Article Text

Quality framework for remote antenatal care: qualitative study with women, healthcare professionals and system-level stakeholders
  1. Lisa Hinton1,
  2. Francesca H Dakin2,
  3. Karolina Kuberska1,
  4. Nicola Boydell3,
  5. Janet Willars4,
  6. Tim Draycott5,
  7. Cathy Winter6,
  8. Richard J McManus2,
  9. Lucy C Chappell7,
  10. Sanhita Chakrabarti8,
  11. Elizabeth Howland9,
  12. Jenny George10,
  13. Brandi Leach10,
  14. Mary Dixon-Woods1
  1. 1THIS Institute (The Healthcare Improvement Studies), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
  2. 2Nuffield Department of Primary Health Care Sciences, Oxford University, Oxford, UK
  3. 3Usher Institute, University of Edinburgh, Edinburgh, UK
  4. 4Department of Health Sciences, University of Leicester, Leicester, UK
  5. 5Royal College of Obstetricians and Gynaecologists, London, UK
  6. 6PROMPT Maternity Foundation, Bristol, UK
  7. 7Maternal and Fetal Research Unit Division of Women's Health, St Thomas’ Hospital, London, UK
  8. 8NHS Bedfordshire Clinical Commissioning Group, Bedford, Bedfordshire, UK
  9. 9University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
  10. 10RAND Europe, Cambridge, Cambridgeshire, UK
  1. Correspondence to Dr Lisa Hinton, THIS Institute (The Healthcare Improvement Studies), Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire, UK; lisa.hinton{at}thisinstitute.cam.ac.uk

Abstract

Background High-quality antenatal care is important for ensuring optimal birth outcomes and reducing risks of maternal and fetal mortality and morbidity. The COVID-19 pandemic disrupted the usual provision of antenatal care, with much care shifting to remote forms of provision. We aimed to characterise what quality would look like for remote antenatal care from the perspectives of those who use, provide and organise it.

Methods This UK-wide study involved interviews and an online survey inviting free-text responses with: those who were or had been pregnant since March 2020; maternity professionals and managers of maternity services and system-level stakeholders. Recruitment used network-based approaches, professional and community networks and purposively selected hospitals. Analysis of interview transcripts was based on the constant comparative method. Free-text survey responses were analysed using a coding framework developed by researchers.

Findings Participants included 106 pregnant women and 105 healthcare professionals and managers/stakeholders. Analysis enabled generation of a framework of the domains of quality that appear to be most relevant to stakeholders in remote antenatal care: efficiency and timeliness; effectiveness; safety; accessibility; equity and inclusion; person-centredness and choice and continuity. Participants reported that remote care was not straightforwardly positive or negative across these domains. Care that was more transactional in nature was identified as more suitable for remote modalities, but remote care was also seen as having potential to undermine important aspects of trusting relationships and continuity, to amplify or create new forms of structural inequality and to create possible risks to safety.

Conclusions This study offers a provisional framework that can help in structuring thinking, policy and practice. By outlining the range of domains relevant to remote antenatal care, this framework is likely to be of value in guiding policy, practice and research.

  • healthcare quality improvement
  • health services research
  • obstetrics and gynecology
  • qualitative research
  • womens health

Data availability statement

Data are available on reasonable request. The data that support the findings of this study are available from the corresponding author on reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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WHAT IS ALREADY KNOWN ON THIS TOPIC

  • The COVID-19 pandemic disrupted the usual provision of antenatal care, with much care shifting to remote forms of provision. Yet, research on remote antenatal care undertaken prior to 2020 is surprisingly limited.

WHAT THIS STUDY ADDS

  • This large UK qualitative study enabled the generation of a framework of the domains of quality that appear to be most relevant to stakeholders who use, provide and organise antenatal care remotely: efficiency and timeliness; effectiveness; safety; accessibility; equity and inclusion; person-centredness and choice and continuity.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE AND/OR POLICY

  • By offering a systematic way of structuring thinking about quality in remote antenatal care, this new maternity-specific framework can guide policy and practice. Our findings suggest that a hybrid model should be on offer, but one that has sufficient flexibility to accommodate the needs and priorities of different groups and that is highly sensitised to equity and inclusion.

