQ can be administered to a
Factor 5 – Availability 4.18 (0.65) woman after 36 weeks gestation and up to 6 weeks
Factor 6 – Support and Respect 4.35 (0.52)
postpartum.
Exploratory factor analysis resulted in a six-factor so-
Total QPCQ 4.19 (0.50)
lution for the QPCQ, with six factors retained in the
Table 5 Number of participants per site for each time period in phase five of the study
Recruitment Before delivery After delivery 4-6 week Total matched Total matched Total matched
site QPCQ –T1* QPCQ –T2* QPCQ –T3* T1/T2 T2/T3 T1/T2/T3
n (%) n (%) n (%) n (%) n (%) n (%)
Vancouver 9 (4) 6 (3) 5 (2) 6 (3) 5 (2) 5 (2)
Calgary 79 (33) 77 (32) 65 (27) 74 (31) 64 (27) 62 (26)
Winnipeg 67 (28) 42 (18) 32 (14) 42 (18) 32 (14) 32 (14)
Hamilton 79 (33) 69 (29) 56 (24) 69 (29) 56 (24) 56 (24)
SUBTOTAL 234 194 158 191 157 155
*T1 = time one, T2 = time two, T3 = time three.
confirmatory factor analysis. This indicates that the con- needed something”). Items in the QPCQ “Information
cept of quality of prenatal care is multidimensional and Sharing” and “Anticipatory Guidance” subscales primarily
the instrument consists of six subscales [56]. In addition measured the clinical or technical processes of care, while
to the total QPCQ score, the score for each of the sub- items in the “Approachability” and “Support and Respect”
scales can be examined separately. The derived factors subscales reflected interpersonal processes. Mean scores
made conceptual sense, and were consistent with the for the subscales ranged from 3.84 to 4.37, and indicated
themes arising from our qualitative descriptive study that women rated the quality of “Anticipatory Guidance”
[48]. The six subscales of the QPCQ measure both the lowest, and “Information Sharing” and “Support and
structure and process attributes of Donabedian’s model, Respect” the highest (Table 4). In the temporal stability
with more emphasis on clinical and interpersonal pro- testing phase, the Anticipatory Guidance subscale was the
cesses of care. Although the initial draft of the QPCQ only one showing significant (although small) differences
contained several items related to structure of prenatal in mean scores over time, with both postpartum scores
care, many of these items were rated low on importance being higher than the prenatal score. Some of the Antici-
in Phase One and were subsequently deleted from the patory Guidance items may be more accurately assessed
questionnaire (e.g., “The office/clinic was in a convenient by women in the postpartum period (e.g., “I was given
location,” “The waiting area was crowded.”). This is con- enough information to meet my needs about breastfeed-
sistent with Campbell’s viewpoint that structure is not a ing”), possibly resulting in higher rating scores.
component of care “but the conduit through which care The subscales and items in the QPCQ measure com-
is delivered and received” [37]. As such, structure may ponents of quality of prenatal care identified by women
influence the way in which care is provided and thus as important in other qualitative studies [17-19] and an
women’s assessment of quality. For example, having ad- integrative review [64]. Wheatley and colleagues found
equate funding, facilities and personnel may influence that markers of quality prenatal care included the extent
women’s responses to items in the “Sufficient Time” sub- to which the provider listened carefully, showed respect,
scale (e.g., “I had as much time with my prenatal care explained things, and spent enough time with the woman
provider as I needed”) and the “Availability” subscale (e.g., [18]. The main elements of quality of maternity care ser-
“I could always reach someone in the office/clinic if I vices identified in Goberna-Tricas’s study were technical
