Women's satisfaction with traditional and reduced antenatal visit schedules Sarah Clement, Jim Sikorski, Jennifer Wilson, Sarah Das and Nigel Smeeton

Sarah Clement PhD, CPsychol, Non- clinical lecturer

Jim Sikorski MRCP, MRCGP, DRCOG, General Practitioner and Honorary Research Fellow

Jennifer Wilson MSc, RGN, RM, Research Midwife

Sarah Das BSc, RGN, RM, Project Coordinator, National Maternity Records Project, Chiltern House, 188 Baker Street, London NWI 5SD

Nigel Smeeton MSc, CStat, Lecturer in Medical Statistics, Department of Public Health Medicine, United Medical and Dental School, Guys Hospital, St Thomas Street, London SEI 9RT, UK

(Address correspondence to: SC) Accepted for publication March 25th 1996

Objective: to ascertain: (i) which demographic, obstetric, maternity care, practical and attitudinal variables, and which variables relating to social support and life problems predict satisfaction with traditional antenatal visit schedules; and (ii) which of these variables predict satisfaction with reduced antenatal visit schedules.

Design: a secondary analysis of data from the Antenatal Care Project (a randomised controlled trial comparing two schedules of routine antenatal visits).

Setting: three hospitals and their community sites in south-east London.

Participants: 1882 pregnant women, that is all those who took part in the Antenatal Care Project, on whom maternity record data were available, and who returned their antenatal questionnaire.

Intervention: participants were randomly allocated to follow either the traditional schedule of 13 routine antenatal visits, or a reduced schedule of seven visits for nulliparous women and six visits for multiparous women.

Measurements: a questionnaire developed specifically for the Antenatal Care Project. Also some data extracted from women's maternity records.

Findings: women satisfied with reduced schedules were more likely to live in rented accommodation, and to have a caregiver who both listened and encouraged them to ask questions than women not satisfied with reduced schedules. Women satisfied with the reduced schedules were less likely to be depressed in pregnancy than those not satisfied with reduced schedules. Women satisfied with the traditional schedule were more likely to have their general practit ioner involved in their antenatal care, and to receive social support from relatives than those not satisfied with the traditional schedule. Initial preferences and expectations were also associated with satisfaction.

Key conclusions and implications for practice: (i) groups most likely to be satisfied with traditional or reduced antenatal visit schedules cannot be easily identified. It is therefore necessary to talk to women individually, and tailor care to their particular preferences; (ii) social support for depressed women needs to be safeguarded if reduced schedules are to be introduced; (iii) improving the psychosocial quality of antenatal care may be a good strategy for making reduced visit schedules more acceptable to pregnant women.

I N T R O D U C T I O N

Traditionally, women in the UK have been offered routine antenatal visits at monthly intervals to 28 weeks gestation, then fortnightly until 36 weeks ges- tation, and finally weekly visits until delivery. Women are therefore offered around 13 routine antenatal visits. Following the work of Hall et al

(1985) some practitioners began to offer fewer ante- natal visits (Marsh 1985), but reduced schedules were not widely adopted in the 1980s. In Britain, Changing Childbirth (Department of Health 1993) recommended that the number of antenatal visits be reviewed in the light of the available evidence and the guidelines set out by the Royal College of Obstetricians and Gynaecologists (RCOG). The

Midwifery(1996) 12, 120-128 © 1996PearsonProfessional Ltd

Women's satisfaction with traditional and reduced antenatal visit schedules 12 i

RCOG guidelines suggest that women with a normal pregnancy should have eight antenatal visits in a first pregnancy and five in a subsequent pregnancy (RCOG 1982). Consequently, many units are now reducing the number of routine antenatal visits they offer.

Similar recommendations have been made in the USA. The guidelines produced by the National Institute of Health Expert Panel on the Content of Prenatal Care are that nulliparous women should receive eight routine antenatal visits, and that multi- parous women should receive six routine visits (Public Health Service Expert Panel on the Content of Prenatal Care 1989). Schedules involving fewer visits have been in use for many years in parts of Europe. For example, the recommended number of antenatal visits is seven in France; five in Luxembourg, and three to four in Switzerland (Blondel et al 1985).

