A qualitative study of the dynamics of access to remote antenatal care through the lens of candidacy

Why it matters

Antenatal care (pregnancy care) which is designed to support women to have a healthy and successful pregnancy, underwent a significant transformation to remote consultations during the pandemic. It’s likely that some remote provision, via telephone or video, will remain a long-term feature of maternity care in the NHS going forward, and we wanted to understand the impact of this shift on access to antenatal care.

Only a handful of studies have used the candidacy construct (meaning the ways in which people’s eligibility for medical attention and intervention is jointly negotiated between individuals and health services) to examine maternity care or women’s health. Research focused on digital health and maternity care has remained very limited, but the distinctive features of antenatal care warrant specific attention, given its critical role in securing positive pregnancy outcomes, safeguarding women’s well-being and mitigating inequalities for under-served groups.

We aimed to explore the experiences and perspectives of pregnant women, antenatal healthcare professionals, and maternity care to understand the impact of the implementation of remote provision of antenatal care.

Our approach

We conducted a qualitative study involving semi-structured interviews with 93 participants, including 45 individuals who had been pregnant during the study period, 34 healthcare professionals, and 14 managers and system-level stakeholders. Analysis was based on the constant comparative method and used the theoretical framework of candidacy.

What we found

We found that remote antenatal care had far-reaching effects on access when understood through the lens of candidacy – remote care altered women’s own identification of themselves and their babies as eligible for antenatal care. Navigating services became more challenging, often requiring considerable digital literacy, access to digital media, and sociocultural capital (such as the privacy to take a call). Services became less permeable, meaning that they were more difficult to use and demanding of the personal resources of users.

Remote consultations were seen as more transactional in character and were limited by lack of face-to-face contact and safe spaces, making it more difficult for women to make their needs – both clinical and social – known, and for professionals to assess them. Operational and institutional challenges, including problems in sharing of antenatal records, were influential. Socially or financially disadvantaged women found services more difficult to use, as did some people from minority ethnic backgrounds.

There were strong suggestions that a shift to remote provision of antenatal care may increase risks of inequities in access to care in relation to every feature of candidacy we characterised. Moving to a remote antenatal care model isn’t a change that should be taken lightly; these types of switches come with consequences. It’s important that we take care when implementing remote care because while it may work very well for some people, we also risk amplifying existing intersectional inequalities, putting up barriers for those who we should be encouraging to access appropriate care. Addressing these challenges through policy and practice action is needed to tackle these risks.

We need to design inclusive services in ways that consider issues like digital exclusion and phone poverty and provide adequate information on the range of options for access. It will also be important to keep under review how women are accessing information and allow them to make an informed choice where possible.