Table 6 Comparison of QPCQ subscale and total scores Table 7 Comparison of QPCQ subscale and total scores
between Time 1 and Time 2 in Phase five, using paired between Time 1 and Time 3 in Phase five, using paired
t-test t-test
Subscale N Time 1 Time 2 p Subscale N Time 1 Time 3 p
Late Early Late 4-6 weeks
pregnancy postpartum pregnancy postpartum
Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Factor 1 –Information Sharing 191 4.27 (0.52) 4.29 (0.50) 0.41 Factor 1 – Information Sharing 155 4.29 (0.45) 4.27 (0.44) 0.43
Factor 2 – Anticipatory Guidance 191 3.55 (0.73) 3.77 (0.66) <0.001 Factor 2 – Anticipatory Guidance 155 3.53 (0.70) 3.70 (0.67) <0.001
Factor 3 – Sufficient Time 191 4.09 (0.67) 4.10 (0.68) 0.69 Factor 3 – Sufficient Time 155 4.11 (0.64) 4.12 (0.56) 0.73
Factor 4 – Approachability 191 4.24 (0.68) 4.25 (0.71) 0.92 Factor 4 – Approachability 155 4.30 (0.60) 4.31 (0.61) 0.75
Factor 5 – Availability 191 4.02 (0.63) 4.07 (0.66) 0.19 Factor 5 – Availability 155 4.02 (0.58) 4.04 (0.68) 0.70
Factor 6 – Support and Respect 191 4.23 (0.55) 4.26 (0.58) 0.52 Factor 6 – Support and Respect 155 4.25 (0.51) 4.25 (0.51) 0.97
Total QPCQ 191 4.04 (0.53) 4.11 (0.52) 0.01 Total QPCQ 155 4.05 (0.48) 4.09 (0.48) 0.12
Table 8 Comparison of QPCQ subscale and total scores and providers of care. The five study sites provided a
between Time 2 and Time 3 in Phase five, using paired broad cross-section of the childbearing population in
t-test Canada and its multicultural uniqueness. For instance,
Subscale N Time 2 Time 3 p Winnipeg has a large and growing Aboriginal popula-
Early 4-6 weeks tion, Vancouver has a high concentration of immigrants
postpartum postpartum from East Asia, and Halifax serves a large rural popula-
Mean (SD) Mean (SD) tion. Similarly, there are differences in the options for
Factor 1 – Information Sharing 157 4.31 (0.44) 4.26 (0.44) 0.05 prenatal care available to women across the five study
Factor 2 – Anticipatory Guidance 157 3.77 (0.64) 3.69 (0.67) 0.02 sites. Midwifery care was not regulated or integrated
Factor 3 – Sufficient Time 157 4.14 (0.60) 4.12 (0.56) 0.47 into the health care system in Nova Scotia at the time of
this study, but was more widely available to women liv-
Factor 4 – Approachability 157 4.31 (0.65) 4.31 (0.60) 0.99
ing in certain areas of Ontario, such as Hamilton, and
Factor 5 – Availability 157 4.08 (0.60) 4.04 (0.68) 0.16
other provinces where midwifery was a regulated profes-
Factor 6 – Support and Respect 157 4.27 (0.54) 4.25 (0.50) 0.36 sion. In some provinces, obstetricians were the most com-
Total QPCQ 157 4.13 (0.47) 4.09 (0.48) 0.05 mon provider of prenatal care (e.g., Ontario) compared to
family physicians in others (e.g., British Columbia) [65].
expertise of the health professional, the human dimension Finally, some prenatal programs had integrated additional
of the relationship between the caregiver and the patient or substitutive prenatal care through nurse specialists and
(interpersonal skill), and the structural aspects that deter- nurse practitioners [66]. The study protocol thereby en-
mine the context in which the health care is provided sured the development of an instrument that captured
[17]. Hildingsson and Thomas analyzed responses of 827 core elements of quality applicable to the Canadian popu-
Swedish pregnant women to an open ended question in a lation as a whole under a system of universal health care.
survey, and grouped the findings into the following cat- Our study also has limitations. The QPCQ was devel-
egories: technical aspects of care (being skilled and com- oped in the context of the Canadian health care system,
petent), psychological aspects of care (being a good so its applicability to health care systems, prenatal care
