Table 3

Study findings on quality domains for remote antenatal care

Quality domain	Illustrative data on where remote antenatal care works well	Illustrative data on where remote care does not work so well
Efficient and timely Efficient—avoiding waste, in particular waste of equipment, supplies, ideas and energy Timely—reducing waits and sometimes harmful delays for both those who receive and those who give care	Potential for more convenience for women and staff ‘It’s (remote care) flexible, so if I’m, like, feeling tired or unwell, I can just stay at home and still get the same level of care.’ W03 ‘That’s been really useful actually, to be able to take phone calls, or video calls, because I'm at a desk Monday to Friday full-time. So if I would have had to go to the hospital more(…)it would have taken more time out of my day.’ W05 ‘They don’t have to drive to the hospital, they don’t have to park, they don’t have to pay for parking, they don’t need to organise childcare. There are some considerable advantages to it.’ H01 Efficient ‘Information-wise…you can do that quite quickly over the phone, whereas in person, because you have got that bit more of a rapport going, there’s more of a conversational element to it, so they kind of can go off track and things.’ H21 Flexible ‘So we can be a lot more responsive to these women, by literally just picking up the phone and having that chat with them. You don’t have the practical issues, is there a clinic room available, how long is it going to take her to come in, I haven't got a clinic slot for 3 weeks’.’ M14	More operational work behind the scenes ‘There’s a couple of times where like you’d ring people and they’d be like oh, I’m just out. Can I call you back later? Like they didn’t take it as seriously, like, this was your appointment.’ H09 Compensatory labour ‘You have a lot more leg work to make the two (Attend Anywhere and hospital appointment system) combine…well, they don’t. I’ve got this form as I said, I have to fill in and then save it in their file and retrieve it when I need it. You know, that’s a bit of a hassle.’ H26 Invisible burdens ‘It feels like you have to do so much detective work, looking at all the different sites like their results and their records, their letters from the past, what’s happened in maternity, what happened in their past obstetric histories.’ H23 Loss of communicative spaces for healthcare professionals ‘We always function best when we’ve had a team meeting, so like one of us will go through all the emails we’ve received, and then we’ll discuss them all, and that tends to embed it better.’ H21
Effective Services are based on high quality evidence, with low value care minimised	Potential for new ways of working, reconfigured care pathways ‘We’ve had accelerated innovations around home blood pressure monitoring, which again has been popular with women, it gives them a degree of autonomy. It reduces the footfall of unnecessary visits to the midwife or to hospital for blood pressure and urine checks.’ H11	No evidence yet of effectiveness ‘Frequently, there was not enough information to be able to provide safe care ensuring risks were not missed. The infrastructure is not in place and I don't feel satisfied with the care I can give.’ H56 ‘I don’t yet have the evidence I would like about the impact on women, about the acceptability from women, about whether women prefer this style.’ M08
Safe Care that does not cause avoidable harm	Helps in preventing COVID-19 infection since in-person contact is reduced ‘Actually for a significant number of women who we were previously dragging to the hospital, they didn’t need that. So I think one of the positives I think will be, moving forwards, we’ll be a bit clever about how we triage women to who needs true face-to-face care.’ H11 ‘If I was high risk or if I had an issue, they would have told me to come in. But for me, at least it was completely over the phone, which I was fine with, because(…)I’d had no issues that I think needed to be seen in person.’ W32	Remote care suppressing opportunities for women to raise concerns ‘I'm a stranger that’s just called them in their pregnancy, if it’s over the phone, it’s really difficult for them. One of the questions is have you had any life events that you feel might make pregnancy difficult, things like sexual abuse or domestic violence, parents breaking up a relationship in the past, anything that you feel might make a pregnancy difficult.’ H20 ‘Everything’s been through the phone. It’s been – maybe because of the anxiety of it being my first pregnancy – it was really impersonal, it was really short. Because it’s over the phone it was just really brushed over.’ W29 Loss of vital visual and non-verbal cues ‘(W)e look at how swollen people are, we look at the colour of their skin, how pale they are, you know, whether or not they look anaemic, whether or not they look depressed…You know, we can’t do that on the phone.’ H15