There is now a growing body of literature on the clinical effectiveness of reduced schedules (Hall et al 1985, Binstock & Wolde-Tsadik 1995, Sikorski et al 1996). These investigators have also measured women's satisfaction with traditional and reduced antenatal visit schedules. Given the central impor- tance of the concept of choice in Changing Childbirth (Department of Health 1993), and the significance accorded to patients' views in health care evaluations, it is vital that any form of care offered should be acceptable to the recipients of that care. All three groups of investigators found that women allocated to the reduced antenatal visit schedules were less satisfied with visit frequency than those allocated to the traditional schedule. However, there was evidence of wide variation in women's views, with some women being satisfied with fewer visits. To date, no studies have been reported which have examined individual differ- ences in satisfaction with traditional and reduced visit schedules, or ascertained which variables are associated with maternal satisfaction with the differ- ent schedules.

The existing literature suggests that there are numerous possible variables which might predict women's satisfaction with traditional and reduced antenatal visit schedules. Research on women' s gen- eral satisfaction with antenatal care has shown that women's dissatisfaction tends to be centred on long waiting times, impersonal care, poor communication and lack of continuity of caregiver (Reid & Garcia 1989). It is possible that women who receive antena- tal care with low continuity, poor communication, impersonal interactions and long waits would be more likely to be satisfied with reduced antenatal visit schedules.

Conversely, it is possible that women may be more satisfied with reduced schedules if they are receiving high quality antenatal care, since high quality care may more than compensate for a reduc- tion in the quantity of care received. This possibility is supported by the finding that women receiving

care from the Midwifery Development Unit in Glasgow, who received a high quality of care on most indices of satisfaction, had fewer antenatal vis- its than women in the control group receiving 'shared care', but were more satisfied with the visit frequency than the controls (Shields, personal com- munication).

Research on the characteristics of women who 'book' for antenatal care late in their pregnancies may also be relevant. Researchers have found that late bookers are more likely to be multiparous, young, single, separated, widowed or divorced, and with an unplanned pregnancy (Thomas et al 1991). Attitudinal factors have also been shown to play a part in delayed attendance for antenatal care (Parsons & Perkins 1980). It is possible that women in these categories, or women with particular atti- tudes to pregnancy, may also be more likely to be satisfied with fewer antenatal visits.

Demographic and obstetric characteristics may also be important because women from different social groups may have different needs. Because they lack prior experience of pregnancy and birth, first-time mothers are likely to have a greater need for information during pregnancy. Nulliparous women might, therefore, prefer more frequent visits than multiparous women. Women living in deprived socio-economic circumstances, or women facing difficult life problems, may have an increased need for social support, and so may prefer frequent visits. However, it has been argued that little social support is provided during routine antenatal visits, and that visits can sometimes act as an additional stressor for women in deprived or difficult circumstances (Oaldey 1992). It is therefore possible that such women may be more satisfied with fewer antenatal visits. The amount of social support women receive from sources other than their antenatal care - such as partners, family and friends - may determine the amount of support they need from their antenatal caregivers, and consequently influence their satis- faction with different antenatal visit schedules.

Demographic characteristics may also be related to satisfaction with traditional or reduced visit schedules as at least three studies have found evi- dence suggesting that women in different social groups receive a different quality of antenatal care. Green et al (1988) have shown that women who left school at 16 years of age were less likely to be given a choice about place of 'booking' or consultant. Similarly, Hemingway et al (1994) have shown that working-class women and women from ethnic minorities receive less continuity of caregiver than white middle-class women. Also, researchers in Australia have found that women whose economic and social circumstances meant that they were most likely to need 'care' from caregivers were more likely to be limited in their choice of caregiver and to be dissatisfied with the care they received (Brown & Lumley 1993). If working-class women receive a lower quality of antenatal care, this may well affect

122 Midwifery

their satisfaction with traditional and reduced visit schedules.

Other research has indicated the importance of prior expectations in determining satisfaction with care, and has suggested that individuals who expect a certain type of care will be less satisfied with other forms of care than individuals with no prior expecta- tions (Porter & Maclntyre 1984).