listener, being supportive, treating the woman with re- provision, or populations that are substantively different
spect), personal characteristics (not judging, not being will need to be assessed prior to widespread use. The in-
rushed), health-related content and information (checking strument was intended to be applicable to all pregnant
the baby’s health, providing information about physical women; therefore the items may not fully capture all
and mental changes and breastfeeding), and structural as- elements of quality in specific situations, such as care
pects of provider visits (enough time during visits, con- provided to women with a complicated or high risk
tinuity of care) [19]. The items in the QPCQ capture the pregnancy. The QPCQ reflects the woman’s perception
majority of these aforementioned elements of quality of of the quality of prenatal care she received; further re-
prenatal care. search is needed to determine the congruence between
the woman’s assessment of quality and the extent to
Strengths and limitations of the study which the care she received conformed to guidelines for
The QPCQ was developed taking into consideration prenatal care using methods such as chart audits. The
effective prenatal care practices, the diversity of the relatively high mean scores found among some of the
Canadian population, and variations in the way prenatal QPCQ subscales may be a reflection of selection bias in-
care is delivered, and with input from both consumers curred as a result of using a convenience sample, in that
women who agreed to participate in the study may have
Table 9 Intra-class correlation coefficients for QPCQ viewed the quality of their care more positively than
subscales across three time points in Phase five women who declined participation. In addition, the re-
Factor Name Intra-class 95% confidence sponse rate for completion of the retest version of the
correlation interval QPCQ was relatively low (43%), although the number of
coefficient
respondents (n = 182) exceeded the minimum sample size
1 – Information Sharing 0.75 0.69-0.80
of 79 estimated as needed in the sample size calculation.
2 – Anticipatory Guidance 0.76 0.71-0.81 Finally, we acknowledge there are competing views re-
3 – Sufficient Time 0.76 0.70-0.81 garding use of non-parametric versus parametric statis-
4 – Approachability 0.67 0.61-0.74 tics to analyze Likert scales [67,68]. Although individual
5 – Availability 0.76 0.71-0.81 Likert items are ordinal in character, we support the pos-
6 – Support and Respect 0.74 0.69-0.79
ition that Likert scales (collections of Likert items) pro-
duce interval data, and that it is appropriate to summarize
Total score 0.81 0.76-0.85
the ratings generated from Likert scales using means and
standard deviations, and to use parametric statistics to quality of care and a variety of maternal and infant health
analyze the scales [68]. Health care providers may find it outcomes.
helpful to examine the rank order of (dis)agreement for
Abbreviations
individual items on the QPCQ to identify specific aspects QPCQ: Quality of Prenatal Care Questionnaire; CTP: Content and timing of
of prenatal care in need of quality improvement. However, care in pregnancy tool; PESPC: Patient Expectations and Satisfaction with
for research using the QPCQ, we agree with Carifio and Prenatal Care instrument; PIPC: Prenatal Interpersonal Processes of Care
instrument; ICC: Intra-class correlation coefficient; RBD: Randomized block
Perla’s view that treating the data from Likert scales as design.
interval in character permits “more powerful and nuanced
analyses” [68]. Competing interests
The authors declare that they have no competing interests.
Recommendations for future research Authors’ contributions