Introduction

Accessed by around 750 000 women in the UK in 2019 alone,1–3 antenatal care is crucial in improving birth outcomes and in reducing risks of maternal and fetal mortality and morbidity.4–7 Traditionally delivered face-to-face, antenatal care monitors the well-being of pregnant women, promotes healthy pregnancies, discusses options for care during pregnancy, labour and birth and offers a safe space to answer questions and provide reassurance. Those under the care of England’s National Health Service are, in normal circumstances, offered 10 antenatal appointments in their first pregnancy or 7 if they have previously given birth, with care provided according to defined best practice.

Though antenatal care normally involves a defined schedule of professional consultations, the COVID-19 pandemic created powerful imperatives to reduce in-person contact as a means of infection control. From March 2020, remote antenatal consultations (receiving care via telephone or video platforms) were recommended where possible, steered by guidance that was revised and updated over time.8 A survey of over 80 UK obstetric units conducted between May and July 2020 reported that almost 90% of the available antenatal appointments were being conducted remotely, indicating a major shift in the organisation and delivery of care.9 Some evidence of reduced attendance at antenatal care appointments has since emerged.10

Recent policy developments have shown an appetite to ‘lock in’ what appear to be promising solutions that were deployed during the pandemic.11–14 Given emerging indications of increases in some adverse outcomes of pregnancy linked to the pandemic,15 it is important that the future role, design and organisation of remote antenatal care is based on good evidence. Yet, research on the remote provision of antenatal care undertaken prior to 2020 is surprisingly limited.16 Pre-pandemic studies reported promising findings in terms of safety and patient experience for remote antenatal care. However, these studies are typically small-scale and concerned only with low-risk women. They also tend to focus narrowly on just one component of care (e.g., gestational diabetes monitoring or blood pressure monitoring)17 18 or to address only one aspect of quality, such as satisfaction.19 Attention to issues of equity and inclusion has been notably weak.20 Ethnic and socioeconomic diversity of participants has been mostly lacking in studies,20–24 even though minority ethnicity and deprivation are strongly associated with poor pregnancy outcomes.5 25 26

The danger is that well-intentioned enthusiasm for realising a post-pandemic vision of remote antenatal care may, as in other areas, risk unintended consequences for quality and safety including the perpetuation and amplification of inequalities.20 27 28 Recent work has drawn attention to the need for clear principles to guide and evaluate the quality of remote care.29 While there is no universally agreed definition of quality in health systems, it is generally recognised as a multidimensional construct.30–32 What those dimensions look like for specific areas of care needs to be grounded in understanding of what matters to the stakeholders—those who use, provide and organise care.15 16 33–40

In this article, we propose that this understanding is key to the design, operationalisation, delivery and evaluation of remote antenatal care.41 We report a study that sought to use the real-world experiment of the shift to remote antenatal care during the COVID-19 pandemic in 2020–2021 to generate evidence about what quality would look like for remote antenatal care, based on the experiences and perspectives of pregnant women, the healthcare professionals who care for them and system leaders.

Methods

Participants

Between September and December 2020, we undertook a UK-based qualitative study involving three groups:

  1. People aged 16 or over who were or had been pregnant since March 2020. All participants self-identified as women, and so for simplicity of language, we use ‘pregnant women’ and ‘women’ to describe them.42

  2. Healthcare professionals involved in delivering maternity care services, including community, unit-based and specialist midwives; maternity service support workers; consultant and trainee obstetricians and physicians with an interest in maternal medicine.

  3. Managers of maternity services and system-level stakeholders, including individuals from local, regional and national maternity systems, royal colleges, charities and advocacy groups.

