MOTHERS’ EXPERIENCES OF TEAM-BASED ANTENATAL CARE IN RURAL
BRITISH COLUMBIA
by
Amanda Green
B.Sc., University of Victoria, 2005
B.N., University of Lethbridge, 2011

THESIS SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE
IN
NURSING

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
May 2023
© Amanda Green, 2023

Abstract
Introduction: The health care system in British Columbia places priority on providing teambased primary maternity care. Participation of mothers in planning their care is an essential
component of team-based care. Therefore, it is important to understand mothers’ experiences of
team-based maternity care.
Background: An integrated literature review resulted in 12 articles focused on mothers’
experiences with antenatal care delivered by a team of providers. Evidence highlighted the
positive impact of team-based speciality antenatal care. Mother’s experiences of community
team-based antenatal care were a notable gap in the literature.
Objective: To explore antenatal care experiences of mothers living in rural British Columbia,
where team-based antenatal care is known to exist.
Method: To understand the perceptions of mothers' experiences of team-based antenatal care a
qualitative methodology was used. An interpretive description approach combined semistructured interviews with eight mothers purposively selected from two rural communities.
Findings: Mothers played a key role in shaping the continuity of their care. Mothers
collaborated with their providers across three types of continuity expressed within a team-based
antenatal care context: management, informational, and relational. Building the relationship
between the mother and a consistent provider (relational continuity) required clinical
coordination (management continuity) and clear communication (informational continuity).
From the mother's perspective, a specific team composition did not rate as highly as the
connection to a consistent provider with whom they had respectful and trusting relationship. For
all eight mothers a nurse and physician team-combination promoted continuity and patientcenteredness. Specifically, a primary care maternity nurse role supported stability in the mother's

2

antenatal care. Gaps in continuity arose from experiences of antenatal care during the Covid-19
global pandemic and in the mothers’ mental wellness and pelvic floor health.
Conclusion: When the mothers shared responsibility for continuity in care this strengthened the
mother-provider partnership, regardless of which discipline was providing care. Mothers
appreciated the continuity of carer – a provider who could develop a relationship with them
during their antenatal care. The mothers valued providers who worked as part of a network,
collaborating with a range of interdisciplinary providers to support the mothers’ antenatal care
needs.
Clinical Implications: There is merit in expanding discussions on the value a consistent
provider working alongside mothers in rural team-based primary maternity care brings to
mothers’ experiences of and engagement with antenatal care. Future research on how both
continuity of care and continuity of a carer can support sustainable team-based antenatal care to
improve outcomes is warranted in all community contexts.

3

Table of Conte nts
Abstract .................................................................................................................................. 2
Table of Contents .................................................................................................................... 4
List of Tables .......................................................................................................................... 7
List of Figures ......................................................................................................................... 8
Acknowledgment .................................................................................................................... 9
Glossary of Terms ..................................................................................................................10
Chapter One: Introduction.......................................................................................................12
History of Team-Based Primary Maternity Care...................................................................12
Patient Experience at the Centre of Team-based Primary Maternity Care ..............................15
Patient Experience of Team-Based Antenatal Care ...............................................................16
Researcher Context .............................................................................................................17
Rurality as a Focus ..............................................................................................................17
Research Question ..............................................................................................................18
Conclusion..........................................................................................................................19
Chapter Two: Literature Review .............................................................................................20
Review Question.................................................................................................................20
Sampling ............................................................................................................................21
Searching ........................................................................................................................21
Screening and Selection ...................................................................................................25
Critical Appraisal of Sample ................................................................................................27
Data Synthesis and Thematic Analysis .................................................................................27
Findings and Discussion......................................................................................................28
Understanding Patient Satisfaction with TBANC ..............................................................28
Aspects of TBANC That Influence Mothers’ Perceptions of Care Experience....................34
Composition of the Team..............................................................................................36
Attitudes of the Team. ..................................................................................................38
The Role of TBANC in Complex Antenatal Care Planning ...............................................39
Summary of the Literature ...................................................................................................40
Satisfaction versus Experience of TBANC .......................................................................41
Aspects of TBANC that are Important to Mothers ............................................................42
The Impact of TBANC on Addressing Determinants of Health .........................................43
4

Limitations .........................................................................................................................44
Conclusion..........................................................................................................................46
Chapter Three: Research Methodology and Study Methods ......................................................48
Situating the Research Methodology....................................................................................48
Interpretive Description.......................................................................................................49
Study Methods ....................................................................................................................51
Setting and Context .........................................................................................................51
Participant Sampling, Selection, and Recruitment .............................................................51
Data Collection ...............................................................................................................52
Data Management & Analysis .............................................................................................54
Ethical Considerations .........................................................................................................55
Dissemination .....................................................................................................................56
Conclusion..........................................................................................................................56
Chapter Four: Findings ...........................................................................................................57
Overview of Mothers’ Experiences of Team-based Antenatal Care .......................................57
Structure and Function of how the Mothers Received Antenatal Care ...................................58
Team Structure ................................................................................................................59
Team Function ................................................................................................................62
Value that Mothers Placed in the Relationships that Shaped their Experiences ......................65
Relationships with the Team ............................................................................................66
Relationships with Other Mothers ....................................................................................67
Pandemic Impact on Relationships ...................................................................................69
Appreciation that Mothers had for Patient Centeredness .......................................................70
Tailored Team Members ..................................................................................................71
Tailored Education and Resources....................................................................................74
Focus on Health and Wellness .............................................................................................76
Conclusion..........................................................................................................................80
Chapter Five: Discussion ........................................................................................................81
Mothers’ Experiences of Antenatal Care as Continuity of Care .............................................81
Multiple Providers Collaborating to Create Continuity .........................................................83
Organization of Care .......................................................................................................83
Organization of Care in Community-Based Clinics ...........................................................85
5

Organization of Care as Continuity in Specialty Clinics ....................................................85
Disruption to the Organization of Care .............................................................................86
Mothers and Providers Shared Responsibility for Continuity ................................................87
Mothers’ Responsibility in Continuity of Care ..................................................................87
Mothers Feeling Known in Continuity of Care..................................................................89
Gaps in Care Challenging Continuity ...............................................................................90
Relationships between Mothers and a Carer led to Continuity ...............................................91
Influence of Teams on Continuity ....................................................................................91
A Primary Care Maternity Nurse as Part of the Team........................................................92
Limitations .........................................................................................................................99
Conclusion........................................................................................................................ 101
References ........................................................................................................................... 103
Appendix A: Literature Matrix .............................................................................................. 111
Appendix C: Recruitment Email and Invitation Poster ........................................................... 121
Appendix D: Information Letter and Consent Form ............................................................... 124
Appendix E: Interview Questions .......................................................................................... 128
Appendix F: Thematic Analysis of Semi-Structured Interviews .............................................. 131

6

List of Tables
Table 1: Population, Concept, Context (PCC) ..........................................................................21
Table 2: Inclusion and Exclusion Criteria ................................................................................22
Table 3: Search Result Combinations ......................................................................................24
Table 4: Number of Professions that were part of the Participants Care team…………………..60

7

List of Figures
Figure 1: Timeline of Primary and Community Care Transformation and a Maternity Services
Context ..................................................................................................................................14
Figure 2: PRISMA..................................................................................................................26
Figure 3: Thematic Analysis of Current Evidence on Mothers’ Experiences of Team-based
Antenatal Care…………………………………………………………………………………...58

8

Acknowledgme nt
I want to start by expressing my gratitude and admiration for the study participants who
took the time to share their stories. I was able to discover what was significant to you about the
care you received while pregnant thanks to your openness and, at times, vulnerability. I feel
honoured to have had the chance to include your perspective in the body of growing research on
community-based antenatal care.
I cannot thank my supervisor, Dr. Caroline Sanders, enough for her unwavering
encouragement and support as we navigated various facets of my life together. Your
consideration and kindness have been vital to my capacity to carry this through to completion. I
will always be appreciative of the genuine you, both as a person and as a teacher.
Thank you to Dr. Martha McLeod and Lee Yeates for serving on my committee. Your
guided discussion, practical knowledge, wealth of experience, and availability were crucial to
this study. Thank you to Dr. Margolin for your time and insight as an external examiner. I valued
the team-based nature of my entire committee and thank you all for coming together to share and
collaborate as the study findings, discussion, and implications took shape.
Thank you to Dr. Ilona Hale and the University of British Columbia’s Rural Scholar
Program for providing a welcoming and high-quality multidisciplinary space to explore the
concepts of research focused on enhancing health outcomes in rural communities. Our time
together was invaluable to my learning journey and growth as a novice researcher.
Thank you to Robin and Jessi for keeping me laughing. Robin, thanks for going first, and
Jessi, thanks for having the courage to jump in. I appreciated your roles as sounding boards, and
I appreciate our friendships.
Without the dedication of my husband Roland and my three children Grady (16), Adelle
(13), and Leo (4), I would not have been able to complete this work. Although I am aware of the
effects pursuing a graduate degree has had on your lives and our family unit, I hope you will find
inspiration in our family's commitment to and prioritization of education. One year into my
graduate studies, the note that you slipped me while I was sitting at my desk has kept me going.
We never give up.

Finally, I want to express my gratitude to my family in Newfoundland for teaching me
the value of education, hard work, perseverance, and positivity. From an early age of flipping
through dusty nursing books, Mom, your influence as a dedicated nurse has encouraged me to be
here today. I owe a debt of gratitude to you and Dad, Molly and Reg, and ‘Super Nan’ especially
for shaping who I am today.
9

Glossary of Terms
Perinatal Care: While the terms maternity and perinatal are often used interchangeably, for this
study of Mothers’ Experiences of Team-based Antenatal Care in Rural British Columbia (BC),
perinatal care refers to the period from “greater than or equal to 20 weeks gestation to 7 days
completed days of life” (Perinatal Services BC [PSBC], 2017, p. 3).
Maternity Care: Maternity care refers to “care from conception through to the postpartum for
the mother, the baby, and the family” (British Columbia Ministry of Health [BCMOH], 2014, p.
2). Maternity care will be the most referenced term to acknowledge the care mothers receive
along the continuum of pregnancy, through labour and birth, and into the postpartum period.
Antenatal Care: Antenatal care will refer to care received during pregnancy, from the earliest
point possible, including all subsequent visits with providers during pregnancy and leading up to
labour.
Community-based Antenatal Care: Community-based antenatal care will mean any antenatal
care service provided outside of a hospital in a rural community.
Rural Community: Rural communities within BC are not clearly defined across regional health
authorities but are suggested to range from rural (population 3,500-20,000) to small rural
(population 1,000-3,500) or remote (population 0-1,000) (BCMOH, 2020). A rural community
for the purpose of this study’s recruitment is a community in BC that offers planned obstetrical
services totalling less than 250 births per year per PSBC’s 2020/21 fiscal report on facility-level
indicators (2023).
Pregnant Person: Within this study, the patient, mother, and woman refer to any pregnant
person who received antenatal care and is dependent upon the term used within a referenced
document. While pregnant person is a gender inclusive term (Trans Care BC, n.d.), the term

10

‘mother’ is most frequently used when referring to pregnant people in this study who have
identified as female as an identity oriented, patient-voice approach to the use of terminology.
Team-based Care: Depending on the terminology in the critical literature relevant to the
research question, terms like multidisciplinary, integrated, interdisciplinary, collaborative, and
interprofessional care are also used interchangeably throughout the study to describe team-based
primary maternity care. Team-based antenatal care for this paper means at least two or more
disciplines involved in the mother’s care while pregnant.
Patient-centered Care: The terms person- and patient-centered care will be used
interchangeably in this study to reflect the following definition offered by Nurses and Nurse
Practitioners of BC (2020):
Patient and family-centred care, also referred to as person-centred care or client-centred
care, is an approach to care that puts patients and families at the forefront of their health
and care by building strong partnerships and involving them in shared decision making as
well as the design, delivery and evaluation of healthcare services.” (para. 1)

11

Chapter One : Introduction
Team-Based Primary Maternity Care is comprehensive and coordinated maternity care
provided by a collaborative, multidisciplinary team to women, babies, and the family from
conception, birth, and into the postpartum period (BCMOH, 2014). More specifically, teambased care requires at least two interdisciplinary health care providers collaborating to offer
quality care through shared decision-making with the patient (Mitchell et al., 2012). The
interdisciplinary team includes “physicians, nurses and nurse practitioners, allied health
providers, administrative support staff, volunteers, and community agencies” (BCMOH, 2020, p.
2). In recent years, efforts to restructure the British Columbian health care system have focused
on advancing primary and community care to improve access, quality, and equity in health
services (BCMOH, 2019; 2015a). Primary and community care includes team-based care, which
has progressed from an “essential element” (BCMOH, 2017, p. 4) to a “central model”
(BCMOH, 2020, p. 2) guiding the planning and implementation of primary and community care
services. Maternity care is a service area within the province’s guiding policies on primary care
transformation (BCMOH, 2014). Therefore, team-based primary maternity care is an emerging
approach focused on delivering comprehensive care in the primary care setting in partnership
with pregnant women.
Chapter one will introduce 1) the concept of team-based primary maternity care and 2)
the relevance of patient experience in team-based primary maternity care guiding the research
question of this study.
History of Team-Based Primary Maternity Care
Two decades ago, in 2000, team-based primary maternity care emerged as a service area
in policy discussions on primary health care system transformation. Four years following the

12

increased federal focus on primary care transformation, the BCMOH completed the Maternity
Care Enhancement Project to examine the sustainability of maternity care, including
recommendations for collaborative and women-centered approaches to maternity care (BCMOH,
2004). Two years later, the Federal government established the Multidisciplinary Collaborative
Primary Maternity Care Project (MCP2) to outline a national approach to implementing quality
maternity services focused on interprofessional collaboration (Peterson & Mannion, 2005;
Multidisc iplinary Collaborative Primary Maternity Care Project, 2006). Since then, discussion on
progress on team-based primary maternity care in BC remained relatively silent until 2014.
In 2014, the province released Primary Maternity Care: Moving Forward Together to
support ongoing maternity service improvements. Maternity care includes the pregnancy, birth,
and postpartum stages and requires a multidisciplinary team approach (BCMOH, 2014). One
year later, guidance on primary health care transformation guidance began with focused policy
development, including The British Columbia Patient-Centered Care Framework (BCMOH,
2015b), Primary and community care in BC: A strategic policy framework (BCMOH, 2015a),
Primary and Community Care Initiative: Overview and Update (BCMOH, 2019), and Supportive
Policy Direction: Team-Based Care (BCMOH 2020, 2017). Each subsequent policy
complements the previous as they relate to supporting the widespread implementation of teambased primary care in BC. See Figure 1 for an outline of policies, guidelines, and frameworks
that have shaped BC’s team-based model of primary maternity care.

13

Figure 1
Timeline of Primary and Community Care Transformation and a Maternity Services Context

Shortly after introducing the patient-centered care frameworks, a team-based approach
proposed a ‘how-to’ element of implementing the primary and community care and patient14

centered care mandates. In 2018, PSBC, the provincial governance on maternity services under
the Provincial Health Services Authority (PHSA), created and shared tools to enable and enhance
interprofessional collaboration and interdisciplinary teams in maternity care (Shared Care
Committee, 2019, 2018). The General Practice Services Committee (2019) also supported a
billing structure for team-based care physicians and the BC Patient Safety and Quality Council
(BCPSQC) produced and made available a team-based care resource list in 2020. The BCMOH
and PHSA are developing a ‘Maternity Services Strategy’ to be patient-centered and encourage
“interprofessional, collaborative teams” (PSBC, 2020a, p. 2). The Strategy is yet to be released,
but the overall context of patient-centered and team-based primary maternity care is timely to
this study, given current provincial policies and developing frameworks.
Patient Experience at the Centre of Team-based Primary Maternity Care
The patient is central to BC’s team-based policies, guidelines, and frameworks. The
BCMOH identifies the aims of improving health outcomes and patient experiences through
primary and community health care initiatives. The Ministry indicates that the patient experience
is an important consideration of primary care transformative initiatives (BCMOH, 2019). The
BC Health Quality Matrix further iterates the importance of individual perspectives combined
with system perspectives to provide quality health care services (BCPSQC, 2020). The BCPSQC
has outlined seven team-based care enablers, one of which overlaps with patient-focused teambased primary maternity care; ‘Patient- and Family- Engagement/Centered Care’ focuses on
encouraging health system planners to include the patient voice in team-based care planning,
implementation, and evaluation (BCPSQC, 2020). This enabler affirms that the patient
experience is critical in planning, delivering, and understanding care at the patient, provider, and
system levels. Preliminary readings have indicated that team-based primary maternity care has

15

benefits for both the patient, providers, and health system in improving care satisfaction and
improving patient outcomes (Harris et al., 2015; Munro et al., 2013; Peterson et al., 2007; Winn
et al., 2018; Yeates & Kay, 2018). The World Health Organization (WHO) holds that a positive
childbirth experience includes “the concept of experience of care as a critical aspect of ensuring
high-quality labour and childbirth care and improved woman-centered outcomes, and not just
complementary to provision of routine clinical practices.” (WHO, 2018, p. 1). Therefore, we
need to learn about and recognize primary maternity care patient experiences to understand and
guide the development of team-based maternity services.
Patient Experience of Team-Based Antenatal Care
The purpose of this study was to shed light on how mothers perceive the components of
rurally based team-based primary maternity care, specifically which elements were important to
them. Qualitative inquiry of mothers’ experiences of team-based maternity care, can capture
important aspects of patient experience within team-based care. This approach is fitting for
experiences of maternity care, as suggested by Beecher et al. (2020):
Women’s experiences of their maternity care is a complex concept referring to women’s
interpretation of their care encounters within the maternity services. It is subjective in
nature and evolves throughout the course of pregnancy, childbirth, and the postpartum
period. It is dependent upon a woman’s individual needs and expectations, shaped by
their personal circumstances and influenced by how their care is organised and delivered.
(p. 423)
The information gained from this study has the potential to add to the discussion about the
importance of the patient's perspective in the design, provision, and comprehension of
community-based maternity services. The findings can guide future research on service and

16

patient outcomes in team-based antenatal care from the patient's perspective. These results could
propel the agenda for quality improvement in transforming primary care approaches to maternity
service provision.
Researcher Context
As a mother and patient living in rural BC, I know firsthand the advantages and
disadvantages of receiving team-based or conventional maternity care. Being a mother and a
primary care nurse sparked interest in patient experiences of team-based primary maternity care
by examining personal ways of knowing or what Rolfe (1998) described as professional
judgment produced by an individual's personal experiential and scientific knowledge. I believe
that team-based maternity care could lower health inequities and improve patient and provider
experiences through interprofessional and collaborative care, patient-driven approaches. Through
my professional experiences as a team-based primary maternity care provider in a rural setting, I
gathered clinical expertise supporting the need for quality improvement of team-based practice
principles to enhance patient outcomes. As a result, a combination of clinical and personal
judgement informed the study topic and question development. My professional judgement led
me to conclude that to begin to understand how to improve maternity services, I needed to
explore the mother’s lived experience, since this could help inform future health service
maternity care models that strongly emphasize patient experience in rural areas.
Rurality as a Focus
British Columbians who live or reside outside urban areas experience increased health
disparities (BCMOH, 2015c). Access to high-quality healthcare is a factor affecting health
outcomes (WHO, 2017) and “rurality is a powerful determinant of women’s health, as a
geographic and sociocultural influence” (SOGC, 2017, p. e395). Access to health care services,

17

particularly maternity care services, may be limited in rural locations and overall outcomes are
typically worse for British Columbians living in communities that cannot access maternity care
close to home such as higher rates of caesarian sections, longer neonatal hospital stays, more
significant travel costs, and less social support system (Grzybowski et al., 2011). Additionally,
current access to consistent rural maternity care remains unstable and unsustainable in rural
British Columbia (Kornelsen et al., 2023). Team-based primary maternity care can support the
sustainability of maternity services in rural and isolated regions, increasing patient-centered
quality care that contribute to improving access to services (Yeates & Kay, 2018). Despite
implementation of team-based primary maternity care, further research is required to improve
our knowledge about the components and overall quality and success of BC community-based
antenatal and postnatal services in BC (Yeates & Kay, 2018; Giesbrecht & Shum, 2020).
Specifically, team-based antenatal care (TBANC) is a promising approach to addressing health
inequities, such as rural living, through the lens of the patient experience in BC. Learning from
patient experiences has been identified as the ‘how to’ of addressing health inequities (National
Collaborating Centre for Determinants of Health [NCCDH], 2021; Public Health Agency of
Canada [PHAC], 2020). Therefore, examining mothers’ experiences of team-based antenatal
care is a necessary step towards understand the rural context of community-based primary
maternity care services.
Research Question
The overarching research question of this study was: What are mothers’ experiences of
team-based antenatal care in rural British Columbia?

18

Conclusion
The maternity and team-based landscape is complex and adaptive. While primary care
and primary maternity care delivery approaches change according to economic and policy
directives, the consistent factor is mothers who receive maternity care. How they rece ive care
varies, even within team-based maternity care.
The following chapter outlines a review of the literature on mothers’ experiences of
team-based antenatal care completed that informed the study design.

19

Chapter Two: Literature Review
Chapter two represents a review of the research and grey literature pertaining to patient
experiences of team-based primary maternity care, specifically antenatal care. An integrative
literature review (ILR) approach was chosen to capture the complexities of clinical settings and
the range of methodologies applied to examine practice. (Whittemore & Knafl, 2005). While
Whittemore and Knafl (2005) is a commonly applied research review method for postgraduate
students, it falls short of efforts to enhance research rigor in the absence of a critical analysis of
the sample for inclusion in the study. In applying a five-step approach drawn from Whittemore
and Knafl (2005) and adapted by Lubbe et al. (2020), sample rigor was addressed through a wellorganized and straightforward approach to examine unique clinical complexities of the subject
matter. The five-step approach outlined by Lubbe et al. (2020) applied to this study included the
following: 1) review question, 2) sampling of the literature (searching, screening, and selection
of documents), 3) critical appraisal of the sample, 4) data extraction including synthesis and
analysis, and 5) presentation of findings and discussion.
Review Question
Starting with a broad topic of team-based primary maternity care, the aim was to explore
any existing uncertainty in team-based antenatal care. As a provider, experiential knowledge and
preliminary reading highlighted the complexity of team-based primary maternity care and
limited voice of mothers’ within TBANC. Formulating a literature review question was a
deliberate step in focusing the investigation. The Population, Concept, and Context (PCC) model
presented in Table 1, served as an effective approach to determine a clear position to guide the
literature review (Aromataris, E. & Munn, Z., 2020). Starting with the population of mothers

20

who have experiences receiving primary maternity care, specifically antenatal care, from two or
more disciplines focused the review question.
Table 1
Population, Concept, Context (PCC)
Population
Mothers who have received
antenatal care

Concept
Experiences of receiving
team-based antenatal care

Context
Antenatal care with two or
more health care providers
from two or more disciplines
(family physician, midwife,
obstetrician, nurse,
community agency,
administrative support staff,
allied health providers such
as physiotherapist, social
worker, and dietician)

The final question generated to guide the integrative review was, what are mothers’ experiences
of team-based antenatal care?
Sampling
A three-step sampling of 1) searching, 2) screening, and 3) selecting research to include
for synthesis was the next stage (Lubbe et al., 2020).
Searching
A search strategy was developed to discover the extent of the evidence available on
patient experiences of TBANC. Informed by experiential knowledge and broad reading on the
topic of interest, inclusion and exclusion search criteria were set and keywords were developed
to guide a focused search strategy. To select documents for review, criteria were set to focus on
the PCC identified in the review question relevant to the patient experience of team-based
antenatal care. Criteria used to guide sample searching are set out in Table 2 and explained in
detail.
21

Table 2
Inclusion and Exclusion Criteria
·
·
·
·
·
·

Inclusion
Years of publication: 2000-2023
Publication language: English
Peer reviewed literature
From any country
Patient experiences or satisfaction
with antenatal care provided by more
than one provider
Team-based care in hospital settings
or community-based

·
·
·

·
·
·

Exclusion
Publications prior to 2000
Non-peer reviewed
Care received during
labour/birth/post-partum that does not
include antenatal care
Only one discipline providing
antenatal care
Team-based education for health care
providers or students
Group-based or shared maternity care
not offered by a team

Studies of patient experiences or satisfaction with TBANC were included in the
sampling. The literature was limited to English articles only with full-text and peer-reviewed
limiters, when available in the databases. Articles were excluded if they focused on group
prenatal care only which refers to groups of patients receiving care and not groups of
professionals providing care, or collaboration within disciplines that did not involve other
disciplines or that were discipline specific. Studies were also excluded if team-based care
discussions were between the same or similar disciplines (i.e., between labour and delivery nurse
and public health nurse or between family physician and obstetrician). Studies were excluded if
they focused on team-based education of health care providers or students. Studies dated prior to
the year 2000 were excluded as this was the point in Canadian history that marked the onset of
primary health care transformation efforts. Initially, an inclusion criterion was set to include only
studies conducted in rural Canada to promote similar health care system structures relating to
team-based care, however low primary yield resulted in a widening of the inclusion criteria to
urban and/or international studies on the recommendation of the University of Northern British
22

Columbia (UNBC) Librarian. The UNBC Librarian was consulted to guide database usage,
discuss search strategy, and refine search headings and keywords. Based upon the Librarian’s
suggestions and limited initial search results, the search expanded outside of the initially desired
Canadian rural geographical areas to increase results.
Sources of evidence were extracted from electronic databases and hand searching.
Electronic databases Cumulative Index to Nursing and Allied Health Literature (CINAHL),
PsycINFO, MEDLINE (Ovid), and Web of Science were selected for their relation to health care
and psychological concepts of experience and satisfaction. Hand searching included searching
reference lists of database articles, initial and unstructured database searching, and grey literature
hand searching. Grey literature hand searching included accessing reports, research, policy
literature, and white papers from federal and provincial government, PSBC, and the University
of British Columbia via the Google search engine. Preliminary readings on team-based primary
maternity care were completed April 2021 and a focused literature search on patient experience
of team-based antenatal care was conducted September 21, 2021. The literature search was
repeated April 22, 2023, using the same search parameters. New evidence was included in Table
3. Table 3 summarizes key terms, including Boolean operatives and MeSH terms, and sources of
evidence that guided searches and number of results from each search.