WAS and MIH wrote the grant application, directed the implementation of
This valid and reliable instrument can now be used as the study protocol, and had overall responsibility for the research. All authors
an outcome measure to evaluate quality of prenatal care, contributed to conception and design of the study, and interpretation of the
to identify predictors of quality of prenatal care, to com- results, with input from the collaborators. AB coordinated the study. MIH,
WAS, ST, PAJ, and DCY supervised participant recruitment in their respective
pare and contrast quality of prenatal care across regions, sites. NA-D performed data analysis, assisted by AB. MIH drafted the manuscript.
populations, and types of health care providers and ser- All authors provided feedback on the draft manuscript, and read and approved
vice delivery models, and to assess the relationship be- the final manuscript.
tween quality of care and a variety of maternal and
Acknowledgements
infant health outcomes. The outcomes studied should This study was funded by an operating grant from the Canadian Institutes of
not be limited to gestational age and birth weight, but Health Research (CIHR) (MOP - 84427). Dr. Heaman received career support
rather encompass a range of health status and behavioral from a CIHR Chair in Gender and Health award. We thank our collaborators
for their contributions to the study: Melanie Basso (Vancouver), Laurie Blahitka
indicators. As noted by Alexander and Kotelchuck, (Calgary), Patricia Gregory (Winnipeg), Lynda Tjaden (Winnipeg), Jackie Barrett
“there are several other perinatal outcomes that may be (Hamilton), Glenda Carson (Halifax), and Kate Lively (Halifax).
modified by prenatal care” [1]. Rosenberg has suggested
that attention should be given to studying the effect of
optimal prenatal care on maternal self-esteem, attach-
ment, connections to both the health care system and The QPCQ is licensed under a Creative Commons Attribution – Non
social services, and maternal physical and mental health Commercial – No Derivatives 4.0 International License. © Copyright 2013.
W. Sword, M. Heaman, and the QPCQ Research Team. McMaster University.
[69]. Other appropriate outcomes include postnatal All rights reserved.
health status of mother and infant, the adoption and
maintenance of healthy behaviors, disclosure of sensitive Author details
1
College of Nursing and Departments of Community Health Sciences and
concerns, postpartum behaviors, maternal and infant Obstetrics, Gynecology and Reproductive Sciences, College of Medicine,
health care utilization, and infant injury and disease Faculty of Health Sciences, University of Manitoba, 89 Curry Place, Winnipeg
rates [1]. The relationship between quality of care and a R3T 2N2, Manitoba, Canada. 2School of Nursing and Department of Clinical
Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster
variety of outcomes may have implications for allocation University, 1280 Main Street West, Hamilton L8S 4K1, Ontario, Canada.
of resources, program planning, and policy development. 3
Gilbrea Centre for Studies in Aging, McMaster University, 1280 Main Street
With a valid and reliable QPCQ, researchers and decision West, Hamilton L8S 4M4, Ontario, Canada. 4Departments of Paediatrics and
Community Health Sciences, Faculty of Medicine, University of Calgary, 2888
makers will be well positioned to collect evidence that can Shaganappi Trail NW, Calgary T3B 6A8, Alberta, Canada. 5School of
be used to design and refine programs to improve Population and Public Health, University of British Columbia, 2206 East Mall,
women’s experiences and enhance perinatal outcomes. Vancouver V6N 1Z3, British Columbia, Canada. 6Department of Obstetrics
and Gynecology, IWK Health Centre, Dalhousie University, 5980 University
Avenue, P.O. Box 9700, Halifax B3K 6R8, Nova Scotia, Canada. 7Faculty of
Nursing, University of Alberta, 5-258 Edmonton Clinic Health Academy,
Conclusions 11405-87th Avenue, Edmonton T6G 1C9, Alberta, Canada. 8Department of
The QPCQ is a new self-report instrument that mea- Obstetrics and Gynecology and Department of Clinical Epidemiology and
sures overall quality of prenatal care, and quality of care Biostatistics, Faculty of Health Sciences, McMaster University, 1280 Main
Street West, Hamilton L8S 4K, Ontario, Canada. 9Department of Obstetrics,
for six factors or subscales. Following a rigorous process Gynecology and Reproductive Sciences, College of Medicine, Faculty of