Recruitment

We intentionally sought diversity in terms of ethnic and socioeconomic backgrounds and geographical location and, for health professionals, a range of specialities, job roles and seniorities. Using purposive sampling,43 we invited a subset of survey respondents to take part in the interview, aiming to identify a broad range of experiences. We also recruited using online network-based approaches, professional and organisational networks and snowball sampling.44 45 Nine English NHS maternity units were purposively selected to increase diversity of participants and assisted in identifying participants in all three groups. Further, we recruited via organisations that support women underrepresented in research with the help of our Expert Collaborative Group as well as via professional organisations.46 Vouchers were offered to service user participants (women) on completion of an in-depth interview. As data collection and analysis progressed in parallel, the size of the sample was adapted to ensure a variety of experiences were captured, in line with the principle of information power.47

Ethical approval

All participants were provided with information about the study and gave consent (online supplemental file S3). We followed the Standards for Reporting Qualitative Research recommendations (online supplemental file).48

Supplemental material

Supplemental material

Data collection: free-text surveys and interviews

To comply with UK lockdown regulations, all data were collected remotely. The study comprised two elements: first, a survey inviting free-text responses and, second, remote semi-structured interviews either conducted live by an interviewer (over telephone or video platform) or asynchronously (using online prompts without an interviewer present). To enable broader participation from those without digital devices or internet availability, the survey could be completed either online or via telephone.

The survey was designed to generate qualitative data in response to free text questions and to support sampling for the interviews, to ensure we could recruit a diverse sample for in-depth interviews. Survey questions (online supplemental file S1) were developed and piloted by the research team with input from the study’s Expert Collaborative Group. A Qualtrics survey was embedded in THIS Institute’s online research platform Thiscovery 49 and was open for 6 weeks between September and October 2020.

Interview topic guides (online supplemental file S2) were developed following review of existing literature. They were discussed with the study's Expert Collaborative Group and clinical co-investigators and were piloted internally by members of the research team and tested on the Thiscovery platform. Interviews were completed between October and December 2020. The live interviews were conducted by one of four experienced qualitative researchers (LH, KK, FD, JW) and audio-recorded for transcription and analysis. Interviews were transcribed by a professional transcription service. Two health professionals were interviewed together in one interview. Two interviews with women involved a partner. Four interviews involved an interpreter from a community group supporting women through pregnancy in order to facilitate inclusion. Three-way telephone interviews, with the women, interpreter and researcher, were conducted with the interpreter simultaneously translating. The interviews were then full transcribed into English by a professional translator.

Supplemental material

Data analysis

The two datasets (free text responses from the survey and interview transcripts) were analysed sequentially. Researchers at RAND Europe undertook an initial analysis of the free-text responses from the survey using a coding framework developed by researchers, with additional analysis by LH and FD to establish reliability and validity.50 Interview analysis, supported by NVIVO,51 was undertaken by LH, FD, KK and NB based on the constant comparative method, with a coding framework developed by LH in discussion with KK, NB and FD.52 Analysis was adaptive, integrating thematic areas that researchers had generated with quality domains that we had identified from the literature on quality in healthcare30–32 53 as sensitising concepts.54 Consensus was reached through regular analysis discussions. The deductive codes were based on a literature review conducted by KK and included, for example, language and communication, practical barriers and practical benefits.

Service user, stakeholder and public involvement

A 13-member Expert Collaborative Group provided advice and guidance throughout the study. It included ‘lay’ people who were (or had recently been) pregnant, representatives from charities and healthcare professionals. Members helped frame the research question, design the study, provided feedback on study instruments, supported inclusive recruitment, provided guidance on analytic strategy and increased sensitisation at every stage to the needs and priorities of the groups under study.

Results

In total, 211 people took part across the two elements (survey and interviews) of the study. Survey respondents (143) included 75 women who were or had recently been pregnant, 54 healthcare professionals and 14 managerial/systems-level staff (table 1).

Table 1

Total study sample (created by the authors)

We conducted 90 live interviews and two asynchronous interviews with 45 women, 34 healthcare care professionals and 14 managers and system leaders. One interview involved two healthcare professionals. Six managers held dual roles as clinicians and spoke from both perspectives. Twenty-five participants took part in both survey and interview. The duration of the interviews ranged from 24 to 164 min. Both survey and interview responses reflected a broad geographical spread across the United Kingdom (UK). We collected data on ethnicity for women only. Those who responded to the survey largely reflected makeup of the population of theUK by ethnic group. The interview sample for women (table 1) had greater representation from ethnic minority groups compared with the distribution in the UK population.55

In both survey responses and interviews, a widespread shift to remote antenatal care was described. Women reported receiving much of their antenatal care remotely via telephone or video platforms, and healthcare professionals reported providing care remotely from their clinical base or working from home, suggesting that their views were directly informed by experience. Our analysis enabled generation of a framework (table 2) of the domains of quality that appear to be most relevant to the key stakeholders in antenatal care: efficiency and timeliness; effectiveness; safety; accessibility; equity and inclusion; person-centredness and choice and continuity. Table 3 reports this framework with supporting quotations for the analysis we present below.