From a practical point of view, it would be advantageous if specific groups of women, prefer- ring traditional or reduced antenatal visit schedules, could be identified as this would aid caregivers when planning antenatal services which are accept- able to women. It would also help caregivers who wish to offer individualised antenatal visit sched- ules. Some practitioners report offering reduced visit schedules to the majority of women, but offer more- frequent visits to women in certain social groups such as unmarried women, those of low social class, financially deprived women, and women from some ethnic minorities (Marsh 1985). It is important that any categorisation used is based on research evi- dence rather than speculation about the needs and preferences of different social groups.

The objective of this study was to examine the association between various demographic, obstetric, practical, attitudinal variables, and variables relating to maternity care, social support and life problems, with satisfaction with traditional and reduced ante- natal visit schedules. The aims were to answer two main questions: (i) Which type of women are satis-

fied with reduced antenatal visit schedules ?; and (ii) Which type of women are satisfied with the tradi- tional antenatal visit schedule ?

METHODS

Sample

The sample consisted of 1882 women who were enrolled in the Antenatal Care Project (ACP), who had completed and returned an antenatal question- naire which was sent to them at 34 weeks gestation, and on whom data were available from their mater- nity records.

The ACP was a randomised controlled trial com- paring two schedules of routine antenatal visits. The trial took place in three hospitals and in community settings in south-east London. This area is demo- graphically diverse, with pockets of high social deprivation. Women were invited to participate in the trial if they were considered to be at low antena- tal risk, as defined by a set of clinical exclusion cri- teria detailed elsewhere (Sikorski et ai 1996), 'booked' for antenatal care before 22 weeks gesta- tion, and had a reasonable understanding of English or seven other languages into which information leaflets had been translated.

Women in the trial were randomly allocated to receive the traditional schedule of 13 routine antena- tal visits (at 'booking' , 16, 20, 24, 28, 30, 32, 34, 36,

37, 38, 39 and 40 weeks gestation), or a reduced schedule of seven routine visits for nulliparous women (at 'booking', 24, 28, 32, 36, 38 and 40 weeks gestation) and six routine visits for multi- parous women (at 'booking', 26, 32, 36, 38 and 40 weeks gestation). Women were also informed that, whichever group they were allocated to, extra visits would be arranged if they, or their caregivers, were concerned, or felt the need for extra visits.

In all, 2893 eligible women were enrolled into the ACP. Two withdrew and 97 were lost to follow-up, leaving a final sample of 2794. Retrospective data from maternity records were obtained for all but 36 of these women. The Maternal Antenatal Questionnaire (MAQ) was sent to 2652 women in the trial at 34 weeks of pregnancy. The questionnaire was not sent to women who had delivered or lost their babies before 34 weeks gestation, or who did not have a rea- sonable understanding of English. The number of questionnaires returned was 1882, giving a response rate of 71%, a rate which is above that expected in an inner city area (Mason 1989). Nine hundred and sixty-two of these women had been allocated to the traditional schedule of antenatal visits, and 920 had been allocated to the reduced schedule.

Further details of the ACP, including the main findings of the trial, are given elsewhere (Sikorski et al 1996).

Measurements

The majority of variables examined in this study came from the MAQ, a questionnaire which was developed specifically for the ACP. The MAQ was designed to examine the psychosocial effectiveness and acceptability to women of traditional and reduced antenatal visit schedules. The MAQ con- tained 85 individual questions and two existing scales (a scale is a series of questions for which answers are combined to give an overall score for a particular variable). For the research reported here, each question and scale in the MAQ was scrutinised by the research team for its relevance to the ques- tions Which type of women are satisfied with reduced antenatal visit schedules? and Which type

of women are satisfied with the traditional antenatal visit schedule? Thirty nine of the individual ques- tions and one of the scales were considered to be rel- evant. The relevant scale was the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al 1987). This scale has been used extensively and has been shown to be both valid (sensitivity 86%, speci- ficity 78%, positive predictive value 73%) and reli- able (split-half reliability 0.88, standardised alpha co-efficient 0.87) (Cox 1994). The EPDS has also been validated for the detection of depression in pregnancy (sensitivity 64%, specificity 90%, posi- tive predictive value 50%) (Murray & Cox 1990). Many of the individual questions in the MAQ were from the Office of Population, Censuses and Survey (OPCS) Survey Manual on Women's Experiences

Women's satisfaction with traditional and reduced antenatal visit schedules 123

of Maternity Care (Mason 1989). Some of the ques- tions came from questionnaires developed by the Centre for Family Research, Cambridge (Green et al 1993). A small number of individual questions were developed specifically for the ACP.