of development and psychometric testing, the QPCQ Health Sciences, University of Manitoba, 735 Notre Dame Avenue, University
has been shown to demonstrate construct validity, in- of Manitoba, Winnipeg R3T 2N2, Manitoba, Canada.
ternal consistency reliability, and test-retest reliability. Received: 16 September 2013 Accepted: 16 May 2014
This valid and reliable instrument will be useful in future Published: 3 June 2014
research to evaluate women’s perceptions of quality of
prenatal care, to compare quality of care across regions, References
1. Alexander GR, Kotelchuck M: Assessing the role and effectiveness of
populations, types of health care provider, and service prenatal care: history, challenges, and directions for future research.
delivery models, and to assess the relationship between Public Health Rep 2001, 116(4):306–316.
2. Lu MC, Tache V, Alexander GR, Kotelchuck M, Halfon N: Preventing low 25. Handler A, Rosenberg D, Raube K, Lyons S: Prenatal care characteristics
birth weight: is prenatal care the answer? J Matern Fetal Neonatal Med and African-American women’s satisfaction with care in a managed care
2003, 13(6):362–380. organization. Womens Health Issues 2003, 13(3):93–103.
3. Moos MK: Prenatal care: limitations and opportunities. J Obstet Gynecol 26. Lawrence JM, Ershoff D, Mendez C, Petitti DB: Satisfaction with pregnancy
Neonatal Nurs 2006, 35(2):278–285. and newborn care: development and results of a survey in a health
4. Heaman MI, Newburn-Cook CV, Green CG, Elliott LJ, Helewa ME: Inadequate maintenance organization. Am J Manag Care 1999, 5(11):1407–1413.
prenatal care and its association with adverse pregnancy outcomes: a 27. Omar MA, Schiffman RF, Bingham CR: Development and testing of the
comparison of indices. BMC Pregnancy Childbirth 2008, 8:15. patient expectations and satisfaction with prenatal care instrument. Res
5. VanderWeele TJ, Lantos JD, Siddique J, Lauderdale DS: A comparison of Nurs Health 2001, 24(3):218–229.
four prenatal care indices in birth outcome models: comparable results 28. Clement S, Sikorski J, Wilson J, Das S, Smeeton N: Women’s satisfaction
for predicting small-for-gestational-age outcome but different results for with traditional and reduced antenatal visit schedules. Midwifery 1996,
preterm birth or infant mortality. J Clin Epidemiol 2009, 62(4):438–445. 12(3):120–128.
6. Partridge S, Balayla J, Holcroft CA, Abenhaim HA: Inadequate prenatal care 29. Seguin L, Therrien R, Champagne F, Larouche D: The components of
utilization and risks of infant mortality and poor birth outcome: a women’s satisfaction with maternity care. Birth 1989, 16(3):109–113.
retrospective analysis of 28,729,765 U.S. deliveries over 8 years. Am J 30. Erci B, Ivanov L: The relationship between women’s satisfaction with
Perinatol 2012, 29(10):787–794. prenatal care service and the characteristics of the pregnant women
7. Korenbrot CC, Wong ST, Stewart AL: Health promotion and psychosocial and the service. Eur J Contracept Reprod Health Care 2004, 9(1):16–28.
services and women’s assessments of interpersonal prenatal care in 31. Ivanov LL, Flynn BC: Utilization and satisfaction with prenatal care
Medicaid managed care. Matern Child Health J 2005, 9(2):135–149. services. West J Nurs Res 1999, 21(3):372–386.
8. Beeckman K, Louckx F, Masuy-Stroobant G, Downe S, Putman K: The 32. Ivanov LL, Champion VL: Development of a Russian satisfaction with
development and application of a new tool to assess the adequacy of the prenatal care scale. J Nurs Meas 2000, 8(2):117–129.
content and timing of antenatal care. BMC Health Serv Res 2011, 33. Donabedian A: Evaluating the quality of medical care. Milbank Mem Fund
11:213. Q 1966, 44(Suppl 3):206.
9. Kogan MD, Alexander GR, Kotelchuck M, Nagey DA: Relation of the 34. Donabedian A: The quality of care. How can it be assessed? JAMA 1988,
content of prenatal care to the risk of low birth weight. Maternal reports 260(12):1743–1748.
of health behavior advice and initial prenatal care procedures. JAMA 35. Aday LA, Andersen R: A framework for the study of access to medical
1994, 271(17):1340–1345. care. Health Serv Res 1974, 9(3):208–220.
10. White DE, Fraser-Lee NJ, Tough S, Newburn-Cook CV: The content of 36. Andersen RM: Revisiting the behavioral model and access to medical
prenatal care and its relationship to preterm birth in Alberta. Canada care: does it matter? J Health Soc Behav 1995, 36(1):1–10.