Table 2

Framework for quality in remote antenatal care (created by the authors)

Table 3

Study findings on quality domains for remote antenatal care

Table 4

Impacts of remote care on equity

Efficiency and timeliness

Efficient and timely care—avoiding wasted effort, waits and delays—is an important domain of quality for remote antenatal care that was identified across all participant groups. Potential efficiency advantages of remote care reported by women included saving time, stress, travel expenses and needing to take time off work or arranging childcare. Healthcare professionals suggested that remote consultations had the potential to be more time-efficient and allow increased flexibility, under optimal conditions. Among the aspects of care that were considered by participants to have potential for the efficiency gains associated with remote care were the form-filling components of the initial antenatal ‘booking’ appointment, discussions about birth after a previous caesarean section and conversations about induction of labour.

Participants also reported, however, that achieving the potential for efficiency through remote care was not straightforward. Digital infrastructure (compatible hardware, software and connectivity) was critical, but varied across different organisations. Some healthcare professionals had well-integrated electronic records that they were comfortable navigating, but others operated heterogeneous systems, where information was easily lost or hard to access. Remote consultations were often frustrated by inconsistently or incompletely digitised records/notes and incompatibilities between different care providers’ record systems. Women and healthcare professionals reported technical issues affecting remote consultations including difficulties getting through, dropped calls and inability to use video.

Professionals and managers emphasised that remote care often generated hidden work that increased workload, describing many challenges in organising remote appointment lists and keeping to schedule. Women also found that the organisation of remote care was inefficient and inconvenient. They reported often being offered an extended timeslot during which they might expect a call rather than a specific appointment time, but this led to missed or late appointments because they could not be reliably available throughout. Rescheduling appointments resulted in invisible work or compensatory labour for healthcare professionals,56 including rework, extra steps or additional complexity, and for women it added to the burden of treatment.57 Further, though remote care enabled faster throughput of appointments and thus apparent efficiency gains, women often described their appointments as feeling rushed. Crucially, healthcare professionals emphasised that providing care remotely resulted in the loss of shared professional spaces that are fundamental to teamwork, communication, cooperation and positive working relationships, resulting in potential efficiency and safety challenges.

Effectiveness

Effectiveness describes care that is based on high-quality evidence.31 Participants expressed concern about whether remote care was as effective in achieving the same outcomes of antenatal care as in-person care. Some participants suggested that remote provision might improve effectiveness of some forms of care, for example, by enabling women to participate more actively in their own care through self-monitoring of blood pressure or blood glucose. However, there was consensus across all participant groups, from system level stakeholders and healthcare professionals through to women themselves, that there is not yet enough evidence available to demonstrate whether remote care has similar, better or worse effectiveness in achieving good outcomes of pregnancy compared with in-person models. Also clear is that effectiveness might vary according to outcome, including clinical outcomes such as live births and normal birth weights, or participant-reported outcomes such as user experience.

Safety

Ensuring safety—which can be defined as preventing or reducing risks of avoidable harm58—was consistently identified by participants as a key goal of antenatal care. An immediate safety benefit of remote care was that it reduced risks of COVID-19 transmission. However, participants were not always confident that remote antenatal care was reliably safe. In particular, concerns were raised as to whether remote care was as safe as in-person care, given the risk of missing physical and other signs.

Further concerns arose when harm was broadly defined beyond narrow clinical parameters. For example, healthcare professionals reported concerns that remote care suppressed opportunities for women to raise concerns, including those relating to domestic violence or abuse, previous trauma or to flag up complex social issues. When providing care remotely, even with video, professionals’ view of the room, and who was in it, was restricted. They felt that remote care was likely to have adverse impacts on women’s trust of professionals, particularly if continuity of care was low.