The MAQ was piloted before use. A two-stage piloting process was used. Firstly, five face-to- face pilot interviews were undertaken, and minor amendments resulting from these pilot interviews were incorporated into the questionnaire. Secondly, this amended version of the MAQ was sent to a pilot sample of 100 women who were between 33 and 35 weeks pregnant. The first 50 pilot questionnaires returned were analysed, and further minor amendments made. The final version of the MAQ was sent to women in the ACP in their 34th week of pregnancy, and two postal reminders were sent to non-respondents at fortnightly intervals.

Data on maternal age, parity, gestation at book- ing, and the extent of antenatal continuity of carer (measured by signature count) were collected retro- spectively from women' s maternity records.

This process resulted in a total of 44 possible pre- dictor variables. These variables are listed in Table 1, and group into seven main categories: demo- graphic, obstetric, maternity care, practical and atti- tudinal variables and variables relating to social sup- port and life problems. The demographic variables included ethnic group and two proxy measures of social class. Ethnic group was measured by self- report using census classifications. The two proxy measures of social class were those recommended by the OPCS Survey Manual on Women's Experiences of Maternity Care (Mason 1989), age at finishing full-time education and housing tenure. Proxy measures were used to avoid the time con- suming coding of occupational data, and because there is some debate about how satisfactory occupa- tional classification systems are for women (Mason 1989).

The two main outcome variables examined in the present study were satisfaction with reduced antenatal visit schedules and satisfaction with tradi- tional visit schedules. Data for these variables came from women's answers to the question How do you

feel about the number o f antenatal check-ups you have had overall? in the MAQ. Women who had been allocated to the reduced schedule group were classified as satisfied if they answered that the num- ber of check-ups was just right for them, or that they would have preferred fewer check-ups (since this suggests that they would be satisfied with a sched- ule which was reduced still further). They were classified as not satisfied if they would have pre- ferred more check-ups. Likewise, women allocated to the traditional schedule of visits were classified as satisfied with the number of visits if they reported that the number of check-ups was just right for them, or if they would have preferred more check-ups.

Analysis

The data were analysed using the Statistical Package for the Social Sciences (SPSS Inc. 1990). The first question addressed was Which type of women are satisfied with reduced antenatal visit schedules? Firstly, univariate associations between the possible predictor variables listed in Table 1 and the outcome variable, satisfaction with reduced antenatal visit schedules, were examined using the Z 2 test of asso- ciation, or Fisher's Exact test, as appropriate (when the expected cell frequency was less than five for more than 20% of the cells). This analysis was car- ried out only on women in the reduced schedule group (n = 920), since we were interested only in women's satisfaction with a type of care they had actually experienced. All the variables which the univariate analysis had shown were significantly (P < 0.05) related to satisfaction with reduced visit schedules were then entered as possible predictor variables in a stepwise logistic regression analysis, with satisfaction with reduced visit schedules as the outcome variable. Thus, the variables which were independently associated with being satisfied with reduced visit schedules could be identified.

The process was then repeated to answer the sec- ond question, Which type of women are satisfied with the traditional antenatal visit schedule? In this analysis, we looked only at women who had been allocated to follow the traditional schedule of visits (n = 962). Firstly, a univariate analysis was under- taken. Those variables which were found to be sig- nificantly related to satisfaction with the traditional visit schedule were then entered as possible predic- tor variables in a stepwise logistic regression analy- sis, with satisfaction with the traditional visit sched- ule as the outcome variable.

Before the variable difficulty o f previous preg- nancy was entered into the logistic regression analy- sis, a category of 'missing' was created for this vari- able to prevent first-time mothers from being excluded from the whole of the regression analysis.

