The study findings provide information on the important elements of quality prenatal care as described by women and care providers, which reflect the structure of care and clinical and interpersonal care processes. There has been much attention in the literature to access to prenatal care, which is one dimension of structure of care. Our findings along with those of other researchers [30, 31] suggest that convenience of care is a key consideration. This issue has been framed in the context of personal costs, including direct dollar costs (e.g., transportation costs) and costs of time (e.g., time away from work/school, travel time) . We also determined that appointment flexibility, ready access to care providers by telephone, and access to educational resources are important in the provision of quality care.
Physical characteristics of the care setting deemed to be important to quality prenatal care identified by study participants have been reported in other studies. For instance, Proctor  found that cleanliness and homelike surroundings were quality indicators and in a study of group prenatal care privacy was identified as an issue by some women . Staff characteristics also were noted to be elements of quality care. Women study participants commented on the importance of office staff who are pleasant and other research suggests that rude treatment by staff can negatively influence a woman's desire to return for appointments . While both women and care providers remarked on the importance of a care provider's clinical knowledge, women additionally valued the knowledge and understanding practitioners gained through personal experiences with pregnancy and childbirth.
Clinical care processes and interpersonal care processes emerged as being most essential to quality care as discussions of these elements of care were far more prominent than discussions of structure of care in the interviews with both women and prenatal care providers. Care providers spoke of screening and assessment, a clinical care process, in terms of guideline adherence to ensure better perinatal outcomes. This perspective is congruent with discussions of the role of evidence-based care and guidelines in promoting quality prenatal care [12, 13]. For women, these medical aspects of care provided reassurance about their health and their baby's health. Health promotion and illness prevention, including attention to risk factors, also emerged as components of quality care and are explicitly addressed in prenatal care guidelines [35–38].
Some of the other clinical care processes identified in the study have been identified previously in the research literature. For instance, the importance of sharing of information is captured in findings that women appreciate being offered information by clinicians [30, 39], being kept well informed , and having their questions answered . The importance of continuity of care provider also has been highlighted in a number of studies [30, 39, 42, 43] and relates to women wanting clinicians to know them and to remember them from one visit to the next [40, 42]. When women see more than one care provider, we found that sharing of information was valued as it facilitated a smooth transition. Some prenatal care guidelines specifically address continuity of care [35–37].
Sensitivity to women's life contexts or circumstances, an essential element of women-centred care, has been identified in other research [41, 44] as has women's active involvement in decision making [30, 45]. Professional guidelines often refer to a woman's right to informed choice. By way of example, the NICE guideline for antenatal care explicitly addresses informed decision making in stating that "pregnant women should be offered information based on the current available evidence together with support to enable them to make informed decisions about their care" (p. 12) . Another key feature of women-centred care, personalized care, also has been noted in several studies [34, 40, 41]. Consideration of each woman's unique situation and needs provides opportunity for early intervention, particularly for risk factors associated with adverse life circumstances and socioeconomic conditions.
We additionally found that non-medicalization of a woman's pregnancy was a feature of quality care. In a study of group prenatal care, women appreciated that their pregnancy-related changes and fears were normalized . Medicalization has transformed pregnancy and childbirth into an illness where there is an assumption of risk to fetal and maternal health that becomes the focus of prenatal care . However, this orientation has been criticized because it creates dependency on medical care, undermines women's rights to autonomy, and minimizes the relevance of women's life contexts [46, 47]. It therefore is not surprising that non-medicalization of pregnancy emerged as a component of quality care as many elements of quality identified in our study respond to these criticisms.
The interpersonal care processes revealed in our study as having a role in quality prenatal care included respectful attitude and emotional support. The importance of women being treated with respect has been noted in previous research [30, 34, 42]. Interestingly, only one of the prenatal care guidelines reviewed explicitly addresses this issue by stating that women should be treated with consideration and respect, and that the relationship between a woman and her care provider should be characterized by mutual respect . Listening, which is an element of providing emotional support, has been highlighted as essential to quality care in other studies [14, 30, 44]. The value of clinicians who express caring is reinforced by a study that found ratings of antenatal care were higher if care providers were sensitive and understanding and women's concerns were taken seriously . Caring also is conveyed through the expression of concern for and assessment of a woman's psychosocial well-being . Importantly Sheppard, Zambrana, and O'Malley  identified that lack of caring and insensitive behaviour can deter willingness to follow advice and return visits.