Healthcare professionals were concerned about what was missed through remote care, including touch, and picking up on vital visual and non-verbal cues and clues as to the pregnant woman’s physical and mental well-being. Women reported they felt brushed over and found it harder to raise concerns. For those experiencing or at risk of domestic abuse, telephone appointments removed the safe space of face-to-face consultations and obscured many cues that midwives or other healthcare professionals would be able to spot in person. Other vulnerable groups identified included those with previous trauma or learning difficulties or those for whom remote care could increase social isolation.

Accessibility

Accessibility describes the ease with which care can be reached without barriers to service use.59 60 Remote antenatal care was seen by participants as offering some advantages in increasing accessibility, for example, by expanding the ways care could be provided, reducing challenges to access associated with location and travel and offering opportunities for additional contacts between appointments. Examples of better accessibility cited by participants included provision of perinatal mental support and facilitating consultations requiring multidisciplinary teams or specialist obstetricians working at different hospitals. Some participants were also very positive about new modes of communication (e.g., mobile telephone, email, social media and apps) and digital resources (e.g., hospital trust webpages, videos and podcasts) that they saw as improving accessibility to information and support.

Again, however, remote care was not straightforward in its impacts on accessibility. Care that was more transactional in nature, such as information exchange during the initial antenatal ‘booking’ appointment, was identified by participants as increasing in accessibility when offered remotely. But action that relied on relational care or continuity, such as raising concerns or safeguarding, became less accessible.

Importantly, the resource requirements for delivering and engaging with remote care were cited by participants as a major influence on accessibility. All forms of remote contact assumed access to a quiet, private space. This was often difficult or impossible for women and not always straightforward for healthcare professionals either. Telephone calls required women to have a device, a phone signal and enough credit and charge on the phone. Video calls required clinicians and women to have access to a video-consulting platform, a stable internet connection and internet-enabled device and to be able to use them reliably. Remote care also relied on individuals having the skills and language competence to participate in remote consultations or information provision and to share in the sociocultural expectations of NHS-provided maternity care.

Equity and inclusion

Equitable care is care that does not vary in quality or accessibility because of personal characteristics such as sex/gender, ethnicity, geography or socioeconomic status.31 We identified major concerns in relation to equity of remote care, detailed in table 4. Participants reported that remote care worked very well for digitally enabled and health-literate women who were confident in what to expect from their care, and for women who had pre-existing relationships with health professionals. However, all participant groups raised concerns about the potential for remote care to further disadvantage some groups and to risk amplifying existing structural inequalities.

Groups identified as especially vulnerable included those who were digitally excluded through lack of internet access or the hardware to connect and/or had low levels of digital literacy, a low base level of oracy and literacy in English language and challenges in reading instructions, inputting data and communicating effectively. Participants reported concerns that particular social, cultural and economic risk factors, often associated with communities at risk of marginalisation, could lead to inequality of access and other forms of exclusion.

Person-centredness

Person-centred care can be understood as care that is respectful of and responsive to individual needs, preferences and values, taking into account the preferences and aspirations of individuals and the culture of their community.53 All participant groups reported that establishing and maintaining the relationships and trust necessary to achieve person-centred care was much harder to do remotely. The remote appointments that worked best were those that were largely transactional and protocol-driven in character. Such consultations were typically those that did not rely too much on non-verbal cues, for example, providing uncomplicated information or results without negative implications, or routine recording of blood pressure/glucose levels. However, women and health professionals emphasised that these ‘content-focused’ consultations were only one small part of antenatal care, or one part of a wider antenatal appointment.

Women often described a lack of rapport and reassurance associated with remote care. Because appointments were experienced as shorter and more transactional than therapeutic, women reported that they felt like a ‘tick-box exercise’ focused on the clinical aspects of care at the expense of the relational. They found it harder to raise concerns about symptoms or mental health issues. Healthcare professionals similarly worried that women found it harder to open up about what mattered to them. They reported that it was particularly challenging for women who did not speak sufficient English to follow rapid exchanges.