FINDINGS

Satisfaction with reduced schedules

The univariate analysis looking at the relationship between the predictor variables and satisfaction with reduced schedules revealed that nine predictor variables were significantly associated with satis- faction with reduced schedules (see Table 1). To undertake the multivariate analysis, respondents who had any missing data for the variables in this analysis had to be excluded, thus reducing the sam- ple size from 920 to 805. When the nine significant variables were then entered as possible predictor variables in the logistic regression analysis, it was found that only six remained significantly associ- ated with satisfaction (see Table 2). Women who were satisfied with reduced schedules were more

124 Midwi fery

Possible predictor variables 7~ 2 Probability

Demographic variables Housing tenure (own/rent) Finished full-time education at age 16 (yes/no) Maternal age (< 20 / 20-30 / > 30) d.f. = 2 Ethnic group (white / black Caribbean / black African / other) d.f. = 3 Living with partner (yes/no) Living alone (yes/no)

Obstetric variables Parity (nulliparous/multiparous) Previous pregnancy(ies) difficult (yes/no) Previous births difficult (yes/no)

Maternity care variables Antenatal care in the community (yes/no) GP involved in antenatal care (yes/no) Receiving antenatal care mainly from a midwife (yes/no) Receiving care from a midwifery group practice (yes/no) Saw usual caregiver at at least half of antenatal visits (yes/no) Booked for home delivery (yes/no) Booked antenatal care at > 18 weeks gestation (yes/no) Early participant in trial (yes/no) Encouraged to ask questions at antenatal visits (yes/no) Feels things are explained well at antenatal visits (yes/no) Has caregiver who will sit back and listen (yes/no)

Practical variables Uses public transport to travel to antenatal visits (yes/no) Journey takes > 15 minutes (yes/no) Journey fairly or very difficult (yes/no) Usual waiting time at antenatal visits > 30 minutes (yes/no) Has pre-school children (yes/no) Usually takes children to antenatal visits (yes/no)

Attitudinal variables Initial preference for reduced schedule (yes/no) Expected more antenatal visits (yes/no) Mixed or negative initial feelings about pregnancy (yes/no) Believes antenatal care has enormous influence on baby's health (yes/no) Believes self care has enormous influence on baby's health (yes/no) Sees antenatal care as reassuring (yes/no) Believes good antenatal care guarantees a healthy baby (yes/no) Believes its can be hard for caregivers to spot pregnancy problems (yes/no)

Social support Has partner who will listen (yes/no) Has someone in family who will listen (yes/no) Has friend(s) who will listen (yes/no) Has person at antenatal class who will listen (yes/no) Has no one who will listen (yes/no)

L/fe problems Depressed antenatally (EPDS score < 13 / 13 +) Has some worries about relationship with partner (yes/no) Has some housing worries (yes/no) Has some financial worries (yes/no) Has some worries about employment (yes/no)

5,92 0.015* 0.23 0.635 2.37 0.306 8.13 0.043* 0.37 0.541 0.07 0.792

5.24 0.022* I. 14 0.286 1.48 0.224

0.19 0.662 2.47 0.116 0.20 0.656

# 0.351 0.09 0.76 I 3.38 0.066 0.00 0.987 0.76 0.383

16.77 <0.00 I* 1.80 0.180

21.27 <0.001 *

0.19 0.667 0. I I 0.737 1.67 0.196 0.52 0.47 I 1.86 0.173 0.00 0.985

78.64 < 0.001 * 54.57 <0.001"

0.20 0.656 0.02 0.900 2.35 0.125 1.57 0.21 I 0.28 0.594 0.36 0.549

0.00 1.000 2.17 0.141 0.00 0.962 0.35 0.555 3.06 0.080

16.00 < 0.001 * 1.09 0.296 0.00 0.992 7.26 0.007* 0.14 0.706

* P < 0.05. # Fisher's Exact test used. Degrees of freedom (d.f.) = I, unless otherwise stated.

likely to be living in rented accommodation; to have a caregiver who encouraged them to ask questions and would sit back and listen if they wanted to talk about their pregnancy and their feelings; and to have had an initial preference for reduced sched- ules. They were also less likely to have expected more antenatal visits, and were less likely to be depressed antenatally.