23

Table 3
Search Result Combinations
Boolean/MeSH Terms

CINHAL

1

Patient* OR Mother* OR
Woman*
2 Experience* OR Attitude*
OR Perception* OR View OR
Views
(MeSH: Life Experiences,
Patient Satisfaction,
Attitudes)
3 Antenatal OR Prenatal OR
Maternity OR Perinatal OR
Postpartum
(MeSH: Maternal-Child Care,
Prenatal Care, Perinatal Care,
Obstetric Care)
4 Team-based OR team based
OR Interdisciplinary OR
Multidisciplinary OR
Collaborative
1 AND 2
3 AND 4
1 AND 2 AND 3 AND 4
English
2000-Current
Title & Abstract Review
Excluded for:
· Discipline specific
· Not care provided during
pregnancy
· Only provider perspectives
· Team-based education for
health care providers or
students
· Group-based care
Duplicates not included
Full Text Included
Repeated Search April 2023
Full Text Included

PSYCinfo

1855165

Medline
(Ovid)
7949594

849888

Web of
Science
8072918

Hand
Searching

27886

30057

52045

1274612

14987

18166

2530

169016

77584

175801

81447

220131

17634
649
13
13
13
7

30057
555
11
11
9
8

18598
59
2
2
2
1

262777
1924
113
110
103
17

2
2
2
2

2
0
2

2
3
1
4

0
0
0
0

2
4
0
4

1
1
2

Note: Keywords were searched in the Abstract field.

24

Screening and Selection
From 141 studies identified from initial database searches, inclusion and exclusion
criteria were applied. Once inclusion and exclusion criteria of language, date, peer-reviewed, and
full text was applied, 35 records were then eligible for screening. Additional application of
inclusion and exclusion criteria of title and abstract review led to two duplicate articles being
removed with 10 articles remaining. Following full-text evaluation, 10 articles were included for
final review. Repeating the search led to 2 more articles being added following the same
screening steps to total 12 articles for final review. Figure 2 shows the process for selection of
articles in the review as outlined in the Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) flow diagram. These steps fulfilled the second and third sub-steps of
Lubbe at al.’s (2020) integrated sampling approach, namely screening and selection.

25

Figure 2
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Flow Diagram

Note: This figure was adapted from: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann
TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting
systematic reviews. BMJ 2021;372:n71. doi:10.1136/bmj.n71

26

Critical Appraisal of Sample
High-quality studies were included for the synthesis of the review question through
critical appraisal of studies identified for inclusion in the review. To assess the reliability and
credibility of the studies chosen, the Joanna Briggs Institute (2020) critical appraisal tools were
used to assess the trustworthiness and relevance of chosen studies for review. Commentary
related the appraisal of studies are included in the Literature Matrix table in Appendix A.
Data Synthesis and Thematic Analysis
Of the included studies, two were quantitative (Hodgson et al., 2017; Grote et al., 2015)
including one Randomized Control Trial (Grote et al., 2015). Three studies (Akca et al., 2017;
Perella et al., 2022; Tyson et al., 2022) were mixed methods. Seven studies were qualitative
studies using a variety of approaches: phenomenological, ethnographic, and descriptive (Adeniyi
et al., 2021; Hauck et al., 2013; Howard, 2015; Jarvie, 2017; Morris et al., 2011; Olander et al.,
2020; Phillippi et al., 2016). Qualitative methods used in studies consisted of interviews, focus
groups, and open-ended survey questions. Studies were distributed internationally, with two
Canadian studies conducted in British Columbia (Adeniyi et al., 2021; Hodgson et al., 2017),
three in the United States (Grote et al., 2015; Howard, 2015; Phillippi et al., 2016), two in
England (Olander et al., 2020; Jarvie, 2017), four in Australia (Hauk et al., 2013, Perella et al.,
2022; Morris et al., 2011; Tyson et al., 2022) and one in Turkey (Acka et al., 2017).
I applied a process of thematic analysis as outlined by (Braun & Clarke, 2006) to review
the data extracted from these 12 studies in a literature matrix outlined in Appendix A and then
mapped on the digital platform Miro, as seen in Appendix B. Analysis led to three categories
related to mothers’ experiences of TBANC: 1) understanding patient satisfaction with TBANC,

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2) aspects of TBANC that influence mothers’ perceptions of antenatal care experience, and 3)
the role of TBANC in complex antenatal care planning.
Findings and Discussion
The following section will examine in detail the findings from the 12 reviewed studies,
consistent with Lubbe et al.’s (2020) methodological framework. Each of the theme’s findings
will be presented, with overlap and discrepancies highlighted, to focus the discussion aspect of
the ILR and identify gaps in both practice and research as they relate to mothers’ experiences of
TBANC.
Understanding Patient Satisfaction with TBANC
The concept of patient satisfaction was revealed in the analysis of the 12 studies. Five of
the 12 studies identified patient satisfaction with TBANC as either the aim of the study (Akca et
al., 2017; Perella et al., 2022) or as a study finding (Grote et al., 2015, Hauck et al., 2013;
Hodgson et al., 2017).
Grote et al’s (2015) randomized control trial comparing two multidisciplinary maternity
care programs, a routine maternity care program (MMS-Plus), and a specialized depression
intervention program (MOMCare), demonstrated that patients had a higher level of satisfaction
with their care when the program delivery was specifically focused on clinically specialized
programming for depression care. The evidence-based antenatal depression intervention program
MOMCare, was favourable when compared to receiving depression care as part of routine
maternity care alone, called MSS-Plus (Grote et al., 2015). While both programs were
multidisciplinary in nature, MOMCare programming consisted of unique aspects of personcentered care, such as evidence-based depression treatment and initial assessments to address

28

determinants of health such as transportation and housing in attempts to decrease barriers to
accessing maternity care.
MOMCare participants entered pregnancy care via routine MSS-Plus services and
therefore both study groups received the same model of routine assessment for depression with
depression severity rated as per the Patient Health Questionnaire-9 (PHQ-9) (Grote et al., 2015).
An equivalent number of program visits as well as the same time interval between appointments
was standard care for both MOMCare intervention and MSS-Plus groups throughout the study
duration. The 168 study participants who screened positive for depression on the PHQ-9, a score
of greater than ten were included in the MOMCare intervention program. Eighty-three women
were eligible and randomized to the MOMCare and MSS-Plus programming and 85 were
randomized to the MSS-Plus group only. MOMCare participants had higher rates of
unemployment, were non-White, unmarried, had an unplanned pregnancy, and had a 47% rate of
experiencing childhood trauma as identified via baseline demographics. Follow up assessment
interviews were conducted with both groups at 3-, 6-, 12-, and 18-month intervals. Findings
revealed improved outcomes for the MOMCare intervention program compared to the MSS-Plus
care only to include increased program adherence, improved depression scores from 6 months to
12 months (p=0.03; p=0.02), decreased post-traumatic stress disorder severity at 18 months
(p=0.002) and generalized anxiety over time as reported at 18 months (p=0.05). Findings
indicated that overall, team-based interventions in the antenatal period targeted towards severe
depression can improve the outcomes of the women who participate in antenatal specialized care
services.
Satisfaction was not the primary aim of the study, rather it was included as part of the
study’s quality of care variables. MOMCare participants rated satisfaction with all services as

29

moderately or very satisfied to be 88.8% (n=71 at 3 months, 88.8% (n=71) at 6 months, 87.2%
(n=68) at 12 months and 79.5% (n=62) at 18 months compared to MSS-Plus participants being
70.4% (n=50) at 3 months, 73.7% (n=56) at 6 months, 71.6% (n=53) at 12 months, and 78.1%
(n=57) at 18 months. While satisfaction was slightly lower in the routine depression care group,
until 18 months at which time the findings were comparable, participants of the MOMCare
program reported greater satisfaction with all the care received (p=0.004) during the assessment
periods versus participants of the MSS-Plus program only. The study findings were limited in
that factors affecting ratings of program satisfaction via a Likert Scale were not explored or
correlated by the authors. Additionally, the number of respondents to a question of satisfaction
was markedly less in the MSS-Plus group at each assessment interval when compared to the
MOMCare program participants.
While it is difficult to discern participant satisfaction with team-based models of
antenatal care from Grote et al.’s (2015) study on collaborative care for socially disadvantaged
women, it is evident that study outcomes including ratings of patient satisfaction are improved in
clinically specialized team-based programming for severe depression care. This finding is similar
to Hodgson et al.’s study (2017) where satisfaction was measured as a question on a discharge
questionnaire as part of a non-randomized prospective comparative study to determine client
choice in a team-based antenatal group or team-based antenatal individual program. Findings
from this questionnaire-based study showed participants rated no statistically different level of
satisfaction with group team-based care and individual team-based individual care (p=0.51).
These results contribute to an understanding of the patient perspective of team-based models of
antenatal care within the context of either group or individual team-based antenatal care and not
specifically with team-based antenatal care in a general sense.

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Similar to Grote et al., (2015), Hodgson et al. (2017) outlined patient satisfaction with
team-based care programming as an outcome in the context of two studies involving comparison
models of antenatal care offered by a team of health care providers. Both Grote et al. (2015) and
Hodgson et al. (2017) used patient satisfaction as descriptive statistics from their study findings
to compare the two team-based programs within each of their studies. Neither the study by Grote
et al. (2015) nor Hodgson et al. (2017) clearly defined factors affecting mothers’ level of
satisfaction. However, Hodgson et al. (2017) did include outcomes such as preterm birth and
breastfeeding rates within their study but did not attempt to connect outcomes of either teambased antenatal group care or team-based individual antenatal care to patient satisfaction. Unlike
Grote et al. (2015) and Hodgson et al. (2017), Acka et al., (2017) and Perella et al. (2022) took a
more in-depth approach to understand patient satisfaction by aiming to link satisfaction with
childbirth to the effects of a team-based antenatal birth preparation program (Acka et al., 2017),
including factors that influenced satisfaction (Acka et al., 2017; Perella et al., 2022).
In a mixed methods prospective study, Acka et al. (2017) assigned their study
participants into two groups, both groups accessed labour and delivery at the same hospital;
group one consisted of pregnant women who participated in a free and optional team-based birth
preparation program called Happy Pregnant School (n=77) and group two as a control group who
did not participate in the program (n=75), were unaware of the program, and did not receive any
antenatal education. Participants in the Happy Pregnancy School met once a month for three
hours and received antenatal education from a team consisting of a psychiatrist, a dietician, an
obstetrician and gynecologist, a sports-medicine physician, and a neonatologist. The birth
preparation program consisted of three-hour education sessions once a month for four months
and, of note, there were no statistical differences between the demographics of group one and

31

group two. Satisfaction was determined through two questionnaires and face-to-face interviews
completed within 48 hours following childbirth. Data was analyzed using SPSS 17.0 for
Windows with a statistical significance considered where p < 0.05. While participants were not
directly asked about satisfaction with a team-based model of care, they were asked about their
satisfaction with childbirth with answers compared between groups. Group one rated satisfaction
with childbirth as 76.6% (n=59) while group two rated their satisfaction with childbirth as 49.3%
(n=37), p < 0.001. These findings infer that through TBANC in the form of a structured antenatal
education program that the experience of pregnant women was improved when compared to
pregnant women who did not experience similar TBANC models of care.
A secondary aim of Acka et al.’s study focused on exploring the factors that affected
women’s satisfaction with childbirth experience from the perspective of the women included in
the study. This focused approach generated a comprehensive and rich discussion of women’s
satisfaction with the team-based antenatal education Happy Pregnant School. Obstetric outcomes
between groups one and two focused on examining critical perinatal outcomes to include
decreased duration of labour, induction and caesarean section rates, pain during labour and birth,
and need for a neonatal intensive care unit. Findings from Group 1 highlighted that mothers
perceived improved communication between themselves and the health care providers during
birth. Further, the women described being active participants in their care. Overall, the findings
from the study support the conclusion that a team-based antenatal care education-based program
for low-risk pregnancies lead to increased satisfaction in childbirth.
Patient satisfaction with team-based models of low-risk maternity care have highlighted
the influence of the team on patient antenatal education. While Acka et al. (2017) supports teambased education for pregnant women, what sets Perella et al.’s (2022) findings apart is the

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education provided to providers to develop the team-based skills required to support women. In
this study, 81 women who had given birth during the pandemic (January 2020 to December
2020) completed 24 survey questions on a 5-point Likert Scale and two open-ended questions.
The aim of the study was to evaluate maternal satisfaction with their team-based model of
maternity care, spanning pregnancy, birth, and into the postpartum period. The team consisted of
physicians and midwives, nurses, allied health, and administrative staff. Results showed 91% of
mothers were very pleased with the quality of pregnancy care. The authors suggested the rate of
satisfaction with the One for Women (OFW) model of team-based care was a result of the
preparedness of the team to meet the needs of women. In this model, providers completed
education through Possums and Co workshops. The workshops fostered a “cross-disciplinary,
integrated approach to care, including breastfeeding, infant sleep, mental health issues, and
collaboration with parents” (Perella et al., 2022, p. 2).
In exploring findings of Hauck et al. (2013), the authors differentiated between
satisfaction and experience, although using the terms interchangeably at times, to be a single
question of satisfaction with childbirth while comparing birth experiences between groups based
upon variables contributing to study findings relating to satisfaction with childbirth. The
sometimes confusing terminology choices in Acka et al.’s (2017) study of satisfaction and
experience was simplified and clarified by Perella et al. (2022). The final study discussed the
theme of patient satisfaction was Hauck et al. (2013), which clearly differentiated the concepts of
experience, satisfaction, and perception within women attending a team-based specialist
childbirth and antenatal clinic.
Hauck et al. (2013) measured satisfaction on a Likert scale, as did Perella et al. (2022),
but with less qualitative detail and separate from the conversation of women’s experiences. In

33

Perella et al.’s. (2022), qualitative study, pregnant women’s satisfaction was explored as an
aspect of overall experience of attending a specialist childbirth and mental illness antenatal
clinic. Hauck et al. (2013) completed a series of telephone interviews, 41 women were asked a
question of satisfaction in relation to continuity of care provided by a team of health care
professions, including dieticians, social work, psychiatrists, and other allied health professionals
as required. Participants rated their level of satisfaction with clinic team continuity of care to be
97.6% (n=40) as very satisfied or satisfied. The authors outlined the importance of learning
satisfaction as an “indispensable reflection of client judgement on the quality of care in all its
aspects…” (Hauck et al., 2013, p. 383). The finding of satisfaction with team-based models of
antenatal care is similar to the findings in the other three studies relating to patient satisfaction
(Akca et al., 2017; Grote et al., 2015; Hodgson et al., 2017). By asking study participants about
their experience that led to their overall satisfaction with the team-based approach that the clinic
provided, researchers were able to extend their understanding of the patient experience beyond
that of purely patient satisfaction. They discovered the perceptions that continuity of care
provided as part of team-based care programming in a specialized clinic was important to the
women in their study.
Aspects of TBANC That Influence Mothers’ Perceptions of Care Experience
The remaining seven articles included in this review identified aspects of team-based
antenatal care that influenced the patient experience (Adeniyi et al., 2021; Howard, 2015; Jarvie,
2017; Morris et al., 2011; Olander et al., 2020; Phillippi et al., 2016; Tyson et al., 2022). In
synthesising the findings three main aspects of TBAC influenced the patient experience: 1) joint
appointments and co-location of the team, 2) composition of the team, and 3) personalities and
attitudes of the team.

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Joint Appointments with Co-location of Care Team. In a qualitative exploratory
descriptive study, Phillippi et al. (2016) explored the experience of 50 participants attending a
collaborative antenatal maternal-fetal medicine specialist clinic. This clinic employed a novel
approach to collaborative in-person consultations between women and multiples of their health
care providers simultaneously. Women strongly voiced improved communication because of the
collaborative approach to in-person visits with each of their providers being together, i.e., in the
same room during the same appointment. Such consultations led to the women feeling that they
were a partner in their care and gave them improved feelings of patient safety, with the women
reporting they received care that exceeded their expectations. According to the women, each of
these positive experiences were facilitated by the influence of time spent between health care
professionals in the comprehensive planning of the women’s care as well as the women’s
personal awareness of the plan of care. The positive experience of women at the clinic was
related to their perception of the benefit that in-person collaborative consultations at one location
and at the same appointment added to their overall care planning (Phillippi et al., 2016). This
finding was influenced by the time providers spent both together and with the patient.
Contradictory to the findings of Phillippi et al. (2016), Olander et al.’s (2020) qualitative
study on co-location of maternity services with 29 postnatal women demonstrated that women
did not view the need for all team members to be present at one location to positively influence
their experience of care. Rather, the findings showed that, for mothers, co-location was less
important than integrated care between the health care provider team (Olander et al. 2020).
While co-located care provided by a team was viewed by women as positive, not all women felt
that co-location and joint appointments was a necessary part of team-based antenatal care.
Instead, they shared that convenience and integrated care were more important, “The only thing

35

that would make a difference is if they were working as part of a unified team. But, location
wise, no it doesn’t make a difference at all” (Olander et al., 2020, p. 13). Perella et al. (2022)
support the findings of Olander et al. (2020) with survey results with only 4% (n=3 from 8
participants) noting that they selected the team-based maternity care model because all the
services were in one location. It is evident from both Phillippi et al. (2016), Olander et al. (2020),
and Perella et al. (2022) that process of the team’s communication between themselves and the
patient rather than structure of the team was more important to women.
Composition of the Team. While each of the studies included in this review defined the
team as two or more health care professionals working together to provide antenatal care as an
inclusion criteria, Adeniyi et al. (2021) and Howard (2015) explored how including social work
and dentistry as an extension to traditional team membership of nurses, midwives, and
physicians, could improve the patient’s antenatal care experience. In a qualitative study on
pregnant women’s perspectives on integrating oral health in prenatal care, 14 purposefully
recruited study participants shared their desire to have dental care incorporated into their regular
prenatal care (Adeniyi et al., 2020). Adeniyi et al.’s BC study (2021) posed a question to study
participants without access to co-located team-based antenatal dental care, whether such services
could impact the mothers’ antenatal care experience. Participants viewed dental care providers as
valued members of the team who would be best suited to be co-located where regular antenatal
appointments were conducted and that team-based care was an important part of their antenatal
experience (Adeniyi et al., 2021). Specifically, the study identified the complexity of the medical
versus dental payment structure in BC, as a barrier to expanding the antenatal team to include
dental health care professionals.

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In a similar approach to Adeniyi et al. (2021), Howard’s (2015) qualitative
phenomenology study examined team composition beyond traditional expectations, i.e., nurses,
midwives, and physicians, to include a social worker role in perinatal care. The authors provided
strong rationale for including social work as a core team asset by recognising the need of the
local population, namely pregnant women with opioid use disorders (OUD). Twenty participants
were interviewed and asked their opinions of how included they were in their prenatal decision
making. Answering the question resulted in participant focus on the social worker as a crucial
element of support in their antenatal care. Study participants highlighted the addition of a social
worker to the care team allowed for increased time to address anxieties. Specifically, the social
worker role was able to recognize and address stigmas commonly experienced in pregnant
women with OUD, which included worry about the involvement of child protection services. It
was noted that other team members did not provide the same time as a social worker in
supporting emotional wellbeing surrounding the complexities of their opioid use disorder
(Adeniyi et al., 2021). Time for providers to support emotional wellbeing of women was also
noted in the patient evaluation of the OFW program where high satisfaction was associated with
a team composition that consisted of medical staff (physicians or midwives), nurses, allied health
staff and administrative staff (Perella et al., 2022).
A third study, explored in more detail under the section discussing the role of TBANC in
complex antenatal care planning, discussed the composition of the team in team-based maternity
care, including antenatal care, was Tyson et al. (2022). This mixed-methods study consisted of a
retrospective audit and survey consisting of both open-and closed-ended questions. As an
evaluation study, the focus was to determine if team-based care was delivered respectfully and
minimized birth complications in high-risk women. The analysis of patient demographics and

37

antenatal, labour, birth, and neonatal outcomes highlighted the need for a social worker to be
included in their team-based clinic moving forward. The authors noted how continuity of care
within their clinic that led to women being “known in detail” (Tyson et al., 2022, p. 637) was a
way social workers could provide complex care planning for those who attend their high-risk
clinic. While this finding was from the perspective of the author’s retrospective audit, it aligns to
Adeniyi et al. (2021) and Howard (2015)’s argument for the addition of team members that are
well suited to meet the unique needs of the populations served by team-based programming.
Attitudes of the Team. Two studies (Morris et al., 2011; Jarvie, 2017) identified the
influence that the personalities of the team members, both with the study participants and
between themselves, had on mothers’ experience of TBANC. Affirming the findings of Howard
(2015), an ethnographic study conducted by Morris et al. (2011) consisting of a purposeful
sample of 20 women with OUD completed a series of interviews. Analysis showed a strong and
collaborative voice between the women as they expressed the influence of the health care team’s
personalities and attitudes on their experience of antenatal care. When providers personalities
and attitudes were perceived as being poor, the women sensed they were being labelled or judged
because of their OUD, which negatively impacted their overall experience of the antenatal care
they received (Howard, 2015). Morris et al.’s (2011) study participants revealed the impact that
the dynamic between the midwives and social workers had between each other influenced their
care. This was noted as positive when there was collaboration but inadequate when the mothers
perceived the midwife held negative attitudes about OUD, which resulted in negative perceptions
of the overall care the women received (Morris et al., 2011). Overall, the individual personalities
of the team members affected the women’s perceptions of care.