Health Care Women Int 2006, 27(9):777–792. 37. Campbell SM, Roland MO, Buetow SA: Defining quality of care. Soc Sci Med
11. Handler A, Rankin K, Rosenberg D, Sinha K: Extent of documented 2000, 51(11):1611–1625.
adherence to recommended prenatal care content: provider site 38. Bennett I, Switzer J, Aguirre A, Evans K, Barg F: ‘Breaking it down’:
differences and effect on outcomes among low-income women. Matern patient-clinician communication and prenatal care among African American
Child Health J 2012, 16(2):393–405. women of low and higher literacy. Ann Fam Med 2006, 4(4):334–340.
12. Klerman LV, Ramey SL, Goldenberg RL, Marbury S, Hou J, Cliver SP: A 39. Moore ML, Ketner M, Walsh K, Wagoner S: Listening to women at risk for
randomized trial of augmented prenatal care for multiple-risk, Medicaid- preterm birth. MCN Am J Matern Child Nurs 2004, 29(6):391–397.
eligible African American women. Am J Public Health 2001, 91(1):105–111. 40. Tandon SD, Parillo KM, Keefer M: Hispanic women’s perceptions of
13. Ricketts SA, Murray EK, Schwalberg R: Reducing low birthweight by patient-centeredness during prenatal care: a mixed-method. Birth-Issues
resolving risks: results from Colorado’s prenatal plus program. Am J Perinatal Care 2005, 32(4):312–317.
Public Health 2005, 95(11):1952–1957. 41. Bloom KC, Bednarzyk MS, Devitt DL, Renault RA, Teaman V, Van Loock DM:
14. Carlson NS, Lowe NK: Centering pregnancy: a new approach in prenatal Barriers to prenatal care for homeless pregnant women. J Obstet Gynecol
care. MCN Am J Matern Child Nurs 2006, 31(4):218–223. Neonatal Nurs 2004, 33(4):428–435.
15. Wilkinson DS, Korenbrot CC, Greene J: A performance indicator of 42. Sword W: Prenatal care use among women of low income: a matter of
psychosocial services in enhanced prenatal care of Medicaid-eligible “taking care of self”. Qual Health Res 2003, 13(3):319–332.
women. Matern Child Health J 1998, 2(3):131–143. 43. Chew-Graham CA, Sharp D, Chamberlain E, Folkes L, Turner KM: Disclosure
16. Ruiz-Mirazo E, Lopez-Yarto M, McDonald SD: Group prenatal care versus of symptoms of postnatal depression, the perspectives of health
individual prenatal care: a systematic review and meta-analyses. J Obstet professionals and women: a qualitative study. BMC Fam Pract 2009, 10:7.
Gynaecol Can 2012, 34(3):223–229. 44. Al-Qutob R, Mawajdeh S, Bin RF: The assessment of reproductive health
17. Goberna-Tricas J, Banus-Gimenez MR, Palacio-Tauste A, Linares-Sancho S: services: a conceptual framework for prenatal care. Health Care Women
Satisfaction with pregnancy and birth services: the quality of maternity Int 1996, 17(5):423–434.
care services as experienced by women. Midwifery 2011, 27(6):e231–e237. 45. Langer A, Nigenda G, Romero M, Rojas G, Kuchaisit C, Al-Osimi M, for the
18. Wheatley RR, Kelley MA, Peacock N, Delgado J: Women’s narratives on WHO Antenatal Care Trial Research Group: Conceptual bases and
quality in prenatal care: a multicultural perspective. Qual Health Res 2008, methodology for the evaluation of women’s and providers’ perception
18(11):1586–1598. of the quality of antenatal care in the WHO Antenatal Care Randomised
19. Hildingsson I, Thomas JE: Women’s perspectives on maternity services in Controlled Trial. Paediatr Perinat Epidemiol 1998, 12(Suppl 2):98–115.
Sweden: processes, problems, and solutions. J Midwifery Womens Health 46. Streiner DL, Norman GR: Health measurement scales: a practical guide to their
2007, 52(2):126–133. development and use. 3rd edition. Oxford: Oxford University Press; 2003.
20. Vause S, Maresh M: Indicators of quality of antenatal care: a pilot study. 47. Pett MA, Lackey NR, Sullivan J: Making sense of factor analysis: the use of
Br J Obstet Gynaecol 1999, 106(3):197–205. factor analysis for instrument development in health care research. Thousand
21. Boller C, Wyss K, Mtasiwa D, Tanner M: Quality and comparison of Oaks, CA: Sage Publications; 2003.
antenatal care in public and private providers in the United Republic of 48. Sword W, Heaman MI, Brooks S, Tough S, Janssen PA, Young D, Kingston D,
Tanzania. Bull World Health Organ 2003, 81(2):116–122. Helewa ME, Akhtar-Danesh N, Hutton E: Women’s and care providers’
22. Wong ST, Korenbrot CC, Stewart AL: Consumer assessment of the quality perspectives of quality prenatal care: a qualitative descriptive study. BMC
of interpersonal processes of prenatal care among ethnically diverse Pregnancy Childbirth 2012, 12:29.
low-income women: development of a new measure. Womens Health 49. Feinstein AR: Clinimetrics. New Haven: New Haven: Yale University Press; 1987.