Satisfaction with the traditional schedule

The univariate analysis revealed that 16 predictor variables were significantly associated with satisfac- tion with the traditional schedule (see Table 3). Missing data meant that the sample size for the multivariate analysis was reduced from 962 to 843. The logistic regression analysis revealed that four

Women's satisfaction with traditional and reduced antenatal visit schedules 125

Living in rented accommodation 0.601 O. 182 <0.001 * Ethnic group

other 0.482 white -0.063 0. 150 0.673 black Caribbean -0.276 0.239 0.247 black African 0.302 0.223 0.175

Nulliparous/multiparous 0.164 0.175 0.349 Encouraged to ask questions 0.647 0.217 0.003* Has caregiver who will listen 0.542 0.222 0.015" initial preference for reduced schedule 1.807 0.223 <0.001" Expected more antenatal visits -1.226 0.181 <0.00 I* Depressed antenatally -0.626 0.198 0.002* Has some financial worries -0,135 0.198 0.497 Intercept -0,876 0.466 0.060

* P < 0.05.

variables remained significantly associated with sat-

isfaction with the traditional schedule (see Table 4). Women who were satisfied with the traditional

schedule were more likely to have their general practitioner involved in their antenatal care; to have had an initial preference for the traditional schedule;

and to have had someone in their family who would listen if they wanted to talk. They were less likely to have expected fewer antenatal visits.

The findings of the two logistic regression analy- ses are summarised in Table 5.

DISCUSSION

The finding that the variables which predict satisfac-

tion with reduced schedules are not a mirror image of those which predict satisfaction with the tradi- tional schedule is interesting. Only two variables predicted satisfaction with both types of care. These were initial preferences and initial expectations. It is perhaps not surprising that these variables were

found to be strongly associated with satisfaction with reduced and traditional visit schedules, since previous research has highlighted the importance of

expectations (Porter & MacIntyre 1984), and if pref- erences have some stability over time then they will

inevitably be associated with satisfaction, which is essentially a measure of preference at a later time.

The finding that women who felt encouraged to ask questions and felt that their caregiver would sit back and listen were more likely to be satisfied with reduced schedules supports the notion that improved quality of care can compensate for a decreased quan- tity of care. It refutes the possibility that women will respond to poor quality antenatal care by wanting less of it.

The fact that women who were depressed antena- tally were less likely to be satisfied with reduced schedules suggests that, although frequent antenatal

visits will not make women less depressed (Sikorski et al 1996), depressed women do seem to have

appreciated having frequent opportunities to see their caregiver. This may be because antenatal visits were an important source of social support. It could

be argued that depressed women's dissatisfaction with reduced schedules resulted from their negative mood, rather than anything antenatal care provided. However, this seems unlikely, since, using this argu-

ment, we would expect depressed women in the tra- ditional group to be less satisfied with traditional care, but this was not the case.

Two proxy measures of social class were used in this study, housing tenure and age at finishing full- time education. The former was related to satisfac- tion with visit frequency, but the latter was not. Women living in rented accommodation were more likely to be satisfied with reduced visit schedules

than owner occupiers. If housing tenure is an indica- tor of social class, this would mean that worldng- class women were happier than middle-class women

with reduced antenatal visit schedules. This may have been because the circumstances of their lives made attending for antenatal care more stressful for

women in lower social classes, although difficult life circumstances (financial, housing, employment and relationship worries) were not found to predict satis- faction with the different visit schedules. Another possibility is that women living in rented accommo- dation received a different quality of antenatal care. Further research is needed to clarify this issue. Also,

it is interesting to note that whilst some practitioners advocate more frequent visits for women in lower social classes (Marsh 1985), it appears that these

women may actually be happier with reduced sched- ules than women in higher social classes.

The fact that only one of the proxy measures for

social class was predictive suggests the need for further research into the relationship between dif- ferent measures of social class. In the present study,

there was a statistically significant relationship between housing tenure and age at finishing full- time education (X 2 = 70.14, df = 1, P < 0.001).

However, this relationship was far from perfect, since 57% of women received the same social class

classification (working class or middle class) whichever of the two proxy measures were used, but 43% of women were classified differently by the two proxy measures. This finding casts some doubt on the validity of proxy measures of social class. Consequently, conclusions about the relation- ship between social class and satisfaction with tra- ditional and reduced antenatal visit schedules must be viewed as tentative.