38

Jarvie’s (2017) findings of interviews with women who attended two diabetic antenatal
clinics were consistent with the findings of both Howard (2015) and Morris et al. (2011),
specifically the importance of team attitudes influencing perceptions of care. When studying
women’s lived experience of having a body mass index greater than 30 and co-existing
gestational diabetes, 27 women shared their experience of having maternal obesity and
gestational diabetes mellitus (GDM) over a series of 63 interviews (Jarvie, 2017). Negative
experiences of stigma from health care providers at a multidisciplinary antenatal clinic impacted
women’s overall antenatal care experience. Although the study’s focus was not specifically on
TBANC, it was included in the review as it brought attention to the effects of collaborative care
and provider attitudes on patient care experiences from the standpoint of the patient; effective
collaborative care could address aspects of the social determinants of health that are seen to be
important to women in their management of their pregnancy. Additionally, when team-based
perinatal care providers are viewed by women to have a person-centered approach to providing
care that is attentive to meeting their needs the women describe improved relationships and value
in their maternity care (Perella et al., 2022).
The Role of TBANC in Complex Antenatal Care Planning
A third and final theme from the studies revealed a commonality of the study setting and
participant characteristics. Theme three indicates that study participants in patient experience
TBANC research are commonly those individuals who require complex care planning because of
medical high-risk conditions or characteristics contributing to vulnerabilities during pregnancy.
Six of the included twelve studies were set in specialty clinics or programs dedicated to the
patient’s pre-existing condition. They each involved study participants who had increased risks
during pregnancy due to medical conditions or variables of social determinants of health (Grote

39

et al., 2015; Hauck et al., 2013; Howard, 2015; Jarvie, 2017; Morris et al., 2011; Phillippi et al.,
2016; Tyson et al., 2022). Participants ranged from being chemically dependent (Howard, 2015;
Morris et al., 2011) to those with a pre-existing diagnosis of mental illness (Grote et al., 2015;
Hauck et al., 2013) or those who were deemed medically high risk due to diabetes, high BMI, or
requiring referral to maternal fetal medicine (Jarvie, 2017; Phillippi et al, 2016; Tyson et al.,
2022). In each of the studies (Grote et al., 2015; Hauck et al., 2013; Howard, 2015; Jarvie, 2017;
Morris et al., 2011; Phillippi et al., 2016; Tyson et al., 2022), the benefits of TBANC were either
medically or socioeconomically focused or both. Team approaches allowed for increased
communication between both providers and provider-patients, improved patient-centered care,
and permitted additional time to address medical or socioeconomic factors that could negatively
influence mothers’ antenatal care experience. TBANC was specifically identified in four studies
as a direct approach to reduce health inequities experienced by vulnerable women. Grote et al.
(2015), Jarvie (2017), Hauck et al. (2013), and Tyson et al. (2022) each discussed opportunities
provided by TBANC in addressing social and physical determinants of health impacting
pregnancy, such as negative lifestyle behaviours, social supports, socioeconomic conditions, and
inequitable access to health services.
Summary of the Literature
This integrative review of literature from 2000 to 2023 on patient experience of teambased models of antennal care has identified three main points of discussion: satisfaction versus
the experience of TBANC, aspects of TBANC that are important to mothers, and the impact of
TBANC in addressing determinants of health.

40

Satisfaction versus Experience of TBANC
Overall, satisfaction with team-based models of antenatal care was identified to be
positive but the linkage to factors contributing to the participant being satisfied with models of
TBANC were not always clear. Furthermore, it was determined that satisfaction with care is
different from experience of care. The significance of measuring patient satisfaction in teambased antenatal care research is linked to understanding patient experiences with models of teambased antenatal care – there is a distinction to be made between patient satisfaction and
experience. Understanding patient satisfaction with team-based antenatal models of care showed
that, overall, mothers were satisfied with team-based antenatal care or would have been more
satisfied with their care if team-based approaches had been present.
Patient satisfaction was important for the researchers in three of the four studies (Grote et
al., 2015; Hauck et al., 2013; Hodgson et al., 2017) that asked the question of satisfaction as a
stand-alone descriptive statistic and not an overall aim of the research. While satisfaction was an
interesting finding in these three studies, there was limited detail available on what clearly led to
the study participants’ level of satisfaction with their antenatal care and what having a level of
women’s satisfaction means for team-based models of antenatal care. Only one study, Hauck et
al., (2013), distinguished between study participant satisfaction and experience and discussed
both in relation to their findings. Patient experience outlines the variables that influences an
outcome of satisfaction with team-based care programming. Therefore, if patient satisfaction
matters to team-based antenatal care planning, it is evident that a combination of an overall
rating of satisfaction alongside a rich description of what has led to the level of satisfaction from
the perspective of the patient is important for researchers and health systems planners.

41

While patient satisfaction with care is an overall indicator of successful models of care,
satisfaction alone limits the usefulness of measures that may require quality improvement.
Researchers need a deeper understanding of the factors that influence satisfaction to develop and
apply measures that impact the overall TBANC experience.
Aspects of TBANC that are Important to Mothers
Identifying factors that lead to patient satisfaction with team-based antenatal care
contributed to understanding what it is ‘about’ team-based antenatal care that is important to
mothers. Learning from the perspectives of mothers themselves about what contributed to their
level of satisfaction and experience of antenatal care, as well as what could have improved their
level of satisfaction and experience helped to understand what is important to mothers about
TBANC. Three main aspects of TBANC, within the overall theme of team-based approaches
influencing the mothers’ experiences of antenatal care were identified in the literature: jointappointments with co-location of the team, team composition, and personalities/attitudes of the
team.
While having an appointment with more than one health care team member was seen as
beneficial to the experience of mothers (Phillippi et al., 2016), the need for the appointments of
team members to occur simultaneously was not consistently found (Olander et al., 2020; Perella
et al., 2022). These findings may have implications for planners of team-based antennal care
programming as a lack of co-location may not be as important or impactful to the antenatal care
experience of mothers as opposed to a strong network of coordinated care with a focus on
convenience for the pregnant woman.
What was clear in the findings of the review, was that the composition of the team,
including the personality of the team members encountered, mattered to pregnant women. For

42

example, involving a social worker in the team was positively impactful on women who were
experiencing mental illness (Howard, 2015) while the attitudes or personalities of the health care
providers that were perceived by the women to be negative resulted in poorer experiences of
team-based antenatal care. In the case of provider personalities, it is difficult to draw conclusions
that the team aspect of care has any connection to women’s experience of care, and the
individual relationships that exist between patients and providers contribute to the overall
experience of care. While it is important to recognize barriers such as provider personality,
studies recommended that program planners learn more about all aspects of care that matter to
the women who have been part of team-based models of antenatal care.
A commonality among all studies was that TBANC facilitated an increased in
consultation or appointment time provided to pregnant women during their antennal care. This
characteristic of team-based care offered an environment for addressing the social determinants
of health. Increased time for patient-provider and provider-provider contact through team-based
antenatal care was seen by mothers as an opportunity for providers to integrate care with other
providers and address determinants that were or could negatively impact women’s experiences of
women-centered care, including maternal and neonate outcomes.
The Impact of TBANC on Addressing Determinants of Health
TBANC was noted as an approach that can help to address women’s complex care needs
during pregnancy. By reducing inequities in access to antenatal maternity care through teambased services, strength-based and client-centered approaches were a highlight of mothers’
experiences. With all but four studies including study populations that were notably marginalized
or higher risk populations (Adeniyi et al., 2021; Acka et al., 2017; Hodgson et al., 2017; Perella
et al., 2022), each of the populations experienced cultural, social, or structural circumstances

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directly impacting their pregnancy that were addressed by team-based antenatal maternity care.
Mothers who both self-identified or were identified by researchers or care providers as having
increased risks and vulnerabilities in pregnancy, such as those who lacked social supports and/or
coping skills, were culturally disadvantaged, or were struggling with determinants such as
housing, finances, employment, and/or living in rural geographies, were present in the literature.
Specifically, Tyson et al. (2022) connected the high medical risk in pregnancy secondary to
obesity with the women’s socio-demographic determinants. Social determinants of health, as
outlined by the World Health Organization (2017), such as minority populations impacted by
culture and gender, mental health and well-being, physical access to care, and education and
literacy were positively impacted by team-based models of antenatal care from the perspective of
the mother. Furthermore, addressing determinants of health via TBANC can affect the antenatal
care itself by improving complex care planning and improving interactions with patients with
OUD, as an example. TBANC programming for low-risk and uncomplicated pregnancies or
mothers who are not considered at increased vulnerability in their pregnancies was mostly
missing in the literature. It appears that team-based antenatal care is positioned to benefit
mothers who require complex care during pregnancy, but it remains unknown if mothers with
normal, low-risk pregnancies would perceive a similarly positive or beneficial experience of
TBANC.
Limitations
The integrated literature review of mothers’ experiences of TBANC has potential
limitations in its findings. Firstly, aspects of completing the integrated literature review as a
novice researcher may provide a limitation, particularly through establishing search criteria to
locate all relevant literature relating to the patient perspective of TBANC as well as the ability to

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thematically analyze the findings within the literature located to draw upon common themes.
Furthermore, this limitation is also tied to the process of conducting an integrated literature
review in comparison to other types of literature reviews such as systematic literature reviews
which are often viewed as more rigorous but not often as well suited for clinical practice
(Whittmore & Knafl, 2005).
Secondly, the generalizability of the findings may be difficult for reasons that relate to
the Canadian context, the uniqueness of the antenatal care clinics in which care was delivered,
characteristics of the study designs included for review, and the perceptions of the experience of
individual study participants. To elaborate, global health care systems and subsequent models of
care have their own unique structures and provide unique context to the care experienced by
mothers. Given the limited research based in Canada, findings of the patient experience of
TBANC may be difficult to generalize to the Canadian, publicly funded Medicare system as it
relates to the structure of TBANC models of care. There also may exist limitations in the
generalizability of findings based upon whether the setting of antenatal care was a specialty
clinic tailored to a particular population requiring unique care or non-specialty TBANC, as well
as the differences between health care providers that composed each antenatal care team.
Furthermore, study sample sizes were often small and there was a lack of research
comparing models of team-based or non-team-based care to make comparisons of perceived
experiences of those. It was also difficult to discern the influence of previous experiences of any
approach to antenatal care and associated birth experiences on the perception of care in the
antenatal care received during the studies. This limitation was not explored by any of the studies
but highlights the significance of individual attitudes of study participants affecting outcomes of

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qualitative research. This may lead to difficulty generalizing any findings of patient experience
in team-based antenatal care.
A final limitation was in the aim of the studies included for review in that not all mothers
had experienced some of the aspects of TBANC such as co-located care but were posed a
question on the perception of if they were to have experienced TBANC. It is with consideration
of these overall potential limitations in this integrated literature review, that will provide focus
when developing questions to pose to mothers about their experience of TBANC.
Conclusion
This integrated literature review asked the research question: “What are mothers’
experiences of team-based antenatal care?” By seeking to understand the experiences of mothers
through the review approach proposed by Whittemore and Kanfl (2005), 12 studies were
identified then critically and thematically analyzed. Three key themes of the mothers’
experiences of TBANC were highlighted: understanding patient satisfaction with TBANC,
aspects of TBANC that influence mothers’ perceptions of their care experience, and the role of
TBANC in complex antenatal care planning. Critical analysis of the studies identified aspects of
team-based antenatal care such as joint appointments, composition of the team, and attitudes and
personalities of the team members to have an influence on mothers’ experiences of the antenatal
care they received or could have received. Analysis also determined a clear gap in research
aiming to study the patient experience of team-based models of antenatal care, particularly in the
Canadian context, despite the political direction to advance team-based primary maternity care.
It was evident from limited evidence that consideration of the mothers’ team-based
antenatal care experiences is important to learn from both patient satisfaction and health care
programming perspectives. How mothers perceive their care experience while pregnant can have

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an impact on both their own health outcomes as well as their overall experience along the
continuum of maternity care. Considerations for the composition of the care team and the role of
each team member in shaping mothers’ experiences of team-based antennal care from the
perspective of mothers are areas that require further exploration.
Taking a reflexive approach to designing a research question based on the review
findings and personal ways of knowing, rurality places pregnant women at increased risk of
health inequities. Pregnancy is an opportunistic time for team-based antenatal models of care to
identify and support determinants of health that can either have a positive or negative effect on
the level of satisfaction and type/quality of the experience that mothers have with their antennal
care. These review findings guided a research question focused on increasing our understanding
of how TBANC models of care can impact determinants of health for both vulnerable and
normal pregnancies from the perspective of mothers who live in rural British Columbia. These
findings also supported a need to continue to identify what it is about TBANC that is important
to the mothers who have experienced it.
The following methodology and methods chapter outlines the study design that was
guided by this integrated literature review to further understand team-based antenatal care from
the perspective of mothers.

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Chapter Three : Research Methodology and Study Methods
Chapter three introduces the research methodology and outlines the appropriateness of an
interpretive descriptive study to examine mothers' experiences of team-based primary maternity
care. This chapter includes my philosophical orientation, the study methods for participant
strategies, data collection and analysis, trustworthiness and rigour, and ethical considerations.
Situating the Research Methodology
The ontological underpinnings, or ways of being, allows researchers to examine multiple
realities through qualitative or quantitative approaches to research methodology. In examining
my position and beliefs, the epistemology of constructivism understood as “the assumption of
multiple constructed realities” (Lincoln & Guba, 1985, p. 295), holds resonance with how I
understand learning to be based on prior experiences or knowledge. Individua ls create new
understanding or knowledge through the process of thinking and reflecting on their beliefs in
combination with exposure to new ideas, events, or activities that then inform future interactions
(Streubert & Carpenter, 2011). As such, individuals have a freedom to come to their realization,
interpret, and then explain daily life events – as framed within the individual’s identity (Risjord,
2010).
While the literature review highlighted the use of surveys as data collection approaches to
patient satisfaction, such methodologies limited findings on participants’ experiences
contributing to satisfaction with TBANC. The literature review highlighted that patient
experience evidence with TBANC is limited and based upon readings to shape the literature
review question, the evidence to guide practice in team-based primary maternity care is currently
situated within policies and operational frameworks that are not united in community and in the
context of mothers’ ways of knowing. By linking discovery and applied understanding to the

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“…dynamic, holistic and individual aspect” (Polit & Beck, 2004, p.16) of the human, using
qualitative research situated within a constructivist epistemology was chosen as a fit for a
research question dedicated to expanding and extending understanding of how mothers
experience team-based antenatal care in community-based settings.
Interpretive Description
While there are a range of qualitative approaches that can vary in research focus,
problem, and procedures (Creswell & Creswell, 2018), I chose an interpretive descriptive (ID)
approach. As a methodology ID can help to address experiences with and within complex
clinical health care settings from a holistic and relational perspective (Thorne, 2016). A key
concept of interpretive description is the researcher’s interpretation of the data and the shared
realities of the participant and the researcher in the human experience within the research
question (Thorne, 2016). Interpretive description is well suited for the clinical context of teambased primary maternity care from the complement of the patient experience and the researcher’s
experiential knowledge. My understanding of reflexivity is that it is an ongoing, collaborative,
and multi-dimensional practice. My subjectivity and the framework in which the study was
conducted were both able to be critiqued, appraised, and evaluated by me in a self-aware manner.
I was conscious of how elements relating to my personal life, my interactions with others, and
my previous clinical experiences affected my perspective. I developed credible and relevant
disciplinary knowledge, which is the essence of an ID method, by integrating my personal
approach to reflexivity with the ID strategy.
Other approaches to qualitative research such as phenomenology and qualitative
description were considered for this study but the need to stay close to clinical practice and teambased primary maternity care nursing influenced ID as the most appropriate fit. Constructivism

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emphasizes that knowledge emerges through the individuals' interaction with the environment
during an experience (Schwandt, 1994). While phenomenology is commonly employed when
exploring lived experience (Sandelowski, 2000), being an emerging and novice researcher led
me to choose a less complex but no less challenging methodology of ID. A nurse researcher
cannot remove oneself from the knowledge held and the clinical reasoning behind our research
question’s development. This dictates an inevitable layer of interpretation of the data.
Additionally, the processes of team-based antenatal care are not something that the participants
will likely be experts in within the context of their experiences of antenatal care. Therefore, to
discover the richness of the findings, participants and the researcher together can shape the
perceptions and interpretation of the clinical context that the research question and methodology
demand.
The voice of the participant requires a level of interpretation to be meaningful to the
discussion of team-based antenatal care. The voice of the mother must be heard alongside the
voice of the researcher, within the capacity of a novice researcher. An interpretive description
approach to answering the research question of mothers’ experiences of team-based primary
antenatal care can best be achieved by applying interpretive design methods. In qualitative
research and within clinical practice, the researcher’s theoretical perspective guides data
collection, analysis, and conclusion which draws parallels with interpretive descriptive design
(Thorne, 2016). Interpretive description as a methodology aligns with my previous clinical
experiences and the actionable practicality of the study conclusions; there is an assumption that
what is learned from exploring mothers’ experiences about team-based maternity care will
influence my practice as well as that of the wider health care teams.

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Study Methods
Setting and Context
The setting selected for this study was communities in BC that offer planned obstetrical
services totalling less than 250 births per year as per PSBC’s facility-level indicator data for the
fiscal year 2020/21 (PSBC, 2023). The setting choice of low birth volume compared to higher
birth volumes in more populated, urban settings offers this study the context of a rural
community offering maternity services. As identified in preliminary readings that guided the
literature review question, there is a need to learn more about community-based antenatal
services in BC. Additionally, geographical barriers that often exist in communities across BC
add a level of vulnerability for patients and their families to achieve health and wellness
outcomes. Rural living impacts access to health care services, including maternity services, adds
complexity to the patient experience of receiving health care services, and is an established
measurement of health equity as a social determinant of health (NCCDH, 2021). Additionally,
personal interest and experience in understanding the experiences of rural maternity services
have grown from living and working in rural BC, which makes the setting of communities in
rural BC offering TBANC a suitable fit for this study.
Participant Sampling, Selection, and Recruitment
For this qualitative study, a purposeful selection of five communities were identified.
Communities were identified through a review of a provincial Pregnancy Outreach Program
contact list shared on the BC Association of Pregnancy Outreach Program (BCAPOP , 2021)
website and cross-referenced by sites identified by PSBC to offer low-risk obstetrical services
and less than 250 births per year within the 2020/21 fiscal year (PSBC, 2023). Five communities
were then selected that were known to have established models of team-based antenatal care

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beyond standard prenantal classes as determined from personal knowledge or information
available on community-based programming websites. The researcher does not hold a
membership to the BCAPOP organization or have affiliation with any of the community-based
groups identified by the organization.
Once ethical approval was received for the research proposal, participants were recruited
by an email invitation to organizers of mom and baby pregnancy outreach groups in each of the
selected five communities. See Appendix C for a sample email invitation and invitation poster.
Selected pregnancy outreach groups were sent an email on April 8, 2022 asking them to
distribute the study invitation via their usual communication networks to moms. Two subsequent
follow-up emails were sent to pregnancy outreach groups over the course of six months on May
2, 2022 and July 6, 2022 to the five community pregnancy outreach groups.
Eight participants from two communities contacted me directly via email to express
interest in study participation. I answered any questions that they posed about the study,
following this participant completed the study consent in Appendix D and returned them to me
via email.
Data Collection
To create an understanding of mothers’ experiences of TBANC, individual and semistructured interviews with the eight participants across rural BC communities were conducted.
Interviews ranged between 35 to 55 minutes and were completed over one interview per
participant. The final number of interviews was determined when no further participants
expressed interest in participating in the study. ID inquiry relies on recruitment of a manageable
number of study participants (Sandelowski, 2000), which allow the researcher the time to
explore rich interpretation of the events transcribed and return to participants, as necessary.

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Interview questions were developed by the researcher and guided by The Maastricht
Perinatal Framework (Vogels-Broeke et al., 2020). The Framework includes seven dimensions of
women’s experiences in the perinatal period. The questions posed to mothers in this study asked
them to describe their experience with team-based antenatal care in a way that would touch on
domains outlined in the Framework, particularly patient experience. Interview questions were
adapted as the study progressed, in response to mothers’ responses and incorporating learnings
from gaining experience as an interviewer, reflecting the fluid and flexible nature of interpretive
description research and ongoing analysis.
The interview questions (Appendix E) focused on the organization of antenatal care and
how it impacted experiences while pregnant. In each of the interviews, participants were asked
semi-structured interview questions guided by the research question: What are mothers’
experiences of team-based antenatal care in rural British Columbia? Interviews were conducted
over the IT platform ZOOM and were audio recorded via the IT platform Zoom. This decision
was informed by the ongoing pandemic with public health measures in place to discourage travel
and in-person meetings. Transcription of the interview recordings was performed manually and
stored on a home office computer that was encrypted and locked, to be destroyed following
publication of the thesis.
Participants were asked to complete an optional demographic survey asking questions
about age, gender, Indigenous identity, ethnicity, marital status, highest level of education, health
history, and number of pregnancies. For confidentiality with transcription and within the thesis,
participants were assigned the random names of Glenna, Teri, Hazel, Sylvia, Joelle, Elisa,
Alanna, and Jodi.

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Study participants were offered a twenty-five-dollar digital gift card to an online
merchant of their choice as an honorarium and thank you for their participation in sharing their
experience of antenatal care.
Data Management & Analysis
The interviews were manually coded and themed by the researcher guided by Braun and
Clark (2006) by reading and re-reading the transcripts and following several steps outlined in
Appendix F. Codes and sub-codes were identified and sorted for similarities then placed into a
Venn diagram. Transcripts were then re-read, and main findings of interview questions were
outlined in a word document and into Excel spreadsheets. Codes from step one and findings from
step two shaped themes, also shown in Appendix F, were then combined into a concept map on
the Miro digital platform. Comparative and on-going data analysis and thematic development
continued during writing. Transcripts were read and re-read and compared against coding and
theming documents.
Methodological Rigor
Data collection was linked to the naturalistic inquiry theoretical framework of Lincoln
and Guba (1985), which was recommended by Thorne (2008) as appropriate for interpretive
descriptive data analysis, in which the researcher cannot remove themselves from the views they
bring alongside the research. Based on Lincoln and Guba (1985), strategies to support the
research findings such as purposeful sampling for transferability, detailing methodological
processes for repeating the study for dependability, and reflexivity for confirmability were used.
A key component of ID research methods aims to minimize bias and enhance reliability
of the outcomes is through the process of reflexivity (Thorne, 2008). By situating the researcher
in the research methodology, it was important to pay attention to critical self-reflection and

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reflexive approaches asking myself where, as a clinical-research novice, there could be tensions
in the study methodology (Berger, 2015). As a clinician experienced in rural team-based primary
maternity care, firsthand experiences were essential to the development and implementation of
this study’s research question and methodology. To enhance the validity of the study, the
analysis of the study data required a continuous and open dialogue of my reflexive processes.
This was achieved within the process undertaken to analyze the data while remaining in a
flexible and relational dialogue between myself and the data and subsequently with my
supervisor. By conducting exercises such as coding, creating a logic model, and mind mapping, I
created thematic patterns of what it was like for mothers to experience antenatal care. Examining
my unique understanding of the data via a reflexive approach to data analysis, such as findings of
the benefit a primary care maternity nurse had to mothers’ experiences, was a key aspect in the
iterative and interpretive process of the study findings in collaborative dialogue with my
supervisor and committee members.
Ethical Considerations
This study proposal received ethical approval from the University of Northern British
Columbia Research Ethics Board Approval E.2022.0217.012.00. This approval included meeting
the requirements of the Tri-Council Policy Statement – 2 (TCPS-2). An information letter and
consent form were provided to participants via recruitment email for full disclosure of study
requirements. Once participants expressed interest, written consent was obtained. Participants
were made aware that participation in the interview was voluntary; participants had the right to
choose to not answer a question(s), return to the interview another day if circumstances arose, or
withdraw from the study at any time without any negative consequences to them or their family’s
medical care. Participation in this research was confidential and was not communicated to health

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care providers or part of the participant’s health record. Study data was stored on the researcher’s
personal, locked and password protected computer and data was not documented by personal
identifiers. Following interviews, concluding questions acted as debrief to ensure the safety of
patients following interviews where negative feelings about birth or the participant’s birth
experience may have been triggered. Resources for mental health support were available, as
communicated in the study information letter.
Dissemination
Knowledge translation is an important part of this study. The research proposal was
presented to the University of British Columbia’s Rural Scholar and Clinician Scholar groups as
well as Interior Health’s Rural and Remote Framework team. Feedback received from both
presentations was incorporated into the study design and methods. Study findings and
discussions will be shared as part of a UNBC thesis and through presentations at conferences or
at workshops hosted by groups such as the Rural Coordination Centre of BC or the University of
Northern British Columbia in 2023/24. Presentations of study findings will also include the
University of British Columbia’s Rural Scholar Program and PSBC leadership team in 2023.
Conclusion
This section offers a methodological approach consistent with clinical perspectives of
both team-based antenatal care and researcher professional judgement. The study employed
semi-structured interviews and thematic analysis of findings to capture the essence of mothers’
experiences and perceptions of receiving team-based antenatal care in their rural communities.
The following chapter outlines the studying findings of mothers’ experiences of teambased antenatal care completed that informed the study design.