Choice and continuity

Responsiveness to individual choices and preferences is an important feature of quality of care.31 A particularly important preference for healthcare professionals and women alike was for relational continuity, which they saw as underpinning trusting relationships in antenatal care.61 62 Both choice and continuity were reported to have been adversely impacted by the turbulence of the pandemic. Some women reported that they felt lost in the system and unable to make choices about their care. Participants agreed that one size does not fit all, and that ideally women would be offered a blend and choice of care mode (for example between remote and in-person care), through shared decision-making. They proposed that choice should be supported by information about different pathways. They also emphasised the importance of clear guidance for healthcare professionals for risk assessments to consider the woman’s medical, social and cultural histories, some of which would only revealed through trusting relationships over time.

Discussion

Main findings

The COVID-19 pandemic has led to a new era of remote care, but the principles that should inform its development remain underdeveloped.29 Given the enthusiasm for retaining aspects of remote antenatal care postpandemic, it is important that policy and practice are guided by clarity about ‘what good looks like’.11 12 Evidence in other clinical fields has mostly focused on consultations and on aspects of experience of care.19–23 63–65 Our study suggests that remote care needs to be understood as a whole system—of which consultations are just one part—and that a much broader conceptualisation of the relevant dimensions of care along entire pathways is needed. This large qualitative study of the views and experiences of women, healthcare professionals and system-level stakeholders has generated a framework (table 2) that identifies relevant dimensions of quality and standards for remote antenatal care. The dimensions identified in our analysis map closely onto existing frameworks for quality in health systems, including the Institute of Medicine framework,41 with the additional dimension of Choice and Continuity. The similarity between the two offers some confidence in the validity of the findings. By offering a systematic way of structuring thinking about quality in remote antenatal care, this new maternity-specific framework can guide policy and practice.

Our findings suggest that there are both advantages and disadvantages of remote care across each of the domains. Although participants valued the potential convenience and flexibility offered by remote care, what may appear to be efficiency gains may also involve hidden burdens leading to invisible work and compensatory labour.56 66 Permeating women’s accounts were concerns about safety, effectiveness and person-centredness, linked to the risk that absence of in-person contact might undermine the quality of interactions and hinder safeguarding and recognition of other safety issues. The risks facing women vary and some may need antenatal care that is wholly face-to-face. There was also much concern about the potential for negative impacts of remote care on equality and inclusion, especially given disparities in digital access and variation in maternity outcomes linked to structural inequalities.67–69 Our findings also highlight differences between modes of remote care. While telephones are often cheaper and more ubiquitous, video consultations provide visual as well as audio information. However, both telephone and video platforms are vulnerable to poor connections, and people do not always have access to the necessary hardware or subscriptions to data services. A high-quality evidence-base will need to be built to address these concerns.

In identifying that remote care should be regarded neither as a utopia nor a dystopia, our findings are suggestive of a number of recommendations for policy and practice if the potential of remote antenatal care is to be realised while the risks are mitigated. Optimising remote care for the future will require investment in high quality technology infrastructure, human resources and digital literacy skills and in codesigning pathways, work systems, workflows and processes to support efficiency and convenience for both service users and healthcare professionals. These are not solely practical considerations—they also have profound implications for structural equity. Given evidence of widespread digital poverty—a significant proportion of the UK public lacks adequate access to data infrastructures, such as broadband, connectivity and smartphones69—the design of remote care models will need to mitigate the risks that disproportionately affect some groups.