Women whose general practitioner was involved in their antenatal care were more likely to be satis- fied with the traditional antenatal visit schedule than those whose GP was not involved in their care. It may indicate that there is something about the type of care provided by general practitioners which makes women want to see them more often in preg-

126 Midwi fe ry

Possible predictor variables Z 2 Probability

Demographic variables Housing tenure (own/rent) Finished full-time education at age 16 (yes/no) Maternal age (<20 / 20-30 / > 30) d.f. = 2 Ethnic group (white / black Caribbean / black African / other) d.f. = 3 Living with partner (yes/no) Living alone (yes/no)

Obstetric variables Parity (nulliparous/multiparous) Previous pregnancy(ies) difficult (yes/no) Previous births difficult (yes/no)

Maternity care variables Antenatal care in the community (yes/no) GP involved in antenatal care (yes/no) Receiving antenatal care mainly from a midwife (yes/no) Receiving care from a midwifery group practice (yes/no) Saw usual caregiver at at least half of antenatal visits (yes/no) Booked for home delivery (yes/no) Booked antenatal care at > 18 weeks gestation (yes/no) Early participant in trial (yes/no) Encouraged to ask questions at antenatal visits (yes/no) Feels things are explained well at antenatal visits (yes/no) Has caregiver who will sit back and listen (yes/no)

Practical variables Uses public transport to travel to antenatal visits (yes/no) Journey takes > 15 minutes (yes/no) Journey fairly or very difficult (yes/no) Usual waiting time at antenatal visits > 30 minutes (yes/no) Has pre-school children (yes/no) Usually takes children to antenatal visits (yes/no)

Attitudinal variables Initial preference for traditional schedule (yes/no) Expected fewer antenatal visits (yes/no) Mixed or negative initial feelings about pregnancy (yes/no) Believes antenatal care has enormous influence on baby's health (yes/no) Believes self care has enormous influence on baby's health (yes/no) Sees antenatal care as reassuring (yes/no) Believes good antenatal care guarantees a healthy baby (yes/no) Believes its can be hard for caregivers to spot pregnancy problems (yes/no)

Social support Has partner who will listen (yes/no) Has someone in family who will listen (yes/no) Has friend(s) who will listen (yes/no) Has person at antenatal class who will listen (yes/no) Has no one who will listen (yes/no)

Life problems Depressed antenatally (EPDS score < 13 / 13 +) Has some worries about relationship with partner (yes/no) Has some housing worries (yes/no) Has some financial worries (yes/no) Has some worries about employment (yes/no)

3.30 0.069 5.92 0.015*

12.96 0.002* 4.76 0.191 6.35 0.012* 4.08 0.043*

34.21 <0.001" 6.30 0.012* 1.56 0.21 I

0.00 1.000 8.60 0.003* 0. I I 0.739

# 0.712 0.00 1.000 5.66 0.017* 0.48 0.49 I 0.12 0.730 0.95 0.330 0.00 1.000 0.04 0.851

2.36 0.125 0.30 0.585 # 0.559 1.32 0.251

21.02 < 0.001 * 13.90 < 0.001 *

55.29 <0.001" 45.21 <0.001"

1.03 0.310 6.79 0.009* 0.31 0.575 1.07 0.302 5.78 0.016* 4.17 0.041"

0.27 0.603 7.73 0.005* 0.85 0.358 1.88 0.171 0.01 0.937

1.65 0.199 0.06 0.807 0.93 0.336 1.58 0.209 0.70 0.404

* P < 0.05. # Fisher's Exact test used. Degrees of freedom (d.fi) = I, unless otherwise stated.

nancy. Alternatively, perhaps seeing a doctor increases women ' s perceptions of pregnancy as a medical condition, and, as a consequence of this, women feel it is more appropriate to have frequent visits. It is also possible that women are somehow sensing that general practitioners tend to have less enthusiasm for reduced visit schedules than mid- wives (Sikorski et al 1995).