Accessible Care that does not present barriers to use, including obstacles related to finance, transport, or design	Amplified modes of communication ‘They have a 24 hour pregnancy advice line, so wherever I’ve had a worry I’ve been able to call that number(…)So it was very responsive.’ W35 New ways of providing care, including multidisciplinary team meetings ‘So, in the video clinics they will have a regular appointment with the diabetes specialist nurse and the diabetes specialist dietician, and for our ladies with Type one or Type two diabetes with the consultant as well. So, we can all still have that joint decision-making but just on a video, virtual clinic rather than a face-to-face clinic.’ H14	Level of digital infrastructure and literacy required to deliver and receive remote care ‘We just have it on our computer, so we don’t have iPads or phones that can access it, so we have to be physically in the office to access it. So if we’re not in the office or we’re out somewhere else, we can’t access those records at all.’ H12 ‘The maternity app, if it was done properly, it would have been really useful. Some of the appointments were in there, just not all, and some of the information were there and just not all(…)It’s just half done, half completed, makes it a bit pointless sometimes.’ W30 I mean, the video calls are a bit of an issue, just because of the internet connection, and I think…I mean, I'm not 100 per cent sure but I…so I…I'm in a very rural area, I don't have broadband, I'm relying on my 4G hotspot, so that is a bit of a problem.’ W05
Person-centred Providing care that is respectful of and responsive to individual patient preferences, needs and values	Can fit into women’s needs, especially for providing information or test results without negative implications ‘It provides flexibility, you know, I’m just thinking with the continuity of care model that’s coming into Hospital D, you know, midwives are on call all day, you might be able to have a Zoom meeting at seven o’clock when they’ve put their little one to bed. That sort of sense of flexibility, people you hope are more able to access care.’ H29	Care may become more transactional than relational ‘I’ll be honest, I don’t think I have got a relationship with the midwives, because there isn’t that face to face interaction.’ W33 ‘When done remotely everything feels more formal, like a business interaction.’ W94 ‘I feel very isolated on my own, that the midwife is simply interested in this baby and not interested in the family as a unit.’ Participant W37 Appointments feel rushed ‘In real face-to-face kind of appointments, you get more like chitchats, which somehow sometimes reveal things that you might not have thought of.’ W30
Enables choice and continuity Care should be designed to respond to individual choices and preferences, with continuity of care where possible	Importance of choice ‘I think choice to be seen remotely or face to face is important.’ W93 ‘First time mums should be able to have face to face appointments(…)Second time round mums should be given the choice as to whether they want face to face or remote.’ W11 A hybrid pathway can support personalised care, with the right risk assessment ‘I think that they really need to personalise the care to the individual.’ W31 ‘It’s more about trying to develop a proper personalised understanding of that person’s circumstances and working out what’s appropriate and what’s not appropriate.’ M03	One size does not fit all ‘I do think we should be allowed to use our clinical judgement, rather than just a blanket ‘this is how it’s got to be’.’ H12 ‘People have to feel comfortable with it, the actual using of the platforms, and, you know, there are a number of midwives that are approaching retirement age that would say they are not very digitally savvy, so it’s been difficult for them. And they have probably used the telephone more than video appointments. So, that has certainly been a problem for people’ H24 If it was a longer term thing where we were talking about bringing in remote care as part of standard maternity then that should be communicated to you right at the beginning as part of your package of care.’ W35 ‘Remote consultation doesn’t work for everyone equally. And I think that’s really, really important and if someone, you are talking to someone on the phone and they do speak little to no English, then to insist on them having all of their consultations as remote until 28 weeks I think is really stupid and does a disservice. And I think there needs to be a bit of flexibility in the system and I don’t think there is any currently.’ W15
Equitable Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socioeconomic status	Works for some ‘I think that most (patients/service users)find some positive elements to it, they don’t have to drive to the hospital, they don’t have to park, which is a major pain on our side, they don’t have to pay for parking, they don’t need to organise childcare. There are some considerable advantages to it.’ H01 ‘Remote assessment for the right person is probably absolutely fine, whereas remote assessment for the wrong person is not going to help. And it’s knowing which person you’re talking to or about.’ M10	Does not work for some (see table 4 for expanded set of quotations for equity) 'Sometimes women appear to be a certain way but once they’ve got your trust you can find out so much and actually she might have a dreadful life and sometimes it’s that midwife that helps that woman out.’ H18