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Chapter Four: Findings
Chapter four outlines the experiences of eight mothers who received antenatal care in two
rural communities in southeastern BC, known to offer team-based antenatal care. Qualitative
interpretive description methodology guided thematic analysis of semi-structured interviews in
answering the research question, What are mothers’ experiences of team-based antenatal care in
rural British Columbia? The research findings about antenatal care that affected mothers’
perceptions and researcher's interpretations of their experience in a team-based setting are the
main topic of Chapter four.
Overview of Mothers’ Experiences of Team-based Antenatal Care
Seven participants were first-time mothers with one living child. The eighth mother,
Alanna, had two living children and experiences of antenatal care in the same community for
both pregnancies. All eight participants identified as female, had an education level greater than
a high school diploma, were between the ages of 26-45, were in a relationship or married, and
did not self-identify as Indigenous.
Participants shared detailed accounts of their perception and experiences of the care they
received during their pregnancy, before labour and birth. Their experiences included paying
attention to who provided antenatal care, how care was provided, what they liked most about the
care, what was important to them about the care, what worked well within their experience of
care, and what they would have liked to have changed about the care they received. They also
shared how their antenatal care impacted their post-partum period. The following section
provides greater depth and detail as to the study findings specifically, the mother’s experience of
receiving antenatal care from a team of providers.

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Following analysis of participant interviews, the aspects of the team of care providers in a
team-based antenatal care setting that influenced the overall experience of mothers were
identified. Mothers shared what it was about those aspects of TBANC that influenced their
overall experience of antenatal care. Analysis of the data resulted in four themes as depicted in
Figure 3. The three main overlapping themes are situated within an overarching theme of health
and wellness:
1) Structure and function of how the mothers received antenatal care,
2) Value that mothers placed in the relationships that shaped their experiences, and
3) Appreciation that mothers had for patient-centeredness.
Figure 3
Findings of Mothers’ Experiences of Team-based Antenatal Care

Structure and Function of how the Mothe rs Received Antenatal Care
The following section provides an overview of the structure and function of the team of
professionals within the experience of antenatal care professionals described by the mothers.

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Team Structure
For each mother which professionals stepped into and out of delivering their antenatal
care varied. All mothers had attachment to both a primary care provider, a family physician,
when they learned they were pregnant, and a maternity nurse working in the clinic where they
met their physician during their antenatal care. There was greater variation in the involvement of
professions such as a dietician, physiotherapist, mental health therapist, midwife, doula, and
members of the surgical team such as a surgeon and anesthesiologist. Table 4 below outlines the
overall number of professions that mothers shared were present in their antenatal care. While it is
possible that more providers cared for mothers than what they recalled or chose to share, the
expected involvement of an ultrasound technician, as an example, in every mother’s antenatal
care highlighted variation within the subjective experience of receiving care from multiple
providers and subsequent sharing of the details of that experience retrospectively.

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Table 4
Number of Professions that were part of the Participants Care team.

Overall, participants consistently viewed the key members of their antenatal care team to
be their primary care provider (either a family physician who provided labour and birth services
or a midwife) and the primary care maternity nurse (a Registered Nurse working in a community
clinic alongside a family physician). Geographically, seven mothers received TBANC in their
home community. Due to convenience with her place of employment and the antenatal care
provider’s availability in both her hometown and the nearby community, Teri decided to receive
some of her care in a neighbouring community. Physical and virtual sites where mothers
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received antenatal care included a family physician or midwife community clinic, a hospital for
diagnostics and acute care treatment, over the telephone, on virtual platforms, and on digital
platforms, e.g., SmartMom. All participants shared that they met with their team on what
appeared to them as a routine and expected schedule for pregnancy care. There were differences
in the way appointments occurred as well as the physical spaces in which team members
provided antenatal care to the mothers.
Clinic co-location between the family physician and nurse existed for all eight mothers.
While the clinic space was consistent, the appointment scheduling did not always result in
mothers seeing the family physician and the nurses together in a joint appointment. Several
mothers reported that co-location had the potential to enhance communication between the
family physician-nurse dyad. This was described succinctly by Jodie, “Whoever thought of the
doctor-nurse combo, brilliant!” Two mothers could schedule an appointment to meet the
maternity nurse in a hospital setting. This provided an opportunity to orientate mothers to the
labour and delivery setting as recalled by Elisa, “She met me at the hospital to give us a tour of
the room which I thought would be very beneficial for my partner.” The role of the maternity
nurse was well received throughout antenatal care as affirmed by Teri, in that she wanted more
time with a primary care maternity nurse, “I wanted to see her more.” While Elisa “felt lucky
that I had that part of my antenatal care,” Glenna reflected that having the primary care maternity
nurse in the clinic “made a very big difference with my experience.” Both Glenna and Jodi noted
that it was the experience with a primary care maternity nurse that was their motivation for
participating in this study.
Depending on the TBANC composition, the maternity nurse was not present or available
for all consultations. The midwife had a clinic separate from all other providers, which did not

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include access to a maternity nurse. Doulas met in the participants’ homes, in a local coffee shop,
or co-working space. Joelle expressed how “with the doula, we had two or three social visits at a
coffee shop, that was pretty neat – maybe 45 minutes to an hour each time.” Other team
members such as physiotherapist, surgical team, and dietician were seen at appointments
separate from the family physician and maternity nurse in their own clinic settings.
Team Function
How the team worked together is described as functionality and the most important part
of functionality was communication among the team and with the mother as part of the team.
Communication was often described as “connection.” Mothers appreciated the work providers
did to support antenatal health and well-being, as described by Alanna, “[Having] someone
[family physician] who knew everything that was going on, to me, that was the most important to
have a base, a good base." This is an example of how Alanna understood that the content of each
appointment with another provider was always shared with her family physician. Further, how
providers made connections with community resources such as a pregnancy outreach group was
a welcomed surprise to Jodi, “I think that it was the connections between all the professionals.
[The providers gave] a package from [pregnancy outreach group] with resources and links to
certain things and I think, too, having those people available to me considering [I live in] such a
small town.” Even when the mother’s clinical appointments with the family physician and the
maternity nurse were co-located but asynchronous it was clear mothers recognised how the team
worked together. For example, Glenna “was very aware that they would communicate with each
other between my appointments. The nurse was aware of what the doctor had said the last time I
saw them and vice versa.” For Hazel, communication stood out as the most important aspect of
the antenatal care that she had received from the care team:

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Clear communication … is the most important. Communication is super important in all
aspects in your life, but when it comes to your health and understanding what you are
going through, what your body is going through, what to expect and why you are doing
certain things, this is such a foreign thing to go through, being pregnant; it’s so natural
but so not like anything you’ve ever done before. Communication was the thing I
appreciated the most.
For Sylvia, a positive experience of how communication had an impact her general health and
pregnancy wellness was in how the team monitored her iron levels and set up infusion
appointments when she was anemic as she explained “I found the communication very simple. I
didn’t feel like I was in the lurch at any point.” These experiences highlighted how perceptions
of good communication between providers led to mothers’ increased confidence that they
received supportive antenatal care.
Communication was also noted to be an impactful part of antenatal care for Alanna as she
recalled being required to seek antenatal care in another city due to complications for a previous
pregnancy. From Alanna’s perspective, the importance of seeing a fetal medicine specialist
outside of her home community outweighed the significant travel time that the appointment
required. She was ‘grateful’ to have been able to make the trip for speciality care:
For something like that, where it was something really concerning, the travel wasn’t an
issue as we were grateful to go and grateful to be able to have been given the referral and
to have those resources available to us. It wasn’t a big deal to drive to [urban centre] for
the day to do that. It was more of a sense of gratitude that we were able to access it.
From Alanna’s experience, when a level of risk to either themselves and/or their growing baby
was well communicated, there was a better overall experience of antenatal care.

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There were instances where communication did not go well, which impacted the
mother’s experiences of care. For example, Jodi had decided to have an elective caesarean
section early in her pregnancy, which was supported by her family physician. However, when
faced with a change in family physician, i.e., her regular family physician was replaced by a
locum, there was a shift in communication about her caesarean section (C-section) decisionmaking:
I met with the nurse, and we talked about some stuff, and then the locum came in and
they were talking about my care and what was happing and when the nurse said ‘she’s
having an elective C-section the doctor gave me shade and said ‘Why are you doing that?
Wouldn’t you rather try to have the baby naturally? This is your first and how do you
know that anything bad would happen?’
The combination of a change in provider and a possible shift in Jodi’s antenatal care plan had the
capacity to undermine patient decision-making. What was noteworthy was the primary care
maternity nurse, as the consistent team member for Jodi, was able to advocate for the patient as
described:
The nurse stepped in and said ‘since we scheduled the C-section, her mental health has
been a lot better, and her overall health has really improved so it’s working for her’. So,
the personal judgement from the doctor and then the advocacy from the nurse – she was
advocating for my health and my situation and my history. She knew it all. It felt good.
Communication was a straightforward way in which the nurse was able to demonstrate advocacy
in action. In this situation, the primary care maternity nurse took on an advocacy role and
through clear communication made all the difference to the mother in turning a negative
experience in antenatal care into a more positive one.

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In another instance, Elisa talked about how she felt the team communicated with her in a
selective manner, particularly when it came to making decisions about other team members'
participation or absence in her antenatal care. Elisa noted that the addition of a doula may have
impacted her antenatal care and could potentially impact the care of other mothers. Elisa was
inquisitive and thoughtful about why a doula had not been identified as an option for her to
explore:
There is no real talk in the office about, maybe it’s just me or I didn’t get the information,
but there is no real talk about doulas. That’s something that you have to know about on
your own. I didn’t want a doula because … I asked a [friend] to be my doula. I think
there is a card in a pamphlet you get, but … that’s necessarily a collaboration between
providers. I don’t know if they [providers] want that or not … but for some people if that
was something they didn’t know about and that they could afford and were interested in
that it isn’t mentioned that much … something that’s just not brought up.
In this example, the team’s exclusion of certain roles in antenatal care conversations was
considered by Elisa to devalue certain provider contributions. These interactions with the mother
had an impact on Elisa’s overall experience of care, which sparked her curiosity about how this
might affect other people who may want to have a doula part of their antenatal care. Alanna,
Glenna, Jodi, Hazel, and Elisa each highlight communication as a key element in their
understanding of the functionality of teams providing antenatal care.
Value that Mothers Placed in the Relationships that Shaped their Expe riences
The following section explores the value that mothers placed in the relationships that
shaped their experiences of antenatal care. Exploring what mothers had to say about TBANC
provided an opportunity to examine how mothers valued their antenatal care experiences, which

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shaped their interactions with providers. The defining characteristics of values include selfworth, an appeal or personal advantage, and being person-centric, all of which are influenced by
personal and societal experiences and framed by culture, life, events, and personality (Marzilli,
2016). Values are essential to a person’s character and significantly impact how they behave,
think, and make decisions. Pregnancy was a snapshot in time when care needs and expectations
influenced how the mothers valued their experience of antenatal care. In this study, mothers’
experiences were shaped by relationships within the team, between the team and the mother, and
with other mothers.
Relationships with the Team
How the mothers’ connected or did not connect with the provider played a role in
fostering trust and respect. Mothers’ experiences of antenatal care were better when their team
valued each other and valued the mother. In the example of attachment to a primary care
provider prior to pregnancy and subsequent relationship building with providers during
pregnancy, Teri identified her own personality as an influencing factor in her lack of desire to
develop a relationship with the family physician. The family physician was not her regular
family physician but one who was only supporting her during pregnancy and through labour and
birth, “I was not looking to have a really close relationship with my [maternity] doctor because I
have a family doctor …and I love [my family doctor].” While Teri highlighted how she “was not
looking” for a relationship with the family physician, she did expect to feel valued as a patient.
Teri felt her relationship was undermined since her maternity doctor did not seem to remember
her:
So in my opinion she probably has too much going on. So must have been confusing me
with someone else. Because she was consistent in the things she forgot about me. But

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then she would also just forget, like she forgot that she had booked an induction, she
forgot that I had never been pregnant before, she would forget appointments. So that’s
what I disliked. It was not a nice experience. I think I would have liked / wanted someone
that wasn’t from what I perceived, spread so thin. In my head, she shouldn’t have taken
me on if she didn’t have the capacity to take me on.
This led to a negative experience of antenatal care for Teri where she did not feel valued, which
impacted her relationship with the antenatal care physician. Teri subsequently spoke to her peers
about her this experience. She received affirmation from others regarding her experience as she
cited “the word of mouth consensus was that [the physician] is known to be that way.”
Jodi had a different experience of the impact that relationships can have on antenatal
care, particularly with the pre-existing relationship that she had with her mental health therapist
before she became pregnant. Jodi stated, “I’ve been seeing my therapist since 2016 and I love my
therapist. She’s the best ever because we have that rapport already…COVID and my anxieties
and fear of postnatal depression - she was able to really give me some coping tools and strategies
which I found really helpful.” She spoke about this pre-pregnancy consistent connection to her
mental health therapist as integral to her overall experience of feeling supported with her preexisting mental health concerns and those that also were either exasperated or newly identified
because of pregnancy. In describing her gratitude, Jodi framed access to her therapist as a longterm relationship that was valuable to her during her pregnancy as “therapists are very hard to
come by but because I had been seeing her so long ago … I felt very fortunate.”
Relationships with Other Mothers
Comradery with other pregnant mothers was identified as valuable across all the
mother’s experiencing TBANC. Conversations within their existing social networks with other

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mothers who had received antenatal care provided an opportunity for reflection on what they had
wanted their antenatal journey to be. Glenna discussed the care that she was receiving at the time
with a group of friends living outside of the province. Glenna shared, “I felt like I received great
care. I feel like I received very personalized care. …Talking with them about the experiences
that they had having their babies, that [the family physician and primary care maternity nurse
working together] was a big difference – it felt different for me.” Her peers did not have the
same resource of a maternity nurse in their physician’s clinic during their antenatal care.
Glenna’s reflection of her own care in comparison to her friendship network helped to crystallize
how she valued the relationship with the primary care maternity nurse.
Jodi also had conversations about her antenatal care with a peer who lived in an urban
setting. The conversations provided her with positive feelings about the care that she was
receiving in her rural community in relation to the “million opportunities and resources” that her
friend “obviously” had in a big city and that her own family physician also supported her during
pregnancy, “so that combo worked in my favor. She [her friend] would have to wait and go to an
OB-GYN and then that was a separate process, and they would have to communication with the
doctor. It was more broken care then what I got.” She emphasized, “I felt like I was getting
similar, if not better care” living in a rural setting had not reduced her access to antenatal care.
In this study, the influence of comparison shaped participants’ positive experiences of
their care. Jodi shared that her reason for wanting to participate in this study was a result of a
comparison: She compared the care she received from the family physician and primary care
maternity nurse combination to that of her peers in her home community who have older
children and did not have team-based care available to them. She reflected that the care she
received was better than the antenatal care that her “mom friends” had in the same community

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some years ago, "I had heard from mom friends who have older children here in town … not that
long ago. The care they got was less than what I got.” She continued, “I feel like that’s why I
wanted to participate in this because I can now pay that [care experience] forward so this
outcome can help other families."
In some cases, it was listening to other mothers that influenced decisions in how team
members were selected. Conversations influenced their decisions about who to include in their
care team by determining the level of value that other mothers placed on having certain roles part
of their teams. Such influence, was evident in the instance of seeking out a doula or midwife as
Joelle shared:
I got in touch with a local doula and got her services just because I’d heard that could be
really helpful especially during labour … and she told me that there was a midwife that
had just started practising in our community… so she was like yeah, you should
definitely reach out and see if you can get her.
Joelle did choose to leave her physician and transfer to a midwife for her pregnancy care:
…some of the benefits I had heard was that you get a bit more sort of care one on one
with the midwife as opposed to with the family physician…so I just ended up switching
to the midwife within the community.
Conversations with other mothers were a guide about which professional team members they
wanted, increasing the mothers’ confidence in their ability to make decisions about pregnancy.
This approach allowed them to prioritize self-care and the well-being of their baby.
Pandemic Impact on Relationships
There was a specific challenge that limited mothers’ networking and peer conversations.
Being pregnant during a global pandemic impacted mothers’ ability to grow their social network

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and build relationships with other mothers who were pregnant. Specifically, the COVID-19
pandemic changed the modalities in which antenatal care was delivered and traditional face-toface, group prenatal classes looked vastly different. Prenatal education was delivered via digital
platforms and recorded videos, in attempts by health care providers to minimize exposure to the
COVID-19 virus. Mothers such as Hazel voiced how this change in service delivery limited their
relationship development with other pregnant women:
The video was great and comprehensive, but it would have been nice to have real time,
in-person classes, because that’s also the time to start building connections with other
parents who are having babies around the same time you are going to meet them in class.
So, I just feel I missed out on that, but I understand that is because of COVID ...I think
that [in person] would have been a big benefit.
Jodi emphasized, “I would have loved more connection with other moms and that was [limited
because of] COVID." Overall, there was a sentiment shared amount mothers’ that Jodi
summarized, “Being pregnant during COVID was really scary.” The support network that
mothers perceived they would have gained through in-person interactions was missing during the
pandemic and this prevented mothers from developing relationships with other mothers.
Pregnancy during a pandemic negatively impacted mothers emotional wellness and created a
sense of loneliness as Elisa stated, “One month into it you’re alone … there is no village in a
pandemic.”
Appreciation that Mothers had for Patient Centeredness
The following section shares the patient centred approaches to care that were appreciated
by mothers. When care was perceived by the mothers to be personalized, that it occurred

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throughout pregnancy, overall positive experiences of antenatal care were noted. Hazel
described:
[Care] that was really focused, from what are my needs and wishes and leading up to
labour and delivery...It was about me and a lot of questions about how I am
doing…There were even questions about how my partner was feeling and how my
partner was doing, which was really great. It was really family centered.
Often mothers sought out what they wanted to be included in their antenatal care in appointments
with the care team. Sylvia’s experience was perceived as positive when her needs were met, “I
felt really good about the fact that I wanted certain things for my birth and my physician was on
board for all of those things." Team members, education, and resources that were tailored to
meet the mothers’ needs were most impactful in achieving person-centered care.
Tailored Team Members
The main team members for the mothers were chosen depending on their requirements.
This was especially apparent with the addition of allied health providers. Teri’s team expanded
to include a dietician because of her gestational diabetes diagnosis in pregnancy. On reflection
Teri explained that she had appreciated broadening her antenatal team, especially the patientcentered approach taken by the dietician:
I felt like the most important part was how ‘on it’ they were with my gestational diabetes.
She [dietician] was very thorough. And I think that was really important because I
already had a high-risk pregnancy because of my medication and my BMI so it was really
important how ‘on it’ they were and she was ‘on it’ … I would track it [blood sugars] on
my phone and then my dietician would see it on her end. She would call me and say
‘Hey, I see that you have this this and this’ … she really put it in my court. And I think

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she knew I was very determined to do it on my own. So, she would look at the findings
and call me. And say, ‘I noticed you had a really high one’ and I said ‘Yeah, I had a
ginger ale.’ You know she really let me do it but also like was on it enough that if I
wasn’t doing it well, she would have known.
Teri not only had a positive experience with the dietician as part of her personalized care team,
but she also felt that the dietician provided her autonomy over the management of her own care
and subsequent decision making, resulting in Teri feeling valued as an active part of the care
team.
There was a sense of apathy when introduction of a new team members was not tailored
or was unclear to the mother. The experience of having an anesthesiologist added to the team for
Hazel was one of indifference. She was offered and accepted a consultation without a planned Csection:
I don’t think that [consult with anesthesiologist] was necessary. It also didn’t need to be
an in-person appointment, it could have been a quick phone appointment. The hands on
assessment I don’t think [the anesthesiologist] needed to do. [The anesthesiologist] would
have done that in the moment. It wasn’t that important to me.
In this instance, Hazel reflected that she did not specifically need one for her labour and birth
experience and therefore it was not important to her.
There were times where mothers wished they had experienced a team more tailored to
their needs. For example, Joelle noted that additional support for nutrition was something she
wished she had experienced:
A little bit more advice on nutrition would be helpful that maybe wasn’t quite there. I did
a lot of my own research on that, but especially with worrying about, I always think

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maybe I could have eaten better and she would have been a bigger baby … it’s so easy to
go back and think that maybe there are things I could have done differently or better. So
maybe a little bit more nutrition advice could be something that was missing.
Hazel supported the sentiment that involvement of a dietician would have been a benefit:
I was told I had to eat more calories, but I wasn’t told how many more calories. It would
have been nice to sit and discuss that with a dietician, especially [since] pre-pregnancy I
was always dieting and in a calorie deficit, so I didn’t even know what normal calories
were; And then how many calories on top of that.
Joelle echoed the value of a dietician as part of the antenatal care team:
I think a dietician should be a part of the beginning - you see a GP and you see a nurse,
oh, and you see a dietician maybe three times throughout your pregnancy or more if you
need it obviously. But you should meet with them after each trimester because each
trimester is so different for your body - the size of the baby, your hormones - all that
stuff. I would have loved to have her set me up for success earlier on than when I saw her
late second or early third trimesters … I like to have a plan and know what’s best and
being a first time mom, you don’t know what’s happening and what to expect.
When speaking of the team members involved in her care, Joelle reflected and confidently
shared that she felt she would have received more support if she had asked for it.
Alanna, Sylvia, and Elisa each recognised the importance of having more tailored team
members. A physiotherapist as part of their care team who offered pelvic floor health education,
information, and support was seen as an important member of the antenatal care team. Alanna
suggested “I think just one visit or a consult with a pelvic health physio as like an ‘everybody
does this’ would have been really useful … I didn’t get that information as part of my care.”