The other two dimensions of interpersonal care processes, approachable interaction style and taking time, have received little attention in the literature. The importance of an informal interaction style was identified in a study in which women described their appreciation of a clinician's use of humour . If women are put at ease and feel relaxed, they are more likely to engage with care providers, share information, and participate in making decisions about their care. Enough time with a care provider was identified as a marker of patient-centred care in another study of quality of prenatal care , and Davey, Brown, and Bruinsma  found that having adequate time with care provider increased overall care ratings of prenatal care.
Having a meaningful relationship with a prenatal care provider may be fundamental to quality care, and is inextricably linked with characteristics of the prenatal care provider and clinical and interpersonal care processes. In an integrated review of the literature on women's experiences of prenatal care, Novick  commented that the topic of relationships was discussed in the majority of studies, which further highlights its centrality to quality care. The notion of trust in the care provider was predominant in our participants' references to a meaningful relationship. Trust has been identified as a key indicator of quality in the patient-provider relationship, and having a trusting relationship with a care provider increases the likelihood that professional advice will be followed .
The strengths of this study are its exploration of quality of prenatal care across different settings, populations of women, and care providers. The large sample size of 40 women and 40 care providers ensured that we captured a broad range of perspectives and data saturation was achieved. Interviewer training included orientation to the study and its conceptual framework as well as practice interviews. Additionally, the transcripts of initial interviews were reviewed by the principal investigator and research coordinator, with feedback subsequently discussed with each research assistant. Strategies were put in place to ensure rigor of the analytic process and hence validity of the study findings. Study limitations relate mainly to the sample in that most of the women had been born in Canada, spoke English at home, and had a university degree; however, these characteristics do reflect the majority of women in Canada who have recently given birth . Most of care providers were female, and there was an over-representation of midwives and an under-representation of obstetricians in the sample.
While intended to inform the development of items for the Quality of Prenatal Care Questionnaire, the study findings also provide direction for the planning and delivery of prenatal care. As noted, the findings reflect a number of the published prenatal care guidelines and, in particular, resonate with the Canadian Family-Centred Maternity and Newborn Care: National Guidelines . These national guidelines recommend that: pregnancy be considered a state of health; women be valued and respected; the relationship between a woman and her care provider be consultative and interactive; and care providers facilitate informed decision making. Our study findings also are congruent with other aspects of these guidelines that address the importance of access to care, accommodation of a woman's personal support system, continuity of care, screening and assessment, and health promotion counseling.
Putting many of the elements of quality prenatal care into practice requires clinician time. However, fee-for-service models are disincentives to spending time with pregnant women. Moreover, in Canada the relatively few family physicians who offer maternity care combined with the low number of registered midwives puts pressure on obstetricians to provide care to both low- and high-risk pregnant women [52, 53]. Collaborative models of care may be the answer not only to improving access to primary maternity care in Canada but also to enhancing the quality of prenatal care women receive . Increasing access to midwifery care, which integrates many of the essential components of quality care because it is women-centred, embraces shared decision making, and incorporates emotional care , also may serve to promote quality prenatal care.
The findings of this study will be used to identify specific items for the Quality of Prenatal Care Questionnaire. Following the generation of a preliminary list of items, standard approaches to item reduction and validity and reliability testing will be used. If determined to have acceptable psychometric properties, the questionnaire can be used in future studies designed to explore different models of prenatal care and the ways in which they might enhance the quality of care women receive. Group prenatal care, as one alternative model, shows promise in delivering quality care and in influencing positive outcomes [7, 33]. The Quality of Prenatal Care Questionnaire can be used in a variety of other studies. Research is needed to examine disparities in quality of care as studies have suggested it may vary for different populations of women. Wheatley and colleagues , for instance, found that low-income primiparous women had numerous negative experiences related to specific markers of patient-centredness: listened carefully, explained things, showed respect, and spent enough time. Studies of the ways in which quality of prenatal care varies by care provider also are warranted. Finally, research should examine the impact of quality care on a broad variety of maternal and infant outcomes and on future health service utilization. Preliminary evidence suggests the importance of specific dimensions of quality care, such as attention to lifestyle risk factors, adequate time with a care provider, and relationship-centredness, in improving maternal and infant health [4–7].