A particularly striking finding of our study was the emphasis across all participants on safety as a concern for remote antenatal care, including potential barriers to the role of trusting relationships and continuity70 71 in achieving both safety and person-centred care. In foregrounding the central importance of relationships, our study emphasises that any lasting shift to remote provision will need to be highly attentive to designing care pathways so that they facilitate successful relationships between people who are pregnant and those who are caring for them.72 73 Opportunities and mechanisms for reporting safety concerns will need to be built into these pathways74 and should be broadly conceived. For instance, the loss of ‘communicative spaces’ for healthcare professionals to engage in debriefs, handovers and corridor conversations is likely to generate safety issues as well as impairing their experience of work.75

Strengths and limitations

A strength of this study is its large and diverse sample that brings together of the voices of pregnant women, healthcare professionals, managers and system-level stakeholders. The remote interviewing and survey approach supported the development of an ethnically and geographically diverse sample. The remote approach, however, favoured those we could reach with our study information as well as those with the resources, capacity and time to engage and take part in the survey and/or interviews. While efforts were made to mitigate against these barriers, inevitably we have not been able to capture all perspectives. Thus, the very nature of remote research, compelled by the pandemic, may have also created a self-selecting sample of more digitally-enabled participants. It was not possible to estimate a survey response rate owing to the recruitment methods used. Further, we were unable to measure clinical outcomes or to infer causal relationships. Accordingly, this paper does not make recommendations about the role of the routine physical and mental checks that should be maintained in future antenatal pathways.

Conclusion

The lure of digital transformation is powerful and hard to resist,76 77 but introducing major changes into healthcare systems is rarely straightforward78–82 and requires a systematic approach to quality and safety. Our study offers a provisional framework that can help in structuring thinking, policy and practice and, by drawing attention to the range of domains relevant to remote antenatal care, will help support the development of a codesigned evidence-base. Our findings suggest that a hybrid model should be on offer, but one that has sufficient flexibility to accommodate the needs and priorities of different groups and that is highly sensitised to equity and inclusion. Key areas for development and testing include the extent to which transactional and relational aspects of care are interlinked, the significance of continuity as a feature of quality in remote care and outcomes and experiences of different modes of remote antenatal care.

Details of ethics approval

All participants were provided with information about the study and gave consent (see Consent form in online supplemental file S3 File (redacted)). We followed the Standards for Reporting Qualitative Research recommendations (online supplemental file S4).48

Supplemental material

Data availability statement

Data are available on reasonable request. The data that support the findings of this study are available from the corresponding author on reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

Ethical approval for the study was obtained from the NHS HRA West Midlands—Coventry and Warwickshire Research Ethics Committee on 22 July 2020 (20/WM/0204). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

We are grateful to the study's Expert Collaborative Group for their input and guidance. The group included: Filsan H Ali, Nicky J Lyon, Dr Christine I Ekechi, Jane Fisher, Emma M Crookes, Dr Sharon Dixon, Joyce Darko, Lia Brigante, Jane Brewin, Nadia Brobbey, Marcus E Green, Professor Sara Kenyon and Michele Upton.

References

Supplementary materials

Footnotes

  • Twitter @LisaHinton4, @dakinfrancesca, @K_Kuberska, @richardjmcmanus

  • Contributors The study was conceived by LH, MD-W and TD. Study setup for the survey and interview phases (including planning and approvals) were led by LH and FD, with design input from KK, MD-W and coinvestigators (TD, CW, RJM, LC, SC, EH). KK conducted a literature review to ascertain the existing evidence-base for remote care. The survey was built in Qualtrics by FD with support from Thiscovery team members. Researchers at RAND Europe undertook an initial analysis of the free text responses, with additional analysis by LH and FHD. Interviews were conducted by LH, FD, KK and JW. Interview analysis was completed by LH, FD, KK and NB using a coding framework developed by LH in discussion with FHD, KK and NB. LH, FD, KK and NB met frequently during analysis to discuss the results and confirm the reliability of each researcher’s analyses before discussion with MDW, co-investigators and the Expert Collaborative Contributorship Group. MD-W is the guarantor.

  • Funding This project is funded by THIS Institute’s grant from the Health Foundation. The Health Foundation is an independent charity committed to bringing about better health and health care for people in the UK. Mary Dixon-Woods is an NIHR Senior Investigator (NF-SI-0617-10026). Richard McManus and Lucy Chappell are NIHR Research Professors ((NIHR-RP-R2-12-015, NIHR -RP-2014-05-019) and NIHR Senior Investigators.

  • Competing interests TD is Vice President of the Royal College of Obstetricians and Gynaecologists. RJM has previously received BP monitors from Omron Healthcare for research purposes and is working with them on a telemonitoring system.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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