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Sylvia had taken initiative and self-referred to a physiotherapist while pregnant to meet her needs
during pregnancy, “I did a lot of my own research on my postpartum care. I was doing Pilates
and seeing a pelvic floor physiotherapist in my prenatal care…I put a lot of work in myself.”
Others such as Elisa did not realize until in the postpartum period that the role of a
physiotherapist would have been useful in their antenatal care, supporting physical recovery
following labour and birth:
If I had had more pelvic floor support earlier in pregnancy, preparing for my own
physical body postpartum. I would add an aspect where pelvic floor physio was brought
in and, whether it is a person’s choice to do it or not, cause also it would be out of pocket
if you didn’t have benefits, but luckily for me it’s not. So that role added to the team early
on would - I would change that.
Alanna also acknowledged that there is a barrier in the public health care system that prevents
everyone from having access to physiotherapists, even though they should be part of the care
team.
Tailored Education and Resources
While the majority of antenatal care was focused on the needs of the mothers, there were
some areas that could use improvement in terms of the resources and education provided. These
tools and resources were not always seen as being personalized for each person. Tailoring
resources to enhance personalized care was a suggestion of Alanna’s, as she expressed, "I was
given a lot of resources that I never used, not to say that it wasn't important, I don’t want to say
anything wasn’t important, but just based upon my experience there were certain things that
weren’t an issue for me so I didn’t have to access those experts or resources." Alanna believed

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that in this case, tailoring was missing, she received information that was not specific to her
needs, and she was provided more resources than she thought she required.
While it is known as part of standard antenatal care that education and resources are
based upon PSBC’s Antenatal Record ‘Discussion Topics’ (2022), the education and resources
were offered to mothers in a variety of ways. The mothers reflected on where and from whom
they believed they received “the best source of education and resources” from, citing the primary
care maternity nurse. Jodi supported this position and emphasised its importance, especially for
mothers expecting their first child, “I liked the primary care nurse role. I thought that that it
brought a lot to education because I’d never been pregnant before.” Joelle also commented on
the usefulness of this nurse role early in her antenatal care. Specifically, she focused on the
nurse’s role in her education before she transferred her care to a midwife. Post transfer Joelle no
longer had support from the primary care maternity nurse, which she reflected on. She
differentiated what it was about the primary care nurse and the midwife that set the primary care
maternity nurse apart:
I found it very helpful she kind of provided a bunch of different literature and touched a
bit on nutrition and I found her very approachable, and it felt valuable. Sometimes with
the midwife appointments it was very open-ended. It wasn’t like here are some resources,
it was more ‘Do you have any questions?’ so it was more directed by me which was great
but with the maternity nurse I felt like she was giving me resources and had a bunch of
handouts and kind of giving me a bit of the low down on what nutritional stuff to look out
for … it was helpful.
While Alanna appreciated the ability of the primary care maternity nurse to tailor resources, she
would have liked more time or contact opportunities with the nurse:

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It [the role] was just short of serving its purpose. She was so busy. She was far too
overworked, and I thought that to have her as a resource and to talk to and ask way more
questions to [would have been useful]. She was meant to have the time to go through
stuff for me and she just didn’t.
Alana had thought about solutions to help with access to the “busy” primary care maternity
nurse, suggesting:
Maybe an office hours type thing …where [the nurse] said ‘hey, I am going to be here
and you can just call me or you can come in and ask a question and I will be available.’
Our sessions were great as she sparked a lot of thoughts, but I would have loved the
opportunity to be able to follow up with her and I didn’t really outside of our scheduled
sessions.
Often the mothers reported the education gaps, for example care of the newborn baby
“because I was so obsessed with the labour and delivery" (Hazel), pelvic floor health “because
my insides were falling out” (Elisa), and mental health “because we’re really good at faking it”
(Teri). The proposal that further training be provided in pelvic floor health and mental health
underlines how significant the mothers considered a focus on health and wellness to be. When
specific team members were not included in their care, it seemed like a gap developed and
mothers were left wishing their prenatal care had been better suited to their experiences
managing their own physical health and mental wellness.
Focus on Health and Wellness
The physical health of mothers and their developing child was supported by a team of
providers who collaborated with the mothers throughout their pregnancies. The mothers reflected
on their prenatal care, pregnancy choices, and what they wished they had learnt prior to birth and

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early parenthood by the time they participated in this study. Learning gaps or opportunities were
clearly described by Hazel, Elisa, Teri, and Alanna. Each of these mothers felt that postpartum
psychological concerns could have been better addressed during pregnancy, particularly their
mental health, since good mental health and wellness was linked to physical recovery following
labour and birth. For the mothers their overall emotional wellness could have been strengthened
during the antenatal period. Hazel shared:
What recovery will look like afterwards…could have been better covered by the
team…because you don’t really know what to expect. I had a natural birth but there was
still a lot of recovery, and I didn’t understand what was going to be involved. I was lucky
that my partner was able to take five weeks off work, to help me out… To have a realistic
picture of what you are going to feel like for the first couple weeks afterwards. It was
never discussed. You’re going to be teary and your goanna have mood swings after
birth...so I am not in the right frame of mind to receive any information the day after I
gave birth. It would have been nice to have that discussion during pregnancy just to
prepare myself.
For a few mothers making the connection between the significance of the health and wellness
aspects of the antenatal care as it continued throughout pregnancy, labour, and birth, and into the
postpartum period was made possible by mothers' abilities to anticipate and manage their
physical and emotional recovery after delivery. Alanna, was aware of recent research supporting
that connection:
There is research coming out now that correlates mother’s mental health postpartum with
their expectations specifically for their physical recovery pre-partum. So those that don’t
have any idea of the repercussions of delivery, that pelvic floor injury is a probable

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outcome, have way worse mental health scores postpartum just because their expectations
don’t make their experience and then all of a sudden, they are faced with this huge
recovery that they had no idea about. That is part of the mental health fight, it does have a
huge part in being able to have accurate expectations.
For the mothers with a prior mental health diagnosis there were different emotional strains
postpartum. It was during this period that a few mothers recognized how pacing the right
education delivered by the team could influence later mental and physical health as described
Elisa:
It’s different than a diagnosis of depression not related to antenatal or postpartum.
[Depression was] barely a focus at all, as far as mental health in the antenatal period.
Having a real conversation about, ‘You’re going to leak from everywhere regardless of
whether you have the baby blues’ ‘you literally pushed out an organ that is going to affect
your hormones and you’re going to feel crazy whether you end up with postpartum
depression or not’ and ‘you’re sleep deprived … everything has changed’. It’s defiantly
not a focus and [while] I don’t know if it should be incorporated in the prenatal classes
[maybe it could] with videos, interviews with moms and dads, [listening to] people
who’ve had prenatal depression and prenatal anxiety would be more impactful [by]
giving people a way to talk about it - by seeing other people. Because they do interviews
about labour and delivery in those prenatal classes but [mental health] that’s something
that wasn’t there and that’s somewhere it could be explored more rather than in your
doctor’s office. There is a balance of what that sharing could or should look like. I think
too much information can make people more anxious. I am not that person. I would

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rather have known. For me I would want the information upfront so I wouldn’t be
blindsided.
Elisa proceeded to openly discuss the significance of including information about emotional
wellbeing related to physical healing in antenatal care because, in the absence of this, she
realized that at the doctor's office disclosure of emotional discomfort had not always occurred:
I am [profanity] faking it so you [the doctor] do not say [profanity] to me cause I can’t
deal with you [the doctor] and I just need to get through this – my insides are falling out
and I can’t go for a walk and it’s Covid, which is huge, right.
Lack of disclosure from mothers to providers about their mental health was as a result of the
mother’s perceptions of the care team. Often the mothers believed the team thought they were
“ok” both during antenatal and postpartum care, so failed to ask them about their mental health
and emotional wellness. While Teri, frustratingly shared that there was a lack of effort to meet
her mental health and wellness needs, she also acknowledged her own attempts at selfpreservation, which resulted in limited sharing of information. Teri shared:
I am such an advocate for my own mental health, but I did not get asked [or ask] once
where my or what my mental health [state] was. It was when getting discharged from the
hospital a nurse when I was getting discharged, ‘Do we talk about mental health?’
Teri identified a lack of assessment of her mental health and wellness in pregnancy. She shared
her reflection:
Maybe they didn’t feel that I needed it, a standard form that someone asked if I had seen
before, because we had conversations and they knew I was on medication. But that
doesn’t matter, it should be mandatory. Cause we are also really good at faking it,
because that’s how we survive.

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Overall, mothers noted how their experiences of care continued throughout pregnancy, labour
and birth, and into the postpartum period influenced their health and wellness.
Conclusion
In conclusion, mothers' experiences with antenatal care were either positively or
negatively impacted by a team of care providers' attention to their health and wellness. Good
health and wellness focused antenatal care was achieved by providers who mothers felt
connected to, as this increased value and appreciation in the relationship. The team's makeup,
purpose, and communication between the team and with the mothers, as well as the development
of relationships and the mothers' active participation in their care, were all important in antenatal
care experiences. Despite the effects of being pregnant during a global pandemic, providers and
teams or providers aided mothers' health and wellbeing. Pregnancy was the ideal time to
prioritise health promotion and prevention, especially considering mothers' capacity for self-care
and their subsequent positive experiences when antenatal care providers listened to them and
adapted to meet their changing needs.
The closing chapter outlines an interpretation of mothers’ descriptions of antenatal care
experiences and the clinical significance those experiences have in shaping team-based antenatal
care.

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Chapter Five: Discussion
This study aimed to understand mothers’ experiences receiving team-based antenatal care
(TBANC) in rural BC. First, a summary and discussion of mothers' descriptions of continuity of
care throughout their pregnancies are provided. Second, the discussion is organised into three
sections that explore the connections between the three ways that mothers' perceptions of
continuity in this study and the broader literature are situated:
1) Multiple providers collaborate to create continuity,
2) Mothers and providers share responsibility for continuity, and
3) Relationships between mothers and a carer lead to continuity.
Mothers’ Experiences of Antenatal Care as Continuity of Care
The mothers in the study were drawn from two rural communities where a team-based
approach to antenatal care is practiced. A key finding is that the mothers experienced continuity
of care across their antenatal experiences. The idea of continuity showed up in the mother’s
expectations, opinions, and experiences of receiving care across a range of community settings
and when delivered by various providers. Continuity of care is a keenly debated concept in
clinical practice, specifically in perinatal care as continuity has been applied in many ways, for
example, as an independent variable (Rayment-Jones et al., 2021), a focus on service delivery
(Hargreaves et al. 2022) and outcomes (Homer et al., 2017). The mothers in the study valued
continuity in the way it offered choice in their care as it gave them access to what was perceived
as both important and needed. All the mothers appreciated continuity of care during their
antenatal experience, with several mothers valuing the continuity of the provider.
Continuity of care within the study is closely aligned with the WHO position, “the degree
to which a series of discrete health care events are experienced by people as coherent and

interconnected over time and consistent with their health needs and preferences” (WHO, 2018, p.
8). The interpretation of mothers’ experiences in this study indicates that continuity was not a
single process but a series of coherent yet linked processes. The idea of continuity as episodic,
i.e., a single community, hospital, or ultrasound visit, while sustained between visits by a
network of providers was important to the mothers in the study. This finding aligns with the idea
offered by Reid et al. (2002), as Reid suggests two core elements frame continuity: 1) an
experience of care between a patient and a provider and 2) care that continues over time. In the
present study, continuity occurred due to the scheduling of antenatal care practices in BC, the
clinical spaces, the network of providers from various disciplines working together and critically,
the work the mothers did to engage and connect with antenatal care.
The mothers in the study all valued antenatal care continuity in their community setting.
The mothers experienced different types of continuity from primary care providers and allied
team members during pregnancy as aligned with the three types of continuity described by Reid
et al. (2002): management continuity (coordination), informational continuity (communication),
and relational continuity (relationships). It was interesting to note the mothers' role in shaping
their continuity of care across these three types. It is worth repeating that the mothers in the study
experienced routine, non-specialized antenatal care provided by a wide range of professionals
from different disciplines. Within a rural team-based network, the two consistent disciplines
providing care were the physician and the primary care nurse, a nurse with maternity training
that was focused on maternity care in the community setting. Regardless of the professional
overseeing the mother’s antennal care, each mother influenced their continuity experience. For
the mothers in the study, responsibility for continuity in care strengthened the mother-provider
partnership, regardless of which discipline was providing care, and enhanced the patient-

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centeredness of the antenatal care experience. This was captured within the three types of
continuity as coordination, communication, and relationships. The following sections outline
how mothers played a vital role with the care provider to guide our understanding of the three
types of continuity of care that shaped their antenatal care experiences.
Multiple Providers Collaborating to Create Continuity
The benefits of providers sharing a physical space to promote consistency in managing
antenatal care is highlighted in descriptions of team-based care (Phillippi et al., 2016). Shared
space can be physical or virtual, with a critical element being the need to promote an opportunity
for a range of professionals to collaborate. When such activities happen, active collaboration can
enhance continuity in antenatal care. Reid et al. (2002) summarize this approach to continuity as
management continuity, how providers organize care in collaboration with other providers to
offer care that is “connected in coherent ways” (p. 7). In the current study, the mothers had to be
able to show up at the antenatal visit, which included travelling to a place or having access to
technology to join a consultation. During this time, providers organized the care in a variety of
ways.
Organization of Care
Team-based antenatal care references co-location (Olander et al., 2020), all services at
one location (Perella et al., 2022; Tyson et al., 2022), and joint appointments (Phillippi et al.,
2016) as ways team-based care can be organized and delivered by multiple professionals. Shared
spaces as an approach to care organization can increase the effectiveness of maternity care
service delivery, enhance professional collaboration, and improve perinatal outcomes, as
evidenced in interdisciplinary primary maternity care programming (Harris et al., 2012).
Antenatal care team-based services at one location could be particularly important to mothers

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who struggle with managing transportation or childcare by providing coordination of
appointments to decrease negative impacts of determinants of health on antenatal care attendance
(Tyson et al., 2022). Additionally, co-location, referenced as a tripartite model of clinical
consultation held virtually between patients, midwives or family physicians, and specialists, has
been cited as beneficial from the perspective of providers to improve communication between
the team and patient (Kornelsen et al., 2022). Advancing health technologies and care modalities
supported by a tripartite model of clinical consultation through virtual care or self-management
tools could also benefit mothers’ who are impacted by rurality or negatively by other
determinants of health such as limited transportation. Such mothers could receive antenatal care
from many providers, only if they can have access to technologies. For several mothers in the
study, the convenience of the co-location of multiple providers mattered to a lesser degree than
the existing literature. For example, all the mothers could travel to other communities to receive
antenatal care when necessary. They did not have to worry about travelling to several locations
within their towns or surrounding communities to access care from a variety of professionals,
including dieticians, physiotherapists, acute care providers, or surgical staff. The mothers valued
the opportunity to connect with a network of providers to ensure they received the antennal care
they expected. The mothers appreciated access to providers within their communities for routine
antenatal care, such as ultrasound, which they may have had to travel for in previous
pregnancies. For several mothers, there was an opportunity to have joint appointments in a
primary care clinic between a physician and a primary care maternity nurse. One mother clearly
summed up this opportunity as an impactful part of the antenatal care experience: “Whoever
thought of that combo is brilliant!” Therefore, a few mothers who experienced this more
consistently valued the emerging team-based in-office joint consultations.

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Organization of Care in Community-Based Clinics
In the rural communities where mothers received antenatal care, it was more often noted
that multiple providers collaborated as a network team across multiple locations in a community,
as defined by the BCMOH (2020). In this study, mothers described how, through a coordinated
community-based network of providers, mothers received continuity of care. Mothers described
a community partnership between a family physician and a primary care maternity nurse, in
which the nurse worked side by side with the family physician, though they were not always
seen at the same appointments. They valued the experiences when they saw providers together or
at the same clinic on the same day. Shared spaces have been shown to improve care experiences,
and in this study mothers who had co-location and joint appointments saw a comparable effect to
Phillippi et al. (2016). Mothers also described how multiple professionals joined or exited from
their antenatal care based on the mothers changing antennal care needs. In contrast to recent
research on mothers' experiences of TBANC, mothers' descriptions of how teams arranged their
care in this study were different from how women describe their experiences of antennal care
situated within specialty antenatal care clinics within seven of the studies in the ILR, including
clinic settings within hospitals.
Organization of Care as Continuity in Specialty Clinics
From studies where mother’s experiences of TBANC occurred in specialty antenatal care
clinics, i.e., those dedicated to mental health (Grote et al., 2015; Hauck et al., 2013), chemical
dependence (Howard, 2015; Morris et al., 2011), diabetes and obesity (Jarvie, 2017; Tyson et al.,
2022), or other medical conditions that deem a pregnancy high-risk (Phillippi et al. 2016) teambased care was centralised with multiple providers working in the same physical space. In these
speciality clinics, or in clinics that could support a very specific population i.e., transgender men

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and gender-diverse individuals (Hahn et al., 2019) both specialist knowledge and colocation
were factors in clinic organisation and operation. Mothers in this study experienced antenatal
care in many settings within their communities. This often required the mothers to meet with
providers on a one-to-one basis. Providers working in rural communities often travel between
clinical sites as they work in many locations within their community. Therefore, the organization
of care in this study is different from much of the existing evidence on TBANC, since it is often
located in urban or specialty regional clinics. In specialty clinics, shared spaces are offered so
that multiple providers and the mothers can connect simultaneously. For the most part, the
mothers’ experiences of co-location and joint appointments in the current study aligning more
with the findings of Olander et al. (2020), where co-location was less important to mothers and
joint appointments were a bonus but not necessary as long as providers collaborated and
communicated.
Disruption to the Organization of Care
The mothers did describe frustrations with their antennal care during the COVID-19
global pandemic. This finding was in line with emerging evidence of the negative impact of the
pandemic on maternity care for both providers and patients (Lalor et al., 2023; Flaherty et al.,
2022). The mothers in the study believed that limitations resulting from public health changes
and quarantine mandates influenced their care organization. For example, limitations on the
number of people gathering at appointments together; changes from traditional modalities of
receiving care in-person to telephone and virtual appointments with individual providers. The
mothers acknowledged that having a partner or friend attend consultations, visits, or
appointments is a crucial aspect of continuity that was lost during the COVID-19 pandemic.
However, they also noted that it was providers working collaboratively, such as the family doctor

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and primary care maternity nurse, that were able to narrow the continuity gaps created for
mothers during a pandemic. The study’s findings highlight that coordinating antenatal care by
co-locating providers and scheduling joint appointments with multiple providers simultaneously
with mothers was less critical to mothers than knowing that providers communicated to create
continuity and that they had a support network to rely upon.
Mothers and Providers Shared Re sponsibility for Continuity
Interpretations of mothers’ experiences of TBANC described how collaboration enabled
continuity of care and was vital to the person-centeredness of their care. Communication was the
critical factor in the collaboration experienced by mothers in their antenatal care interactions
with providers. Reid et al. (2002) suggest that the experience of communication embedded in
continuity of care is called informational continuity. Informational continuity presents as the
transfer and use of information about an individual being cared for and the accumulation of
knowledge about the individual over time that providers use to shape patient care (Reid et al.,
2002). In this study, mothers and providers had to work together to ensure informational
continuity. As part of the transfer of information, mothers shared responsibility with providers to
support the accumulation of knowledge about their pregnancy care needs. They had positive
experiences of care when they felt communication had occurred that led to them feeling known
to providers.
Mothers’ Responsibility in Continuity of Care
While information is often referred to within informational continuity as written or
electronic charting (Reid et al., 2002), in the current study, the mothers believed they were the
best source of information for providers. The mothers valued the opportunity to share their
information in conversations with the provider they were seeing or speaking with. The mothers

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described their continuity responsibility as collaborating with the providers through
communication. Specifically, the mothers gave examples of how they had obligations to
communicate information about their care needs and expectations. At the same time, providers
were responsible for listening and further communicating the information mothers shared. There
were also a few examples of where mothers recognized they “held back” information or had
“missed an opportunity” to share information because of a lack of knowledge or questions were
phrased differently depending on the provider i.e., the primary care nurse and midwife. While
these experiences did not limit continuity with the provider, it did limit the mother’s knowledge
about postnatal health and wellness.
When mothers perceived providers’ uptake of their personal information, they felt they
had received person-centred care. When mothers felt heard, it allowed for tailored assessments
and sharing of targeted resources based on their unique and changing needs during pregnancy.
Good communication also led to valuable consultation with other providers, which the mothers
believed was important to meet their changing antenatal health needs. Direct communication
between providers (either verbal, paper, or electronic) resulted in the mothers not having to
repeat their health needs to others. Through direct conversations and the scheduling of
appointments with providers, the mothers were aware that information about their antenatal
health had been transferred between providers. Such communication was viewed positively by
the mothers as it met their expectation that providers could and were working in coordinated and
collaborative ways.
Many mothers thought about how a standardised approach to prenatal care assessments
and education could improve continuity that would be beneficial to mothers in their postpartum.
Upon reflection, a couple of the women mentioned obstacles related to medical benefit

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restrictions that could prevent receiving support for pelvic floor health during pregnancy. One
approach to overcoming this could be via hybrid models of maternity education inclusive of
team-based approaches to care, that include a physiotherapist. Such approaches are emerging in
the more recent literature, for example, telehealth to supplement antenatal care received in clinics
(Buultkens et al., 2022). Recent evidence highlights how mothers value adding a diverse range of
providers to their overall care while pregnant (Adeniyi et al., 2021; Howard, 2015; Jarvie, 2017;
Perella et al., 2022), which suggests that continuity of care can support individualized
information leading to person-centered care, with mothers at the centre of the decision-making.
Mothers Feeling Known in Continuity of Care
Mothers shared examples of when continuity was interrupted or absent due to poor
knowledge transfer between mothers and providers or poor information uptake by providers. For
example, when mothers did not feel known by a provider, the experience was negative. Providers
only sometimes heard mothers’ voices when they communicated information about their care
needs or expectations. A knowledge-trust gap between the mother and the provider grew wider
whenever there was a loss of continuity, a missed opportunity to share information, or when
mothers believed that the providers were uninformed or unresponsive to their pre-existing
medical conditions, such as depression, anxiety, or anaemia. Continuity of care, from the
perspective of Tyson et al. (2022) was what was able to support clinicians knowing their patients
– being known was particularly important for mothers who were negatively impacted by
determinants of health and experiencing a high-risk pregnancy. Mothers in this study had to have
courage to voice when the information-sharing portion of care was not going as planned and they
were not feeling known. Here, the mothers were required to assist in maintaining continuity by
reminding the physicians or midwife during follow-up visits about specifics of their prenatal

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care. At times, it was reassurance from peers or other providers that reminded mothers that these
types of conversations were important in antenatal care and that helped communication recovery
between the mother and a specific provider. While this extra work undertaken by the mothers can
be linked to being an active partner in care, as Acka et al. (2017) suggest, it involves the mother
having the skills, confidence, and courage to question providers. Furthermore, it hinges on the
providers having the skills to listen to, and collaborate and communicate with mothers (Perella et
al., 2022). When communication gaps impact informational continuity it is a responsibility for
mothers and providers to narrow the gap to get continuity back on track.
Gaps in Care Challenging Continuity
When mothers discussed aspects of their team-based care that they felt were poorly
communicated, information continuity seemed to be a problem. From the mothers' perspectives,
these missed communication opportunities had an impact on some antenatal and postnatal
aspects of care continuity. For instance, a couple of the mothers wished they had more education,
preparedness, and connections to a physiotherapist while they were pregnant, to support their
physical recovery after labour and delivery. A growing body of evidence outlines the relationship
between experiencing birth-related pelvic floor trauma and dysfunction, highlighting the benefits
of pelvic floor health education in pregnancy (Johnson et al., 2022). Current evidence on
optimizing prenatal nutrition through team-based care also shows an opportunity for including
topics that are important to mothers but not currently communicated as part of standard
information (Town et al., 2019). While at least one mother recognised they would have received
nutritional information if they had asked for the information this was not something mothers
recognized they needed when receiving antenatal care. Overall, promoting positive health
behaviours needs to be encouraged by providers during pregnancy. Improving mothers’ health

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and well-being in pregnancy can have impacts beyond pregnancy. In this study, the impact of
established relationships that could overcome gaps in continuity as perceived by mothers made a
difference in the person-centeredness of their care.
Relationships between Mothers and a Carer led to Continuity
This study’s findings highlight the importance mothers gave to the relationships that
moulded their experiences, particularly with a primary care maternity nurse throughout their
pregnancy. Reid et al. (2002) describes such relationships between consistent providers and the
individual over time as relational continuity.
Influence of Teams on Continuity
Mothers in this study focused more on their subjective experiences with antenatal care
than on their interactions with and benefits from a team. For mothers, the team was less
important or critical, and the relationship with a provider was more important. The word team
was deliberately left out of the preparation of the interview guide and the subsequent interview
questions so as not to influence or sway the information about mothers’ experiences. The
subjective experience was the extent to which the mothers felt listened to, valued, and included
in their care.
In this study, relationships typically grew between mothers and a primary care maternity
nurse. Those relationships became reciprocal, trusting, and respectful, particularly in the space
where the nurse could compensate for the lack of or limitations in relationships with others.
Scheduling appointment time between the nurse and mother helped to establish a connection that
mothers perceived as reciprocal, respectful, and trusting. Similarly, mothers’ experiences from
the OFM program team-based maternity clinic in Perella et al. (2022) highlighted the importance
of having time with providers to meet mothers’ needs and build relational practice.