Issues 2004, 14(4):118–129. 50. Marx RG, Bombardier C, Hogg-Johnson S, Wright JG: Clinimetric and
23. Vinagre MH, Neves J: The influence of service quality and patients’ psychometric strategies for development of a health measurement scale.
emotions on satisfaction. Int J Health Care Qual Assur 2008, 21(1):87–103. J Clin Epidemiol 1999, 52(2):105–111.
24. Gotlieb JB, Grewal D, Brown SW: Consumer satisfaction and perceived 51. Dillman DA, Smyth JD, Christian LM: Internet, mail, and mixed-mode surveys:
quality: complementary or divergent constructs? J Appl Psychol 1994, the tailored design method. 3rd edition. Hoboken, N.J: John Wiley & Sons Inc;
79(6):875. 2009.
52. Waltz CF, Strickland OL, Lenz ER: Measurement in nursing and health
research. New York: New York: Springer Pub; 2005.
53. DeVellis RF: Scale development : theory and applications. Thousand Oaks, CA:
Sage Publications, Inc.; 2003.
54. Comrey AL, Lee HB: A first course in factor analysis. 2nd edition. Hillsdale, NJ:
Lawrence Erlbaum; 1992.
55. Pedhazur EJ, Schmelkin LP: Measurement, design, and analysis: an integrated
approach. Hillsdale, N.J.: Lawrence Erlbaum Associates; 1991.
56. Strickland OL: Using factor analysis for validity assessment: practical
considerations. J Nurs Meas 2003, 11(3):203–205.
57. Mishel MH: Methodological studies: instrument development. In
Advanced designs in nursing research. 2nd edition. Edited by Brink PJ, Wood
MJ. Thousand Oaks, CA: Sage Publications; 1998:235–282.
58. Polit DF, Beck CF: Nursing research: principles and methods. 8th edition.
Philadelphia: Lippincott Williams & Wilkins; 2004.
59. Nunnally JC, Bernstein IH: Psychometric theory. 3rd edition. New York:
McGraw-Hill; 1994.
60. Walter SD, Eliasziw M, Donner A: Sample size and optimal designs for
reliability studies. Stat Med 1998, 17(1):101–110.
61. U.S.Preventive Services Task Force: U.S. Preventive services task force
grade definitions. 2012, http://www.uspreventiveservicestaskforce.org/
uspstf/grades.htm.
62. Donabedian A: The Lichfield lecture. Quality assurance in health care:
consumers’ role. Qual Health Care 1992, 1(4):247–251.
63. Lees C: Measuring the patient experience. Nurse Res 2011, 19(1):25–28.
64. Novick G: Women’s experience of prenatal care: an integrative review.
J Midwifery Womens Health 2009, 54(3):226–237.
65. Heaman M, O’Brien B: Prenatal care provider. In What mothers say: the
Canadian maternity experiences survey. Edited by Public Health Agency of
Canada. Ottawa: Public Health Agency of Canada; 2009:37–41.
66. Tough SC, Johnston DW, Siever JE, Jorgenson G, Slocombe L, Lane C, Clarke
M: Does supplementary prenatal nursing and home visitation support
improve resource use in a universal health care system? A randomized
controlled trial in Canada. Birth-Issues Perinatal Care 2006, 33(3):183–194.
67. Carifio J, Perla R: Ten common misunderstandings, misconceptions,
persistent myths and urban legends about Likert scales and Likert
response formats and their antidotes. J Soc Sci 2007, 3(3):106–116.
68. Carifio J, Perla R: Resolving the 50-year debate around using and misuing
Likert scales. Med Educ 2008, 42:1150–1151.
69. Rosenberg KD: Benefits and limitations of prenatal care. JAMA 1998,
280(24):2072.
doi:10.1186/1471-2393-14-188
Cite this article as: Heaman et al.: Quality of prenatal care questionnaire:
instrument development and testing. BMC Pregnancy and Childbirth
2014 14:188.
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Quality of prenatal care questionnaire: Instrument development and testing

Article in BMC Pregnancy and Childbirth · June 2014

Noori Akhtar-Danesh Suzanne C Tough

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Patricia Janssen Dawn Kingston

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RESEARCH ARTICLE Open Access

Quality of prenatal care questionnaire: instrument

Background research has frequently relied on prenatal care utilization

Table 2 Demographic characteristics of participants in Table 2 Demographic characteristics of participants in

Recruitment Site Tagalog (Filipino) 3 (0.7) 13 (3.1) 2 (0.8)

Vancouver 82 (19.4) 64 (15.2) 9 (3.8) Other 32 (7.6) 24 (5.7) 13 (5.6)

Calgary 98 (23.2) 61 (14.5) 79 (33.8) Prenatal Care Provider**

Halifax 79 (18.7) 79 (18.7) 0* Midwife 46 (11.0) 39 (9.2) 27 (11.4)

Marital Status Nurse practitioner 30 (7.0) 56 (13.3) 45 (19.0)

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