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In the relatively short pregnancy timeframe, relational continuity was challenged with the
introduction of new providers with whom mothers did not have an established relationship. For
example, the introduction of a locum at a joint appointment saw the nurse acting as the consistent
provider, able to promote advocacy that supported the mother’s decision-making. As with
introducing anyone new to a care team, research shows there is potential for discontinuity,
undermining patient safety, and teamwork (Ferguson & Walshe, 2019). In the present study
informational and relational interruption challenged continuity, which may have resulted in a
negative experience for the mother. Mothers who had a strong relationship with their family
physician expressed a lack of desire to establish a relationship with a new maternity care
provider. It is equally important for mothers to feel comfortable and supported throughout the
process since they wanted to receive safe and informed care while being treated in personcentred ways. Therefore, several mothers recognised that they needed to actively ensure that they
received comprehensive and coordinated care throughout pregnancy.
A Primary Care Maternity Nurse as Part of the Team.
When a mother needed support from a provider to elevate their voice in communicating
with other providers, it was beneficial when a primary care maternity nurse stepped into the
conversation, and both communicated pregnancy care history and advocated for choices made by
the mother. When discontinuity occurred, a primary care maternity nurse was critical in
improving and enhancing communication. This partnership between the maternity nurse and the
mothers elevated the mothers voicing of their care needs, similar to the outcome of Phillippi et
al.’ s (2016) study, where care exceeded expectations when mothers felt they were partners in
their care. Maternity care experiences can improve when mothers can “lead decision making,
whether they are given enough time to consider their options, and whether their choices are

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respected” (Vedam et al. 2017, p. 2). The mothers offered ways that all providers could further
enrich and build relationships i.e., increased contact time or opportunity via open office hours,
and email access. A primary care maternity nurse provided a space for mothers to feel confident
about their involvement in their antenatal care. For mothers in this study, a primary care
maternity nurse was critical in providing person-centered care to improve mothers’ experiences
of care.
Continuity of a Carer
While the nurse role stood out, mothers also noted others, such as the family physician
and mental health therapist were key in providing continuity of care. Where mothers had an
established relationship pre-pregnancy with a provider such as a counsellor, physician or
dietician self-care and continuity during pregnancy were more likely to be maintained. In
interpreting the mothers' experiences of their interactions with providers, mothers require access
to someone with whom they could establish a respectful and trusting relationship throughout
their pregnancy. Ideally for some mothers this happens before pregnancy and carried on
throughout the course of their maternity care.
In coming full circle, the concept of continuity of carer in antenatal care was raised
almost 20 years ago in the federal Multidisc iplinary Collaborative Primary Maternity Care
Project (2006). This early work referenced that “continuity is pivotal for enhancing the
pregnancy experience, and typically refers to the organizational and process context of the
providers” (p. 9). In delivering such a collaborative model the women will “be able to request
continuity of career” (p.16) (Multidisciplinary Collaborative Primary Maternity Care Project,
2006) which was an important factor for the mothers in the current study. Continuity of the carer
continues to be recognised as an effective way to reduce health inequities and improve clinical

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outcomes for mothers and their growing babies (Rayment-Jones et al., 2021). In Rayment-Jones
et al.’s study, continuity, with a community-midwife as carer, was outlined as a key driver of
community-based antenatal care and a benefit to mothers and neonates compared to hospitalbased antenatal care (2021). Mothers in the current study commented less on the clinical
assessments in their antenatal care from a team of providers, as did mothers who responded to
Perrella et al.’s 2022 survey, and more on the experience of their relationships with providers
and the value of support and advocacy from providers. The findings of this study suggest greater
consideration for continuity of carer for mothers during pregnancy and less focus on professional
designation, meaning it does not need to be the primary maternity care provider.
Summary
This section offers a discussion on the experiences of mothers receiving team-based
antenatal care in rural BC. The mothers in this study shared how they wanted to be included in
decision-making and be involved and guide their team-based care planning, which translated to
how they valued and had a shared responsibility for continuity in their antenatal care. To achieve
this goal the mothers in this study described how having one provider facilitated the patientcenteredness of their community-based antenatal care. Since their experiences were centred
around being cared for over the course of their pregnancy, by someone who knew them; the
experience was rooted in the relationships between mothers and providers, mainly a primary care
maternity nurse. In this study it was clear that the nurse held the role of continuity leader in
partnership with the mother but that a consistent provider throughout their pregnancy to work in
partnership with them was critical to their overall experiences. From this study, the BC’s
network teams within team-based primary care are functioning alongside federal intention, noted
in the Multidisciplinary Collaborative Primary Maternity Care Project (2006).

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The following section identifies implications, future research opportunities, and
limitations present within the study.
Implications and Future Research
This research has broad implications for individuals, teams and leaders interested in
primary maternity care in rural BC, namely policy-makers, researchers, health system
administrators, health care providers, and patients/families. In drawing together policy review,
evidence-informed literature and the current study there is a need to:
1) expand community-based network teams in rural BC,
2) support continuity of a carer working within a network team,
3) consider the local context of available providers and advocate for a primary care
maternity nurse where possible, and
4) consider future opportunities to increase mothers’ voices in team-based maternity care
policy, planning, and research to view mothers’ as critical team members.
Expand Network Teams in Rural Communities
The findings of continuity of care focused on coordinated care, communication, and
relationships between mothers and multiple providers throughout pregnancy are essential to rural
primary maternity care sustainability conversations. For mothers in this study, it was less about
the profession-led experience of antenatal care or traditional maternity care providers of
physicians or midwives and more about established or establishing relationships form a
consistent provider. Teams-based or networks of care providers working collaboratively provide
and operational approach to delivering community-driven antenatal care.
There is an opportunity from the interpretation of mothers’ experiences to organize care
with less focus on shared spaces in community-based antenatal care and more on communication

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and collaboration between mothers and other providers, recognizing that mothers share a
responsibility for ensuring continuity of care. Mothers’ understanding of antenatal care teams
highlighted the value of consistent connection for mothers as a way in which to build and sustain
collaborative practice between a range of providers.
Support Continuity of a Carer working within a Network Team
Current recommendations for redesigning the Canadian health system including system
sustainability places less focus on having the physician or midwife always be the primary contact
for continuity but instead, how other providers maybe situated to take on this responsibility (Bell
et al., 2023). This raises an opportunity in rural health care as delivery is multifactorial
dependent on the number and types of providers and opportunities to apply maternity skills
(Kornelsen et al., 2023). Understanding the local context of who is available and able to secure
continuity of care for mothers as part of a network of providers can improve access to and
experiences of antenatal care in rural communities. For example, there may be a primary care
maternity nurse or a community health nurse who can provide assessment, education, and
advocacy in collaboration with other providers. There may be an allied health professional,
social worker or a doula who could be the continuity lead working in collaboration with a family
physician or midwife. Such a shift will be dependent on professional working relationships,
skills and competency, and meaningful and sustained collaboration. This is similar to the
continuity triad as described in the Multidisciplinary Collaborative Primary Maternity Care
Project (2006) whereby “the integrated quality focus which links structure with process and
expected outcomes, thus achieving desired outcomes for women.” (p. 18) is connected to how
the informational, managerial, and relational continuity translate to quality, evidenced-informed
maternity care.

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Consider the Local Context and Advocate for a Primary Care Maternity Nurse Where Possible
There is no doubt that maternity care in rural Canada must be maintained, yet it remains a
persistent challenge. Mothers must be heard and supported with a care structure that meets their
needs by taking into account the local context in which they receive antenatal care. The
maternity care offered in rural communities are known to be “highly context-specific" (Yeates,
2016, p. 2). Community-specific programming seems increasingly relevant for rural
communities where various team-based care models may already exist and is seen as a benefit
from provider (Kornelson et al., 2022) and patient (Liu et al., 2021) perspectives and where
sustainability concerns are at the forefront of health system transformation (Kornelson et al.,
2023; Barclay et al., 2016). In this study, a primary care maternity nurse was the most notable
provider to support continuity of care. However, in communities where TBANC is absent or
where a primary care maternity nurse role does not exist, mothers should have access to a
continuous provider during their pregnancy who works in collaboration with other providers.
The continuity of carer concept needs to be integrated into a network that supports coordination
and collaboration with other providers to meet mothers’ needs and support continuity in primary
maternity care.
The concept of “one size does not fit all” (Munro et al., 2013, p. 651) has been discussed
in research on models of maternity care in rural environments specific to interprofessional
collaboration with midwives. Mothers’ experiences of continuity of antenatal care support must
be driven by the community context. Study findings affirm the policy statement supporting
returning birth to communities in Canada to improve women’s satisfaction with care by staying
in a home community for birth through models that promote safe care without surgical capacity
(SOGC, 2017). Mothers’ descriptions of what was important to them in their team-based

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antenatal care recognised the value in having local skilled similar to Kornelsen & McCartney,
(2015). Therefore, local considerations for providing maternity care need to consider models that
consider the Canadian Institute for Health Information guide (2021) for rural health service
planning whereby local considerations shape rural health service models.
Furthermore, this study exemplifies the need to advocate for and expand the role of the
primary maternity nurse within primary care networks, where possible, within the local context,
given the notable and positive impact this role had on mothers in this study. Returning birth to
communities who have lost services can support sustainable rural maternity care (Miller at al.,
2017) embedding such roles are important considerations when rebuilding maternity services.
Munro et al. (2013) stated that “no single model of interprofessional collaboration would
facilitate the needs of birthing women throughout the province [BC]” (p. 651). Findings from the
interpretation of this study echo this position. Therefore, understanding the function and scope of
emerging roles i.e., primary care maternity nurse, will help to determine operational structures at
local and network levels.
Greater Involvement of Mothers’ Voices in Policy, Planning, and Research
While there is a strong supportive policy direction in BC valuing team-based primary
care efforts focused on patient-centered care, patient voices still need to be identified as the
central and critical aspect of the primary maternity care experience. Future research on teams in
rural communities will help policymakers understand how providers work together while being
inclusive of mother's perspectives, thereby building a collaborative culture (Multidisc iplinary
Collaborative Primary Maternity Care Project, 2006). Policymakers, researchers, health care
administrators, and health care providers need to embrace further the concept of network teams
who work in and from different locations (BCMOH, 2020). This includes understanding how for

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rural communities, virtual and telehealth modalities support continuity of care when the
provider(s) do not live in the community.
Limitations
Limitations presented in this study relate to sample size and the impacts of a global
pandemic, participant demographics, researcher focus on antenatal care only, and participant
focus on health and wellness during a pandemic.
Sample Size and Impacts of a Global Pandemic
Sample size may limit the transferability of the study findings. For example, data
saturation did not occur with eight participants. In each interview, mothers shared various
experiences that, while overlapping, each identified personal traits and factors that contributed to
continuity of care. Follow-up with pregnancy outreach groups did occur to promote additional
recruitment, however, the COVID-19 pandemic may have limited sharing opportunities.
Therefore, additional attempts at recruitment were unsuccessful, which was not detrimental
rather a limitation of the study since in learning from patient experience, every voice matters.
Findings add to the limited evidence on TBANC antenatal care from the perspectives of mothers.
Prior to the COVID-19 global pandemic, recruitment would have occurred through health
authority programming and physician or midwifery clinics, via an operational approval process
which may have resulted in greater study participation. Furthermore, the global pandemic may
have limited interest in participating in research.
Participant Demographics
Demographics of the study may limit the transferability of findings to other populations,
such as marginalized populations, including those known to be negatively impacted by

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determinants of health. Participants in this study were limited to middle-aged Caucasians who
identified as female, in a relationship, and had received education after high school.
Participants were also primiparous (seven out of eight); therefore, there may be a limit to
the transferability of findings to multiparous mothers’ perspectives. Considering the study by
Perella et al. (2022) no significant difference between primiparous and multiparous responses
were reported when evaluating women’s satisfaction with a team-based model of maternity care
including prenatal, birthing, and postpartum perspectives.
Researcher Focus on Antenatal Care
The study’s focus was on mothers’ experiences within a team-based antenatal care
context but some mothers also briefly spoke to their labour, delivery, and postpartum
experiences. All the care they received noticeably intersected across the continuum of pregnancy,
labour, and birth to postpartum. Therefore, this study may have missed key aspects of antenatal
care that would have surfaced in discussions on labour, birth, and postpartum care by asking
mothers to primarily focus on their antenatal care. Despite this possible limitation, focusing on
antenatal care was an overall strength of the study, allowing for an increased understanding of
the experience of community-based antenatal care, in which so little evidence from the
perspectives of mothers exist. On reflection, the addition of a question recognizing antenatal care
as a connection to postpartum events such as caring for oneself or one’s newborn may have
drawn out more information from participants that recognize what could have been different
about their antenatal care.
Participant Focus on Health and Wellness during a Global Pandemic
The COVID-19 pandemic limited the study in several ways including study interviews,
mother’s experiences of maternity care and the ways in which continuity happened as a result of

100

provincial health orders. Similar to Perella et al’s study. (2020) the experience of antenatal care
during a global pandemic may have been affected by the psychosocial impacts, which changed
their priorities related to their health and wellness, which influenced their care expectations and
experiences due to public health messaging and social distancing measures.
Conclusion
Most studies on team-based antenatal care are from the providers’ perspective and in
specialty clinics. Therefore, this study aimed to learn more about mothers’ experiences receiving
community-based antenatal care from a team of providers in rural BC. This study adds to the
small body of research on team-based antenatal care from the perspective of mothers. Mothers’
descriptions of antenatal care received in communities that offer team-based primary maternity
care services suggest that mothers experienced continuity of care. When mothers experienced
continuity of care, it was the relationships between mothers and providers that mothers valued.
The success of the mother-provider relationship, notably with a primary care maternity nurse,
came from the collaborative partnership. The nurse was part of a network team that included
mothers as critical partners who also shared responsibility for ensuring continuity. When a
provider made the mother feel recognised and supported and was able to use the mother's general
and pregnancy health information as well as their understanding of their unique circumstances to
arrange appropriate care, it was a positive experience for the mother. This resulted from having
continuity with an antenatal health care provider.
As team-based primary maternity care remains a priority in BC, mothers’ voices must
continue to contribute to quality-improving team-based antenatal care and sustainability of
maternity services in rural communities. Implications of this study focus on how we view a team
working together as a network to support what mothers value in continuity of care and continuity

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of carer, adding local contextual considerations for guiding how antenatal care teams collaborate,
communicate, and build relationships with mothers to meet their needs.

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References
Adeniyi, A., Donnelly, L., Janssen, P., Jevitt, C., Kardeh, B., von Bergmann, H., & Brondani,
M. (2021). Pregnant women’s perspectives on integrating preventive oral health in
prenatal care. BMC Pregnancy and Childbirth, 21(1). https://doi.org/10.1186/s12884021-03750-4
Akca, A., Corbacioglu Esmer, A., Ozyurek, E., Aydin, A., Korkmaz, N., Gorgen, H., Akbayir,
O., & Ozyurek, E. S. (2017). The influence of the systematic birth preparation program
on childbirth satisfaction. Archives of Gynecology & Obstetrics, 295(5), 1127–1133.
https://doi.org/10.1007/s00404-017-4345-5
Aromataris, E. & Munn, Z. (Eds.). (2020). JBI Manual for Evidence Synthesis. https://doi.org/
10.46658/JBIMES-20-01
Barclay L, Kornelsen J, Longman J, Robin S, Kruske S, Kildea S, Pilcher J, Martin T,
Grzybowski S, Donoghue D, Rolfe M, Morgan G. (2016). Reconceptualising risk:
Perceptions of risk in rural and remote maternity service planning. Midwifery, 38, 63-70.
https://doi.org/10.1016/j.midw.2016.04.007
Beecher, C., Devane, D., White, M., Greene, R., & Dowling, M. (2020). Women's experiences of
their maternity care: A principle- based concept analysis. Journal of the Australian
College of Midwives, 33(5), 419–425. https://doi.org/10.1016/
j.wombi.2019.11.001
Bell, B., Black, G., Butts, J., Goel, V., Lafontaine, A., Lee, A., MacNaughton, D., Martin, D., &
Philpott, J. (January, 2023). Taking back health care: How to accelerate people-centered
reform now. https://ppforum.ca/wp-content/uploads/2023/01/TakingBackHealthcareJan2023-PPF-EN-1.pdf
Berger, R. (2015). Now I see it, now I don’t: researcher’s position and reflexivity in qualitative
research. Qualitative Research, 15(2), 219-234.
https://doi.org/10.1177/1468794112468475
Braun, V. & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in
Psychology, 3(2), 77-101. https://doi:10.1191/1478088706qp063oa
British Columbia Association of Pregnancy Outreach Programs. (2021, December 21). Program
Directory. https://www.bcapop.ca/POP-Programs
British Columbia Patient Safety and Quality Council. (2020). Team-based care resource list.
https://bcpsqc.ca/resources/team-based-care/
British Columbia Patient Safety and Quality Council. (2020). BC Health Quality Matrix.
https://bcpsqc.ca/resource/bc-health-quality-matrix/

103

British Columbia Ministry of Health. (2020, August 27). Supportive policy direction: Teambased care.
British Columbia Ministry of Health. (2019, May). Primary and community care initiative:
Overview and update.
British Columbia Ministry of Health. (2017, November 14). Supportive policy direction:
Interdisciplinary team-based care (version 1.8).
British Columbia Ministry of Health. (2015a). Primary and community care in BC: A strategic
policy framework. https://www.health.gov.bc.ca/library/publications/year/2015/primaryand-community-care-policy-paper.pdf
British Columbia Ministry of Health. (2015b). The British Columbia patient-centered care
framework. https://www.health.gov.bc.ca/library/publications/year/2015_a/pt-centredcare-framework.pdf
British Columbia Ministry of Health. (2015c). Rural health services in BC: A policy framework
to provide a system of quality care. http://www.health.gov.bc.ca/library/publications /
year/2015/rural-health-policy-paper.pdf
British Columbia Ministry of Health. (2014). Primary maternity care: moving forward
together. https://www.deslibris.ca/ID/248084
British Columbia Ministry of Health. (2004). Supporting local collaborative models for
sustainable maternity care in British Columbia: Recommendations from the Maternity
Care Enhancement Project. https://www.health.gov.bc.ca/library/publications/
year/2004/mcep_recommend_dec2004.pdf
Buultjens, M., Gill, J., Fielding, J., Lambert, K. A., Vondeling, K., Mastwyk, S. E., Sloane, S.,
Fedele, W., Karimi, L., Milgrom, J., von Treuer, K., & Erbas, B. (2023). Maternity care
during a pandemic: Can a hybrid telehealth model comprising group interdisciplinary
education support maternal psychological health?. Women and Birth: Journal of the
Australian College of Midwives, 36(3), 305–313. https://doi.org/10.1016/
j.wombi.2022.09.007
Canadian Institute for Health Information. (2021). Rural Health Service Decision Guide.
https://www.cihi.ca/sites/default/files/document/rural-health-servicedecision-guide-manual-en.pdf
Creswell, J. W., & Creswell, J. D. (2018). Research design: Qualitative, quantitative, and
mixed methods approaches (5th ed.). Los Angeles, CA: Sage.
Ferguson, J., & Walsh, K. (2019). The quality and safety of locum doctors: A narrative review.
Journal of the Royal Society of Medicine, 112(11), 462-471.
https://doi:10.1177/0141076819877539
104

Flaherty, S.J., Delaney, H., Matvienko-Sikar, K. et al. (2022). Maternity care during COVID-19:
a qualitative evidence synthesis of women’s and maternity care providers’ views and
experiences. BMC Pregnancy Childbirth, 22, 438. https://doi.org/10.1186/
s12884-022-04724-w
General Practice Services Committee. (2019). Summary guide: GPSC fees supporting teambased care. https://gpscbc.ca/sites/default/files/uploads/GPSC%20TBC
%20Fee%20Summary%20Guide.pdf
Giesbrecht, E. & Shum, J. (2020). Maternal/fetal and newborn tiers of service [Webinar].
Perinatal Services BC. https://www.youtube.com/watch?v=q1ub2gcp4nA&
feature=youtu.be
Grote, N.K., Katon, W.J., Russo, J.E., Lohr, M.J., Curran, M., Galvin, E., & Carson, K. (2015).
Collaborative care for perinatal depression in socioeconomically disadvantaged women:
A randomized control trial. Depression and anxiety, 32(11), 821–834.
https://doi.org/10.1002/da.22405
Grzybowski, S., Stoll, K. & Kornelsen, J. (2011). Distance matters: A population based study
examining access to maternity services for rural women. BMC Health Services
Research, 11(147). https://doi.org/10.1186/1472-6963-11-147
Hahn, M., Sheran, N., Weber, S., Cohan, D., & Obedin-Maliver, J. (2019). Providing patientcentered perinatal care for transgender men and gender-diverse individuals: A
collaborative multidisciplinary team approach. Obstetrics and gynecology, 134(5),
959–963.
Hargreaves, S., Young, S., Prior, S. J., & Ayton, J. (2022). Exploring women’s experiences of
maternity service delivery in regional Tasmania: A descriptive qualitative study.
Healthcare, 10(10), 1883. https://dx.doi.org/10.3390/healthcare10101883
Harris, S.J., Janssen, P.A., & Saxell, L., et al. (2012). Effect of a collaborative interdisciplinary
maternity care program on perinatal outcomes. Canadian Medical Association Journal,
184, 1885-1892.
Hauck, Y., Allen, S., Ronchi, F., Faulkner, D., Frayne, J., & Nguyen, T. (2013). Pregnancy
experiences of Western Australian women attending a specialist childbirth and mental
illness antenatal clinic. Health Care for Women International, 34(5), 380–394.
https://doi.org/10.1080/07399332.2012.736577
Hodgson, Z. G., Saxell, L., & Christians, J. K. (2017). An evaluation of interprofessional group
antenatal care: A prospective comparative study. BMC Pregnancy and Childbirth, 17(1),
297. https://doi.org/10.1186/s12884-017-1485-3

105

Homer, C. S., Leap, N., Edwards, N., & Sandall, J. (2017). Midwifery continuity of carer in an
area of high socio-economic disadvantage in London: A retrospective analysis of Albany
Midwifery Practice outcomes using routine data (1997-2009). Midwifery, 48, 1–10.
https://doi.org/10.1016/j.midw.2017.02.009
Howard, H. (2016). Experiences of opioid-dependent women in their prenatal and
postpartum care: Implications for social workers in health care. Social Work in Health
Care, 55(1), 61–85. https://doi.org/10.1080/00981389.2015.1078427
Jarvie, R. (2017). Lived experiences of women with co-existing BMI >= 30 and Gestational
Diabetes Mellitus. Midwifery, 49, 79–86. https://doi.org/10.1016/j.midw.2016.12.009
Joanna Briggs Institute. (2020). Critical appraisal tools. https://jbi.global/critical-appraisal-tools
Johnson, K.T., Williams, P.G., & Hill, A.J. (2022). The importance of information: Prenatal
education surrounding birth-related pelvic floor trauma mitigates symptom-related
distress, Journal of Women's Health Physical Therapy, 46(2), 62-72. https://doi:
10.1097/JWH.0000000000000229
Kornelsen, J., Nowaczek, D., Johnson, R., Mattei, M., & Moola, S. (2022). Care providers'
experiences with and attitudes towards virtual antenatal care: Findings from a qualitative
study in British Columbia. Digital health, 8, 20552076221131458. https://doi.org/
10.1177/20552076221131458
Kornelsen, J., Webster, G., Lin, S. et al. (2023). Feasibility issues impacting optimal levels of
maternity care in rural communities: implementing the Rural Birth Index in British
Columbia. BMC Health Services Research, 23, 8. https://doi.org/10.1186/s12913-02209008-9
Kornelsen, J. & McCartney, K. (2015). System enablers of distributed maternity care for
Aboriginal communities in British Columbia: Findings from a realist review. https://medfom-crhr.sites.olt.ubc.ca/files/2015/05/apru_fnha_system-enablers-of-distributedmaternity-care-for-aboriginal-communities-in-bc_report_final.pdf
Lalor, J. G., Sheaf, G., Mulligan, A., Ohaja, M., Clive, A., Murphy-Tighe, S., Ng, E. D., &
Shorey, S. (2023). Parental experiences with changes in maternity care during the Covid19 pandemic: A mixed-studies systematic review. Women and Birth: Journal of the
Australian College of Midwives, 36(2), e203–e212. https://doi.org/10.1016/
j.wombi.2022.08.004
Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic Inquiry. Newbury Park, CA: Sage
Publications.
Liu, C. H., Goyal, D., Mittal, L., & Erdei, C. (2021). Patient Satisfaction with Virtual-Based
Prenatal Care: Implications after the COVID-19 Pandemic. Maternal and child health
journal, 25(11), 1735–1743. https://doi.org/10.1007/s10995-021-03211-6
106

Lubbe, W., Ham-Baloyi, W. Ten, & Smit, K. (2020). The integrative literature review as a
research method: A demonstration review of research on neurodevelopmental supportive
care in preterm infants. Journal of Neonatal Nursing, 26(6), 308–315.
https://doi.org/10.1016/j.jnn.2020.04.006
Miller, K. J., Couchie, C., Ehman, W., Graves, L., Grzybowski, S., & Medves, J. (2017). No.
282-Rural Maternity Care. Journal of Obstetrics and Gynaecology Canada, 39(12),
e558–e565. https://doi.org/10.1016/j.jogc.2017.10.019
Mitchell, P., M. Wynia, R. Golden, B. McNellis, S. Okun, C.E. Webb, V. Rohrbach, and I. Von
Kohorn. (2012). Core principles & values of effective team-based health care. Discussion
Paper, Institute of Medicine, Washington, DC. www.iom.edu/tbc.
Morris, M., Seibold, C., & Webber, R. (2012). Drugs and having babies: An exploration of how
a specialist clinic meets the needs of chemically dependent pregnant women. Midwifery,
28(2), 163–172. https://doi.org/10.1016/j.midw.2011.03.002
Multidisc iplinary Collaborative Primary Maternity Care Project. (2006). Guidelines for
development of a multidisciplinary collaborative primary maternity care model.
https://www.homebirthsummit.org/wp-content/uploads/2013/09/MultidisciplinaryCollaborative-Primary-Maternity-Care-May_Ottawa.pdf
Munro, S., Kornelsen, J., & Grzybowski, S. (2013). Models of maternity care in rural
environments: Barriers and attributes of interprofessional collaboration with midwives.
Midwifery, 29(6), 646–652. https://doi.org/10.1016/j.midw.2012.06.004
National Collaborating Centre for Determinants of Health. (2021). Introducing the CPHO
annual report 2020- From risk to resilience: An equity approach to COVID-19.
https://www.youtube.com/watch?v=w9XLYS6le4g
Nurses and Nurse Practitioners of British Columbia. (2020). Patient and family
centered care (Issue Brief). https://www.nnpbc.com/pdfs/policy-and-advocacy/issues/IBPatient-&-Family-Centred-Care.pdf
Olander, E., Aquino, M., & Bryar, R. (2020). Three perspectives on the co-location of
maternity services: Qualitative interviews with mothers, midwives and health visitors.
Journal of Interprofessional Care, 34, 1-9. https://doi.org/10.1080/13561820.2020.
1712338
Perrella, S. L., Miraudo, J., Rea, A., Geddes, D. T., & Prosser, S. A. (2022). Maternal Evaluation
of a Team-Based Maternity Care Model for Women of Low Obstetric Risk. Journal of
patient experience, 9, 23743735221092606. https://doi.org/10.1177/
23743735221092606

107

Peterson, W.E., Medves, J.M., Davies, B.L., & Graham, I.D. (2007). Multidisciplinary
collaborative maternity care in Canada: Easier said than done. Journal of Obstetrics and
Gynecology of Canada, 29, 880-886.
Peterson, W. E., & Mannion, C. (2005). Multidisciplinary collaborative primary maternity care
project. a national initiative to address the availability and quality of maternity
services. The Canadian Nurse, 101(9), 25–8.
Perinatal Services BC (2023, May 5). Facility-level Indicator Data.
http://www.perinatalservicesbc.ca/health-professionals/data-surveillance/
surveillance/facility-level-indicators/data
Perinatal Services BC (2022). PSBC 1905: British Columbia Antenatal Record Parts 1 and 2.
http://www.perinatalservicesbc.ca/Documents/Form/Antenatal-Record-1-and-2.pdf
Perinatal Services BC (2020a, January). Maternal/Fetal and neonatal: Tiers of service –
questions and answers. http://www.perinatalservicesbc.ca/Documents/
Resources/SystemPlanning/TiersOfService/Tiers-of-service-faq.pdf
Perinatal Services BC (2017). Perinatal mortality guide. http://www.perinatalservicesbc.ca/
Documents/Guidelines-Standards/PerinatalMortality/PerinatalMortalityGuide line.pdf
Phillippi, J.C., Holley, S.L., Schorn, M.N., Lauderdale, J., Roumie, C.L., & Bennett, K. (2016).
On the same page: A novel interprofessional model of patient-centered perinatal
consultation visits. Journal of Perinatology, 36(11), 932–938.
https://doi.org/10.1038/jp.2016.124
Polit, D.F. & Beck, C.T. (2004). Nursing research: Principles and methods (7th ed.). Lippincott
Williams & Wilkins: Philadelphia.
Public Health Agency of Canada. (2020). From risk to resilience: An equity approach to
COVID-19. Government of Canada. Ottawa, ON. https://www.canada.ca/en/publichealth/corporate/publications/chief-public-health-officer-reports-state-public-healthcanada/from-risk-resilience-equity-approach-covid-19.html
Rayment-Jones, H., Silverio, S. A., Harris, J., Harden, A., & Sandall, J. (2020). Project 20:
Midwives' insight into continuity of care models for women with social risk factors: what
works, for whom, in what circumstances, and how. Midwifery, 84, 102654.
https://doi.org/10.1016/j.midw.2020.102654
Reid, R., Haggerty, J., & McKendry, R. (2002). Defusing the confusion: concepts and measures
of continuity of healthcare.
Risjord, M. (2010). Nursing knowledge: Science, practice, and philosophy. West Suzzex, UK.
Wiley-Blackwell.

108

Rolfe, G. (1998). The theory-practice gap in nursing: From research-based practice to
practitioner-based research. Journal of Advanced Nursing, 28(3), 672–679.
https://doi.org/10.1046/j.1365-2648.1998.00806.x
Sandelowski M. (2000). Whatever happened to qualitative description? Research in Nursing &
Health, 23(4), 334–340. https://doi.org/10.1002/1098-240x(200008)23:4<334::aidnur9>3.0.co;2-g
Schwandt, T. (1994). Constructivist, interpretivist approaches to human inquiry: Handbook of
qualitative research. Thousand Oaks, California: Sage
Shared Care Committee. (2018, September). Enhancing interprofessional collaboration in
maternity care: Pathway to positive change in community toolkit.
https://sharedcarebc.ca/sites/default/files/IPC%20Maternity%20Toolkit%20Sept%
202018%20-%20Email%20and%20Web%20%28ID%20228182%29.pdf
Shared Care Committee. (2019, January). Enhancing interprofessional collaboration in
maternity care: Technical guide for billing.
https://sharedcarebc.ca/sites/default/files/IPC_BillingGuide_web_Jan23%20%28ID%
20251741%29.pdf
Society of Obstetricians and Gynaecologists of Canada. (2017). No-251-Returning Birth to
Aboriginal, Rural, and Remote Communities. Journal of Obstetrics and Gynaecology
Canada, 39(10), e395–e397. https://doi.org/10.1016/j.jogc.2017.08.013
Streubert, H.J. and Carpenter, D.R. (2011). Qualitative Research in Nursing: Advancing the
Humanistic Imperative. Wolters Kluwer, Philadelphia.
Thorne, S. (2008). Interpretive description. Walnut Creek, CA: Left Coast Press.
Thorne, S. (2016). Interpretive description: Qualitative research for applied practice (2nd ed.).
New York, NY: Routledge.
Town, M., Smoliak, O., Brauer, P., & Forbes, L. (2019). Prenatal nutrition in team-Based care:
Current practices and opportunities for optimization of care. Canadian Journal of
Dietetic Practice and Research, 80(3), 96–103. https://doi.org/10.3148/cjdpr-2018-043
Trans Care BC. (n.d.). Gender inclusive language: Clinical settings with new clients.
http://www.phsa.ca/transcarebc/Documents/HealthProf/Gender_Inclusive_Language_
Clinical.pdf
Tyson, K., Teale, G., Vasilevski, V., Cassells, K., & Sweet, L. (2022). A dedicated antenatal
clinic for pregnant women with morbid and super-obesity: Patient characteristics,
outcomes, perceptions and lessons learnt from establishing the DIAMOND clinic. The
Australian & New Zealand Journal of Obstetrics & Gynaecology, 62(5), 635–642.
https://doi.org/10.1111/ajo.13612
109

Vedam, S., Stoll, K., Martin, K., Rubashkin, N., Partridge, S., Thordarson, D., Jolicoeur, G., &
Changing Childbirth in BC Steering Council (2017). The mother's autonomy in decision
making (MADM) scale: Patient-led development and psychometric testing of a new
instrument to evaluate experience of maternity care. PloS one, 12(2).
https://doi.org/10.1371/journal.pone.0171804
Vogels-Broeke, M., de Vries, P.R., & Nieuwenhuijze, M. (2021). Validating a framework of
women's experience of the perinatal period; a scoping review. Midwifery, 92.
https://doi.org/10.1016/j.midw.2020.102866
Whittemore, R., & Knafl, K. (2005). The integrative review: Updated methodology. Journal of
Advanced Nursing, 52(5), 546-553. doi:10.1111/j.1365-2648.2005.03621.x
Winn, A., Hetherington, E., & Tough, S. (2018). Caring for pregnancy refugee women in a
turbulent policy landscape: perspectives of health care professionals in Calgary, Alberta.
International Journal for Equity in Health, 17(1), 91. https://doi.org/10.1186/
s12939-018-0801-5
World Health Organization. (2018). WHO recommends Intrapartum care for a positive
childbirth experience: Transforming care of women and babies for improved health and
well-being. https://www.who.int/reproductivehealth/publications/intrapartum-careguidelines/en/
World Health Organization. (2018). Continuity and coordination of care: a practice brief
to support implementation of the WHO Framework on integrated people-centred health
services. https://apps.who.int/iris/handle/10665/274628.
World Health Organization. (2017). Determinants of health. https://www.who.int/newsroom/questions-and-answers/item/determinants-of-health
Yeates, L. (2016). Patients at the centre: sustaining rural maternity – it's all about the surgery!
[White Paper]. Perinatal Services BC. https://srpc.ca/resources/ESS/Library/Perinatal%
20Surgical%20Services/RuralNetworksWhitePaper_2016.pdf
Yeates, L., & Kay, C. (2018). The art of the possible: Enabling interprofessional collaboration
and interdisciplinary teams in primary maternity care (Research Summary). Perinatal
Services BC. http://www.perinatalservicesbc.ca/Documents/Research/
Art%20of%20the%20Possible.pdf

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Qualitative

Canada (British
Columbia)

Pregnant
women’s
perspectives on
integrating oral
health in
prenatal care

Author (ye ar);
Title ;
Country;
Study De sign
Adeniyi et al.
(2021)
Explore views of
pregnant women in
BC on strategies for
integrating
preventative oral
health care into
prenatal care services.
Aim not to
specifically study
TBC but they did ask
a question on
perspectives of
integrated care

Resident s of
Vancouver and
living in Canada
for at least a year

Recruited from
5 prenatal
clinics in
Vancouver and
Surrey

n=14
purposefully
chosen
women

Aim

Any age or stage
of pregnancy:
ranged 25 to 40
years, range of
ethnicities, most
have college or
university, 6/14
were primips

Participants
Se tting
De scription

Sample size

Identified limitations
to English speaking
women as well as only
urban perspectives
which they flagged
limits perspectives of
people living in rural
and remote areas of
BC

Inductive thematic
approach for analysis

Semi-structured
interviews

Data colle ction;
Data anal ysis;
Limitations

Appendix A: Literature Matrix

111

3) strategies for addressing prenat al oral health
care
- referral system
- interprofessional education

Barriers to integration – lack of political will;
separate structure for delivery; limited
understanding of oral health benefits by
providers; funding structure “ changing anything
in the health system is difficult” p.6

2)perspectives on int egration and integrated
prenatal oral care
- perspectives varied
- part icipants defined integrated care as “ multiple
health care providers from different streams
working together to ensure the patient’s good
healt h” p.5
- “ team approach essential”
- patient centered was voiced as important
- can come in the form of referrals
- co-location was seen to have been a benefit
- interprofessional education a solution
- not worth it for just 9 months said one
participant
- linked self confidence and self-est eem building
for parent to int egrated care and identified impact
on future generations specific to dental care

T hemes:
1)oral health experiences during pregnancy,

Funding structure in Canada has played a role in
preventing integration of oral health in prenatal
care.

T eam: Inclusion of dent ist; others not mentioned

Findings including De finition of Team

Prospective
study;
Mixed methods

T urkey

T he influence
of the
systematic birth
preparation
program on
childbirth
satisfaction.

Akca et al.
(2017)

Control 1: 4month birth
preparation
program
Control 2:

Group 1
n=77;
Group 2 n=75
142 total who
completed t he
program

3 hour
education
session once a
month for 4
months
Max 15
women in
sessions

*both groups gave
birth in same
hospital and no
statistical
difference in
demographics
between the
groups

Control group
were people not
informed of
program and did
not have antenat al
education

Did not have
maternal request
caesarean, did not
give birth before
34 weeks, did not
have fetal
malformations or
demise, or have
sever maternal
morbidit y

Women between
16 and 20

Studied women’s
assessment of
satisfaction with a
TBC model

Secondary aim was to
explore factors that
affect the childbirth
satisfaction

To investigate the
effect of a
multidisciplinary birth
preparation program
on women’s
assessment s of their
satisfaction with
childbirth experience.

Limitations
- not planned as RCT
- pain rating may have
been affected by
routine analgesia
factors
- only conducted at
one hospital
- small number of
participants (offset by
the validated t ool of
maternal perception of
childbirth experience)
- indirectly shows that
team-based care
antenatal programs
offer greater levels of
patient satisfaction

Multivariate logistic
regression
SPSS was used and
statistical significance
p less then 0.05

Questionnaires & two
face-to-face
interviews: not set up
as a randomized
control

112

Use of a tool: SIL-Ger – validated measure of
maternal perception of childbirth experience

Satisfaction with childbirth experience greater
with program than those without.
Communication and pain during labour p. 1130
out lines comparisons of perceptions of the birth
experience

Satisfaction as a score and outcomes –
satisfaction linked to health and well-being of
mother and baby; satisfaction defined by:
- personal control
- expectations being met
- caregiver support
- caregiver and patient relationship
- supportive partner
- part icipation in decision making
- presence of supportive partner during delivery

Summary: part icipants described their thoughts
on T BC and how oral care could be integrated in
prenatal care through colocation instead of
referrals “to have it in one place would be ideal”
– but acknowledged this challenge specific to
dentistry; interprofessional education was a
solution to this challenge as was including the
dentist as part of t he team whether co-located or
not; building blocks for integration:
communication, collaborative practice
T eam: Psychiatrist, dietician, obstetrician and
gynecologist, sports med MD, neonatologist, and
2 nurses are part of program

- whether dental part of team or not, there should
be a visit prenatally that is compulsory with
support for those who can’t afford

Quant itative:
RCT with
blinded
outcome

United States

Collaborative
care for
perinatal
depression in
socioeconomic
ally
disadvantaged
women: A
randomized
trial.

Grote et al.,
(2015)

83 women all
on Medicare
who were
receiving
maternity care
through
routine MMSPlus
depression
support and
referred to
specialty
program if
met criteria
for screening
VS
MMS-Plus
program is
routing care
delivered by
multidisciplina
ry team of
social workers,
nurses, and
nutritionists

MOMCare
program:
depression
treatment
program
created from
and based
upon previous
RCT evidence.

Client s
randomized based
upon stratification
of depression
severity,
gestational age via
a computerized
program for true
randomization

Referred to by
social workers
and nurses who
completed rout ine
screening for
depression – score
needed t o be
greater than 10
and this ensured
treatment groups
were similar at
baseline despite
women being
aware of which
group they were
being assigned to
(standard care or
MOMCare).

Mental illness

Explored
collaborative care
program versus
normal maternity care
collaborative
program.

“ to evaluate whether
"MOMCare,"a
culturally relevant,
collaborative care
intervention,
providing a choice of
brief interpersonal
psychotherapy and/or
antidepressants, is
associated with
improved quality of
care and depressive
outcomes compared
to intensive public
health Maternity
Support Services
(MSS-Plus)
Limitations
-of self-reported
antidepressant use
- generalizability of
non-English speaking
populations or those
who refused
participation in study
or all populations on
Medicaid
- unable to truly
determine the specific
components of
MOMCare t hat
produced the
significant out comes
Other:
-of number of
responses from both
programs re:
satisfaction at 3, 6, 12,
and 18 months.
- Unaware of what
factors participants
rated or perceived
their satisfaction to be
based upon.
-Impacts of factors
affecting experience
such as provider
personality etc. not
explored as a
limitation with
satisfaction rating.

Data collected at 3, 6,
12 and 18 month
follow up assessments

with their experience
of childbirth

113

- acknowledged that there is inequitable access to
health services and impacts on engaging clients
who are at higher risk of depression during
pregnancy due to factors affected by
socioeconomic status
- view pregnancy as an opportunity to connect
women to health services and attempt t o address
socioeconomic status
- 18 month program attentive to cultural barriers
to care and patient choice including outreach to
address the social determinants of health (food,
housing, employment) compared to MSS-Plus
only)
- MOMCare was a more evidence-based
depression care program including ‘system
outreach, measurement, or stepped care’
*included a pre-evaluation of barriers to care for
patients
- improved patient outcomes compared to MSSPlus program
- Outcomes were measured t he same, and at the
same intervals for both groups
- Patient satisfaction measured and statistically
significant findings (P=0.004) of moderately or
very satisfied at 3, 6, and 12 mont hs in MOMcare
intervention compared to only MSS-Plus
- “ satisfaction with all care received during
intervention period for mood problems or stress
during intervention period including MSS-Plus
services, community mental health provider,
MOMCare depression care specialist, obstetrics
provider”
- MOMCare offered lower per capita cost
connection to quality for treating perinatal

T eam:
Depression Care Specialists, MOMCare team,
and collaboration with 40 OB providers (nurses
and social workers referred to program following
routine depression screening); MSS-Plus also
offered team services

96 for
individual
care and 207
for group care
*individual
care was still
T BC
programming
so hence
article
remained
included

An evaluation
of
Interprofession
al group
antenatal care:
a prospective
comparative
study.

Quant itative
Perspective
Comparative
- not
randomized to
capture

Canada

N= 303
women

41 women (24
primiparous;
17
multiparous)

Hodgson et al.
(2017)

Qualitative

Australia

Pregnancy
experiences of
Western
Australian
women
attending a
specialist
childbirth and
mental illness
antenatal clinic.

Hauck et al.
(2013)

South
Community
Birth Program
(SCBP)

One specialist
clinic for
mental health
in Australia

Normal
pregnancy care

Mental illness

Not measuring patient
experience directly
but did ask
satisfaction score so
article included.

“ to evaluate whether
outcomes in SCBP
clients differed
between group versus
individual prenatal
care”

Explored experiences
within a T BC clinic

“ Our purpose was to
explore the pregnancy
experiences of women
attending a
specialized childbirth
and ment al illness
(CAMI) antenatal
clinic”.

114

- all women received T BC whether in group care
or individual care
- nulliparous and older clients had increased
intervention and similar preterm birth and BF
rates regardless of group care or individual care
- knowledge, satisfaction and readiness didn’t
matter to the group care or individual care
received
- other studies that have indicated better
out comes with group care versus individual T BC
may not have had same composition or definition
of the team – the team composition is speculated
to mat ter
- time of appointments in T BC 30-45min
compared to traditional 10-15 min long standard
prenatal appts. at the SCBP may reflect outcomes
less significantly different than previous studies

Chi-square tests,
general linear models,
logistic regression t o
compare quest ionnaire
scores and perinatal
out comes between
cohorts
Limitations
- Not randomized
- unsure if the findings
would be the same for
women not receiving
T BC

T eam: RM, MD, nurses and NPs +/- doula

- risk for women with severe mental illness due
to frequent social determinants of health
impacting pregnancy and motherhood (less
antenatal care or visits, single parenting, negative
lifestyle behaviours etc)
- explored experience, satisfaction, and
perception (satisfaction was on a likert scale and
97.6% (n=40) were very satisfied or satisfied
with their experience of a team-based clinic
satisfaction is often a descriptive statistic
included in studies
- building relationships, acknowledging as a
person with special needs, and
respect/understanding without stigma
- importance of patient centered decision making
– treatment

T eam: consult ant psychiatrist, GP, OBS, clinical
midwife, and fetal medicine, social work,
dietician, other allied health professionals if
needed

Questionnaire

Limitations – none
stated by authors

T elephone interviews

depression wit h greater rat es of satisfaction
overall

Qualitative
sociological
design

England

Lived
experiences of
women with
co-existing
BMI ≥ 30 and
gestational
diabetes
mellitus.

Jarvie (2017)

Phenomenolog
y

United States

Experiences of
opioddependant
women in their
prenatal and
postpartum
care:
Implications
for social
workers in
health care.

N=27

T wo diabetic
antenatal
clinics

3 women lived
alone with their
children

Age 19-43

Diabetes and
predominantly
lower SES

90% were
comfortable
making decisions
re: their care

Caucasian; have
Medicaid
insurance; 80%
unemployed; 45%
high school
diploma
*SDoH

Age 20-38 years

OUD (opioid use
disorder)

to explore the lived
experiences of
women with coexisting maternal
obesity (BMI ≥ 30)
and GDM during
pregnancy and the
post -birth period ( < 3
months post -birth).

Was not about T BC,
rather the experience
of prenatal care within
a T BC clinic

Perceptions of their
inclusion in their
decision making

Series of 3 in-depth
narrative interviews
before birth and after

NVivo

IPA: Interpretive
phenomenological
analysis

Interviews (6group
interviews and 4
individual interviews)

115

- Women would like more collaborative care to
address SES

- Managing lifestyle and confounding factors of
life made managing pregnancy health difficult.

Summary: Essentially article advocating for an
allied health role to be incorporated into prenatal
care which will increase shared decision making
(a known benefit of T BC)
T eam: Not specifically discussing T BC models;
rather that T BC would improve t heir care from
the women’s perspective

-Addresses the social worker as an essential part
of team-based care
-Acknowledges lack of knowledge from women
on prenatal and postpartum care and their OUD
decision making
-Role of social work: “ perceptions of stigma,
smage, confusions…fear of CPS involvement” role of perinatal social work to supplement HCP
limited t ime
-Social-justice approach – role of team members

T eam: Was not about T BC specifically, no team
members discussed, only social work. Included
because unique in addressing role of an allied
health professional in prenatal care.

Eastern New
England
Region

Howard (2015)

20 postpartum
women who
were 6 months
after delivery

that show group based care is the preferred model
of team-based prenatal care
- satisfaction measure using patient participation
and Satisfaction Questionnaire at discharge
- ethinicity of mainly Caucasian might lead to
different outcomes

differences in
the clients
choices for one
model over
another

Qualitative
Perella et al.
(2022)

England

T hree
perspectives on
the co-location
of maternity
services:
qualitative
interviews with
mot hers,
midwives and
health visitors.

Olander et al.
(2020)

Ethnography

Australia

Drugs and
having babies:
An exploration
of how a
specialist clinic
meets the needs
of chemically
dependant
pregnant
women.

Morris et al.
(2011)

N=81
Convenience
sample from

n =15
midwives
17 health
visitors
29 mothers

N=20
Purposeful
sample

A model for
team-based
maternity

Maternity
policy
supporting
Community
Hubs – colocation for
collaborative
care

Specialist
antenatal clinic

Low-risk
pregnancies (care
transferred if

Not applicable as
only asking
perceptions

Chemically
dependant women

To evaluate maternal
satisfaction with the
model of care.

To explore the extent
to which a specialist
clinic meets the needs
of chemically
dependant women.
1) to provide rich
descriptions of the
range of problems
chemically dependent
pregnant women face;
2) to identify the
extent to which
chemically dependent
pregnant women
believe the services
offered by the
Transitions Clinic at
the Mercy Hospital
for Women met their
needs, and
3) to assess whether
pregnancy is a time of
transition or a turning
point in the lives of
some of t he women
To explore
midwives’, health
visitors’ and postnatal
women’s experiences
and views of colocation of midwifery
and health visiting
services and
collaborative practices

Evaluation survey at 6
to 8 weeks

- joint appoint ments and co-location were not
actually experienced by women, only asked about
perceptions

Limitations
- hypothetical
questions given
mothers had not
experienced
- generalizability of
self-selected
participation in study
to that of relevancy of
perceptions of other
women

116

T eam: Physicians, midwives, referrals to allied
health professionals and education sessions (all
staff had training in ‘Possums and Co

- “ T he only thing that would make a difference is
if they were working as part of a unified team.
But, location wise, no it doesn’t make a
difference at all” (Olander et al., 2020, p. 13).

- Women see co-location as less important as is
integrated care.

T eam: Health visitors, midwives

Summary: A discussion of midwife and social
work interaction and how that influenced care –
more attention to other factors aside from
chemical dependence also brought greater care
from patient’s perspectives. Midwife attitude was
key factor to overall perception of meeting of
needs.

-Desire to be treated like normal pregnant women
– troubles with perceptions of labelling and
judgement
- Collaboration and communication led to better
adherence and treatment out come empowerment
Individual personalities affected perception of
care – this will always play a role

T eam: multidisciplinary t eam of two
obstetricians (Methadone prescribers), a
paediatrician, a psychiatrist and psychologist,
two social workers, two midwives (the first point
of contact ), one midwife/birth educator, a Koori
liaison officer, a dietitian and a postgraduate
research student

Interviews

Codes

Field notes, reflective
journal, chart audits

3 taped interviews
2 before birt h, one
after

United States

On the same
page: a novel
interprofession
al model of
patientcentered
perinatal
consultation
visits.

Phillippi et al.
(2016)

Mixed-methods

Australia

Maternal
Evaluation of a
T eam-based
Maternity Care
Model for
Women of Low
Obsetric Risk.

N=50
Convenience
sample

all women
who attended
One for
Women
(OFW) private
maternity care
provider from
Jan 1 2020 to
Dec 31 2020
and had a live
birth during
that time.

New
collaborative
clinic with inperson
consultation
with all parties

service led by
physicians and
midwives for
low-risk
women

Requiring MFM
specialist
consultation

Age 33+/- 3.9
years;
48 were primips

medically
required to
specialists)

To plan and
implement an
interprofessional
collaborative care
clinic for women in
midwifery care
needing a
consultation with a
maternal–fetal
medicine specialist.

Limitations
- small sample size
- white, non-hispanic
participants and one
location only therefore
generalizability
questionable
Positive bias given
researcher was a
CNM

Semi-structured
interviews with
content analysis

Analyzed through
descriptive statistics

Likert scale for each
of the 24 survey items
PLUS qualitative
questions “ what
aspects of your
maternity care have
been most valuable to
you? And “ Please tell
us what we can do to
improve the maternity
care at One for
Women”

postpartum:
satisfaction with
pregnancy, hospitalbased perinatal care,
and post -discharge
postnatal care.

117

Women’s comments on their experience were
positive and had the theme ‘on the same page’
with six subcategories: clarity, communication,
collaboration, planning, validation and ‘above
and
beyond’.
- improved communication was a result of T BAC
programming, particularly in-person shared
appointments with HCPs and patient
- in-person collaborative appointments facilitated
experiences of patients feeling they were partners
in their care, they had improved feelings of safety
and that they felt in-person collaborative

-Conducted during the pandemic; perspectives
may align with perspectives during my study
(same electronic recruitment).
-Only 3 / 81 choose t he service because of all
services in one location. 4% - not as important to
mothers as other research may indicate. Supports
virtual modalities to support rural communities
-Lowest rating of sat isfaction was waiting for
appointments. 91% very pleased with quality of
pregnancy and 86% with postpartum care
difficult to tell if it was the multidisciplinary
nature of the program that caused this – as only
N=11 or 14% chose the program because of the
model of care
Links to:
T ime to discuss concerns with providers and the
providers’ interests in the mother’s motional
well-being were the highest strongly agrees.
-No significant differences in response from
primips or multips.
-80% of respondent s indicated the most valuable
part of the program was t he high quality and
exceptional support of staff including medical,
nursing, allied health and receptionist.
-Care provider information influenced choice in
model of care for maternity care.
T eam: Nurse-Midwives, nurse, MFM specialists

workshops’ - cross-disciplinary skills training
including breast feeding, infant sleep, mental
health issues and collaboration wit h parents)

Mixed-methods

Australia

A dedicated
antenatal clinic
for pregnant
women with
morbid and
super-obesity:
Patient
characterist ics,
outcomes,
perceptions and
lessons learnt
from
est ablishing t he
DIAMOND
clinic.

T yson et al.
(2022)

Qualitative

Survey: N=38
out of 89
potential

Audit: N=257
Median
booking
weight of 96240kg and
29.9% primips

Multidisciplina
ry antenatal
clinic for
women with
obesity – high
acuity clinic

DIAMOND
clinic: diabetes,
maternal obesity,
nutrition and diet

The aim was to
describe clinic
processes,
demographics,
clinical outcomes and
women's perceptions
of the
Multidisciplinary
antenatal clinic
Survey
3 open text responses
(perceptions of the
benefits of the
dedicated clinic,
potential
improvements for the
clinic and general
comments)

Retrospective audit
and patient
satisfaction survey

118

- Clinic was born from the review of 3 perinatal
losses.
-Showed a linkage between determinants of
health and clinic attendees - socio-demographic
disadvantage
-** “ challenges of caring for the population
counteracted by continuity of care approach that
women are often known in detail by the
clinicians” being known is particularly important
for those im pacted negatively by determinants of
health
-Also noted limited literature to support research
findings – did not compare their findings to
others for that reason
-Staff overemphasized risk; convey risk and
balance fear
-Frustrated with coordinating multiple
appointments – limited transportation, difficulties
with childcare, and other complexities that are
barriers t o attendance – col-location could be
beneficial – as could virtual / self-monitoring –
advancing technologies if they can access those
technologies
-Findings to support earlier access to dietician;
identify demands for higher risk populations on
health human resources and a challenge for this
specialty program
-Clinics such as these support T eam discussion
and shared decision-making
-Mothers N=38
84.2% N=32 received respectful care
N=26 68.4% staff explained t hings weel

appointments provided feelings t hat their care
exceeded their expectations
- findings were influenced by the perception that
an increase in time of HCPs in their
comprehensive care planning and their awareness
of the care plan positively influenced their
experience of care provided by the collaborative
clinic
T eam: 2 obstetricians with interest in high-risk
maternity, clinic midwife coordinator, 2
endocrinologists, diabetic nurse educator,
dietician, and two junior medical staff.

119

N=29 76.3% had trust and confidence in staff
N=30 78.9% rated care very good (7 good)
N=32 would recommend clinic to other people
While qualitative questions were asked, the
answers were not explored in the discussion, or
any aspect included for review and no control
group to compare outcomes and interventions to.
Did not the need for a social worker as part of the
team moving forward.

Appendix B: Thematic Analysis of Current Evidence

120

Appendix C: Recruitment Email and Invitation Poster

Email to Pregnancy Outreach Groups identified for community recruitment:
Hello,
I am reaching out to the [insert name of group] pregnancy outreach program to ask for assistance
with recruiting study participants and seeking a contact person / email to discuss my request
below.
My name is Amanda Green and I am a master’s student working under the supervision of Dr.
Caroline Sanders in the School of Nursing at the University of Northern British Columbia. As
part of my graduate degree, I am conducting an independent research study on mother’s
experiences of antenatal care received during pregnancy, before labour and birth, provided by a
team of health care professionals in rural British Columbia.
The research proposal has been approved by UNBC Research Board of
Ethics, E2022.0217.012.00.
Patient and family centered team-based maternity care is a growing priority in health system
planning. Little is known about the patient experience of team-based antenatal care in rural
communities in BC. Your community is known to offer models of team-based antenatal care and
is included in a list of five communities as part of a purposeful sample.
If you agree with supporting my recruitment efforts, please reply to this email confirming your
willingness. I will then send you everything you need, which has been approved by UNBC's
Research Ethics Board as part of the research proposal application and approval process.
Items will include an email script as well as a flyer and information/consent form for you to
forward to your outreach program email distribution list.
Thank you in advance for your consideration and support of this important topic.
Amanda Green, RN
agreen@unbc.ca
250.278.7222
Email to potential participants from Pregnancy Outreach Program:
Hello,
My name is Amanda Green and I am a master’s student working under the supervision of Dr.
Caroline Sanders in the School of Nursing at the University of Northern British Columbia in
Nursing. As part of my master’s degree, I am conducting a research study on mother’s
experiences of maternity care, specifically antenatal care during pregnancy and before labour
and birth, provided by a team of health care professionals in rural British Columbia.
Team-based care that is patient centered is a growing priority in health system planning. Little is
known about the patient experience of team-based antenatal care in rural communities in BC.

121

Your community is known to offer models of team-based antennal care and your experiences of
the care you received during pregnancy are important to be heard.
If you would like to learn more about this study or to express interest in confidential
participation in the study, please contact me by scanning the QR code, by emailing
agreen@unbc.ca, or calling me at 250-278.7222. See the attached study information letter for
more information.
The pregnancy outreach group that has forwarded my recruitment email will not be made aware
of your participation in this study, unless you choose to notify them yourself.
This study has been reviewed and received ethics clearance through a University of Northern
British Columbia Research Ethics Board (E2022.0217.012.00).
Thank you in advance.
Amanda Green
agreen@unbc.ca

122

Recruitment Poster:

123

Appendix D: Information Letter and Consent Form
April 8, 2022
Mothers’ Experiences of Antenatal Care in Rural British Columbia
Who is conducting the study?
Amanda Green
School of Nursing
University of Northern British Columbia
Prince George, BC V2N 4Z9
agreen@unbc.ca
250-278-7222
Dr. Caroline Sanders
250-960-5848
Caroline.sanders@unbc.ca
This research is part of a thesis to meet the requirements for a graduate degree. The thesis will be
a public document that can be accessed by anyone who chooses to access the UNBC Geoffrey R.
Weller Library Thesis Collections.
Who is funding this study?
This study is part of independent research as part of UNBC’s requirements for the Degree of
Master of Science in Nursing – Thesis Stream. No funding is being received for the completion
of the study.
Why am I conducting this study?
Team-based primary maternity care is a growing priority in health system planning. Little is
known about the patient experience of team-based antenatal care in rural communities in BC.
The patient experience is important to learn for planning, implementing, and improving access to
and quality of population health programs.
This study focuses on mother’s experiences of antenatal care in rural BC communities. A study
aim is to learn about mothers’ experiences of antenatal care, during pregnancy but before labour
and birth, provided by a team of health care professionals. Your experience of being pregnant
and receiving care while pregnant will increase the knowledge of team-based antenatal care in an
under-researched area.
What will happen during the study?
If you say ‘Yes’ to participating in this study, you will be asked to participate in a one-to-one
interview with myself to help me better understand your experiences of care in pregnancy. The
interview will take approximately 30-45 minutes. The questions will focus on how the care you
received while pregnant impacted your prenatal experience. Interviews will be done by
videoconference due to the COVID-19 pandemic and related public health measures, at a time
convenient for you. The session will be recorded on the Zoom platform on a home office
124

computer that is password protected and encrypted. Recordings will be deleted once a thesis
report is completed.
Before the interview, you will be asked to complete a demographic survey asking questions
about your age, gender, Indigenous identity, ethnicity, marital status, highest level of education,
health history, and number of pregnancies. These questions are the same demographic questions
that Perinatal Services BC standardized documents for prenatal care required your primary care
provider to ask. For privacy reasons, these questions are asked again during this interview as
personal health charts will not and can not be accessed by the interviewer in relation to this study
and outside of your prenatal care. You do not have to answer these questions if you do not want
to. These questions can be answered via an email link or by talking with the interviewer at the
time of the interview. The survey should take about 5 minutes. You will also be invited to review
our study findings once all interviews are completed so you can provide feedback about my
conclusions.
The study is planning to include 8-12 interviews from across rural British Columbia where teambased prenatal care is occurring.
Risks or benefits to participating in the project
There are not expected to be any risks or side effects to participation in this study. You will not
be required to answer any questions that you do not feel comfortable answering. If, at any point
in the study, you feel uncomfortable or upset and wish to end your participation, please notify the
researcher immediately and your wishes will be respected. Should taking part in the study cause
you distress, whether you remain in the study or choose to withdraw at any point, I offer a list of
resources for you to please consider reaching out to.
·
·
·

Primary care provider
Mental Health & Substance Use Service telephone 310-MHSU(6478)
HealthLink BC telephone 8-1-1

No one knows whether or not you will benefit from this study. Information learned from this
study can be used to help inform health care providers and administrators / policy makers about
patient experiences of team-based prenatal care and this may benefit future pregnancy patients.
Compensation
After the interview, you will receive a $25 digital gift card as a token of appreciation from a
retailer of your choice who offers digital gift cards such as Amazon.ca.
Study Results
Study results will be reported in a graduate thesis and also may be published in journal articles or
shared at conferences or informal sessions to share learnings with interested parties. Again, there
will be no personal information shared in the final thesis report of this study that will identify
participants or information participants share.

125

Questions, Concerns or Complaints about the project
If you have any concerns or complaints about your rights as a research participant and/or your
experiences while participating in this study, contact the UNBC Office of Research at 250-9606735 or by e-mail at reb@unbc.ca.
Participant Consent and Withdrawal
Participation in the study is voluntary; you have the right to choose to not answer a question(s),
return to the interview another day if circumstances arise, or withdraw from the study at any time
without giving a reason or any negative consequences to you or your child’s medical care. Your
participation in this research is confidential and will not be communicated to your health care
providers. If you choose to withdraw from the study, any information you have provided up to
that point will also be withdrawn and securely destroyed. Your participation in the interview will
not affect the care you or your child will receive in the future. Your child is welcome to be
present during the interview.
Consent
I have read or been described the information presented in the information letter about the
project:
YES

NO

I have had the opportunity to ask questions about my involvement in this project and to receive
additional details I requested.
YES

NO

I understand that if I agree to participate in this project, I may withdraw from the project at any
time up until the report completion, with no consequences of any kind.
YES

NO

I agree to be audio recorded.
YES

NO

I agree that strictly anonymized quotes from my interviews can be used in study reporting.
YES

NO

126

Follow-up information (e.g. transcription and summary of study findings) can be sent to me at
the following e-mail or mailing address:
________________________________
YES

NO

Your signature below indicates that you have received a copy of this consent form for your
own records.
Your signature indicates that you consent to participate in this study.

_______________________________________

_____________________

Participant Signature

Date

_______________________________________
Printed Name of the Participant

127

Appendix E: Interview Questions
Draft Interview
The purpose of this interview is to learn more about your experiences of antenatal care in a rural
community in BC that offers team-based services. Antenatal care means from the time you
learned you were pregnant until, but not including, labour and birth.
My goal with you today is to ask a series of question to help me better understand your
experiences of care in pregnancy. My nine interview questions will focus on how what aspects of
your care impacted your prenatal experience.
Participation in the interview is voluntary; you have the right to choose to not answer a
question(s), return to the interview another day if circumstances arise, or withdraw from the
study at any time without any negative consequences to you or your child’s medical care. Your
participation in this research is confidential and will not be communicated to your health care
providers or become part of your health care record. Your participation in the interview will not
affect the care you or your child will receive in the future. Your child is welcome to be present
during the interview.
Questions
1. Tell me who was involved in the care you received during your pregnancy, before labour and
birth?
a) Where did you see them? Did you see them together during the same appointments, separately
during the same appointments, or separately and at different appointments? Did you see them in
the same location? Did you go to many locations for your pregnancy care?
c) How often did you meet them? How long did you see them for at each visit?
e) Do you feel that anyone was missing from your prenatal care? If so, who do you feel was
missing from your care and why?
2. What did you like most about your prenatal care? What did you like the least?
3. What was the most important part about the care you received throughout your pregnancy?
What was the least important part about the care?
4. Was there anything missing from your care while you were pregnant? If so, what?
4. What worked well with the prenatal care you received? What did not work well?
5. Did you have prenatal care for any other pregnancies? Was it in the same community with the
same providers? Did these experiences differ? If so, how did they differ?
8. What would you change about your care during pregnancy?
9. What would you keep the same about your care during pregnancy?

128

Demographic Information
(based upon Perinatal Services BC Antenatal Record Assessment Questions)

1. What is your age?
____
____
____
____
____
____
____

≤ 18
19-25
26-30
31-35
36-40
41-45
≥ 46

[ ] prefer not to answer

2. What is your ethnicity?
____
____
____
____
____
____
____
____
____
____
____

Indigenous /Aboriginal
European – Western (e.g. English, Italian)
European – Eastern (e.g. Russian, Polish)
Asian – East (e.g. Chinese, Japanese, Korean)
Asian – South (e.g. Indian, Pakistani, Sri Lankan)
Asian – South East (e.g. Malaysian, Filipino)
Middle Eastern (e.g. Iranian, Lebanese)
African
Caribbean
Latin American (e.g. Argentinean, Chilean)
Other(s) (specify) ___________________

[ ] prefer not to answer

3. a) Do you self-identify as Indigenous?
[ ]

Yes

[ ]

No

[ ] prefer not to answer

b) If yes, what is your Indigenous identity?
____ First Nations
____ Métis
____ Inuk (Inuit)
[ ] prefer not to answer

129

4. What is your gender?
____ Female
____ Male
____ Transgender
Other(s) (specify)____________________
[ ] prefer not to answer

5. What is your marital status?
____
____
____
____
____

Married
Relationship, living together
Relationship, not living together
Single (never married)
Separated or divorced

____

Widowed

[ ] prefer not to answer

6. What is your level of education? _________________
Less than high school
High school diploma
Trade or other certificate / diploma
Undergraduate university degree
Postgraduate university degree

[ ] prefer not to answer

7. Have you given birth once before? _________________

[ ] prefer not to answer

8. Have you given birth more than once before? _____________ [ ] prefer not to answer
9. Have you been diagnosed with a health condition before your most recent pregnancy? ______
If yes, please specify: _____________________________________________________
[ ] prefer not to answer
10. Were you diagnosed with a health condition during this most recent pregnancy? _______
If yes, please specify: _____________________________________________________
[ ] prefer not to answer

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Appendix F: Thematic Analysis of Semi-Structured Interviews
Eight semi-structure interviews were conducted. Interviews were recorded digitally and transcribed
manually and analyzed.
Process of thematic analysis: Coding and Theming
Step One:

·
·
·
·
·
·

Read and re-read transcripts
Identified initial codes on transcripts
Sorted initial codes for similarities / grouped them on wall via Post-it notes
Created codes word document table
Re-read transcripts and identified additional codes / sub-codes on white-board
Placed codes into a Venn diagram

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132

Codes
Communication

Sub-Codes
Communication in general
Communication between professionals
Communication with the patient
Lack of communication between
professionals
Lack of communication with the patient

Lack of communication at the right time
Familiarity /
With professionals
Consistency
Where everyone knows everyone
Lack of familiarity of physician with
patient
Time
Nurse had more time to spend with
patient than physician
Nurse spent more time than physician
with patient
Midwife booked more time than
physician with patient
Comfort
Patient comfortable to ask anything
Control / choice In providers
In management of medical conditions
In locations for receiving care
Lack of control / choice in physicians
In delivery modality
In education provided
Influence of others in decision making
Value
Role of maternity nurse in clinic
Role of dietician
Mental health assessments
Modality of care In-person, digital, virtual, telephone
For labour and delivery
For physical recovery
For caring for baby / bringing baby
home
For the unexpected
For physical health during pregnancy
Characteristic of oneself to want to be
prepared
Self-awareness / Didn’t seek info or take available info
insight
Taking responsibility

Comments
Most important
Joint appointments
Joint appointments

Implications for location choice and care
avail.
Close to EDD; Prior to Induction
As a result of rural town
As a benefit of a small town
Reoccurrence at subsequent
appointments

Openness and availability of providers

Impact of COVID-19; convenience;
least or most liked

Preparedness

Diet and exercise

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Own perspective shape experience
Balance of preparedness
Patient-centered
care

Relationship

Expectation
Accessibility

Convenience /
Flexibility

Knowledge /
education

Assessment

Recollection of patient details

Inclusion of partner
Focused on needs and wishes of patient
Being attached to primary care provider
before pregnancy
Shared practice between physicians
Influence of modality of care on
relationship building
Attentiveness and professionalism
versus feelings
Characteristics of provider – supporting
choice
Of physician to provide care in a
particular way
Of local ultrasound
Of physicians to answer questions
For ease of scheduling
To options for providers within and
between professions
Location of appointments
Multiple professionals at the same
appointment
Modalities of care
Inconvenience of time for antenatal care
in hospital
Maternity nurse knowledge
Knowledge increase as a result of
maternity nurse
Knowledge increase because of
repetition from physician and nurse
Knowledge increase because of two
physicians asking different questions
Lacked in certain areas such as lifestyle
(diet, exercise)
Value placed on knowledge / being
informed
Choice in the education provided
Physical assessment such as measuring
belly and from consults

Influence of own personality on
experience of care
For unexpected; for self-management of
medical conditions
Unprofessionalism; small town
influence; personal opinion of the
professional

Less important with delivering physician
due to attachment

Recommendation*

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Trust / Safety
Comparison to
others
Gender
Assumptions
Advocacy
Clarity
Resources /
Support

Pre-existing
conditions
Pandemic

Team members

Mental health assessment
Impact of covid-19 for family-centered
assessments
Between patient and physician and of
physician
Affirmed positive experience of care
received
Role of male and female delivering
physicians
Attentive physician / relationship
For oneself
Role of the nurse in clinic for advocacy
Making appointments and follow up
Family
Having questions answered by
professionals
Relying on past experiences with health
and health system
SmartMom app, prenatal classes
Awareness of available support
Impact of support in place prior to
pregnancy
Impact of COVID-19 on the experience
Increased mental health conditions
Disruptions to care
Lack of family support in person (at
visits and due to no travel)
Increased support by health
professionals
Impact of dietician, physio, surgical
team, doula, midwife, nurse in clinic

During pregnancy and postpartum

On Health portal

STEP TWO:

·
·
·
·
·

Re-read transcripts
Identified main findings from each interview according to interview questions
asked
Combined codes and findings documents as a visual on MIRO for theme and
sub-themes identification
Re-read transcripts / reviewed themes; Inserted analysis by themes via excel
Re-themed in MS Word table

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Themes
Aspects of TBANC
that influence
mother’s
perceptions of
experience

Sub-themes
Structure of TBANC
model of care

Team composition

“whoever thought
of the doctor nurse
combo – brilliant”
Coordination of Care

Rurality
The role of TBANC
in Supporting
Health & Wellness

Pre-existing medical
concern or diagnosis
during pregnancy

“…cause we’re
really good at
faking it”
“there is no village
in a pandemic”

COVID-19 Pandemic

Understanding the
overall experience
of antenatal care in
a team-based
environment

Personal Insight

“it was very
personal to me, it
was the same
people”

Preparation for
postpartum

Influence of others

Patient Choice

Main topics identified in data analysis
Varied model (mat nurse in clinic for team including doc not
midwife; shared practice of MDs)
Location / Modality of care
Concept of time
Primary Care Provider (Family physician, midwife)
Primary Maternity Nurse, Doula
Dietician, Physiotherapist, Ultrasound Technician
Surgeon/Anesthesiologist
Comparison of care offered between providers
Coordination
Continuity
Communication and role clarity
Available services
Patient centered
Mental Health assessment and management
Gestational Diabetes management
Iron deficiency management
Nutrition and Exercise support
Connection & support
Modalities of care
Mental Health
Care of themselves and newborn
Mental Health
Pelvic Floor Health
Reflection of the experience
Self-Awareness about the experience
Expectations of the experience
Comparison to others and to previous experiences with health
system
Word of mouth
Personalities and attitudes of the team members: Interactions
with providers: openness and professionalism
Choice in resources being provided (including timing);
assessments; providers
Location of care
Patient Centered Care – personalized care

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