It is unclear why women who had someone in their family who would listen if they wanted to talk

were more likely to be satisfied with the traditional antenatal visit schedule. However, women ' s own mothers, mothers-in-law and sisters are likely to have followed the traditional schedule of antenatal visits during their pregnancies. It is therefore possi- ble that women who talk to their family about their

Women 's satisfaction wi th tradit ional and reduced antenatal visit schedules 127

Finished full-time education at 16 0.491 0.253 0.052 Maternal age - > 30 0.420 - < 20 0.768 0.707 0.278 - 20 to 30 -0.459 0.363 0.206

Living with partner -0.623 0.348 0.074 Living alone (yes/no) 0.153 0.851 0.857 Nulliparous / multiparous -1.066 0.742 O. 15 I Difficulty of previous pregnancy

- missing 0.085 - not difficult -0.257 0.288 0.371 - difficult 0.443 0.310 0.153

GP involved in antenatal care 0.487 0.218 0.026* Booked for home delivery 0.041 0.461 0.929 Has pre-school children -0.099 0.327 0.76 I Usually takes children to antenatal visits -0.034 0.277 0.902 Initial preference for traditional schedule 1.916 0.335 < 0.00 I* Expected fewer antenatal visits -1.337 0.262 <0.001 * Antenatal care has enormous influence 0.509 0.314 0.105 Good antenatal care guarantees a

healthy baby 0.330 0.238 0.166 Hard for caregivers to spot pregnancy

problems -0.299 0.213 0.160 Has someone in family who will listen 0.547 0.212 0.010 * Intercept 3.506 1.369 0.010

* P < 0.05

more likely to live in rented accommodation feel they are encouraged to ask questions at antenatal visits feel their caregiver will sit back and listen if they want to talk have initially preferred reduced antenatal visit schedules

less likely to have expected more antenatal visits be depressed antenatally

W o m e n w h o a r e s a t i s f i e d w i t h t r a d i t i o n a l a n t e n a t a l v is i t s c h e d u l e s a r e :

more likely to have their general practitioner involved in their antenatal care have initially preferred the traditional antenatal visit schedule to have someone in their family who will listen if they want to talk

less likely to have expected fewer antenatal visits

pregnancy may be more likely to see traditional vis- its as the norm and to feel happier experiencing the

same type of care as their relatives. It is interesting that parity was unrelated to satis-

faction with traditional or reduced schedules. The logistic regression analysis showed that multiparous women are no more likely to be satisfied with reduced schedules than first-time mothers. This can perhaps be understood if we consider that antenatal care has three main psychosocial functions: to pro- vide information, social support and reassurance. In general, multiparous women are likely to need less

information than nulliparous women because they have been through the experience of pregnancy and

birth before. However, in terms of social support and reassurance, multiparous and nulliparous women may have similar needs. The stress of being pregnant at the same time as having to care for one or more children may mean that multiparous women feel in

need of social support. Also, the fact that a previous pregnancy has gone well (women who had major problems in a previous pregnancy were excluded

from the trial) does not necessarily mean that the current pregnancy will also have a good outcome, and therefore multiparous women may also feel in

need of regular reassurance. Alternatively, the apparent similarity between

nulliparous and primiparous women may be due to

the nulliparous women in the project being atypical and not representative of all first-time mothers. This is possible since nulliparous women were signifi- cantly more likely than multiparous women to decline to participate in the project (Sikorski et al

1996). Those nulliparous women who did take part might therefore have been the more confident first- time mothers. If the nulliparous women in the pro- ject were atypical, this would hide any real differ-

ence between nulliparous and multiparous women. Finally, it is interesting to note that none of the

practical variables was related to satisfaction with either traditional or reduced schedules of routine antenatal visits. Perhaps this is because women feel any inconvenience and practical difficulties of

attending for antenatal care are offset by the positive

benefits they may receive from it. This research has some implications for mid-

wifery practice. It suggests that it is not possible to identify any obvious groups, such as multiparous women, who would be satisfied with reduced sched- ules. It seems that the situation is more complex than this, and that it will be necessary to talk to women as individuals to find out how often they would like to be seen during pregnancy, and to tailor schedules of

care accordingly. It has highlighted the need to safe- guard the social support offered to women who are

depressed in pregnancy. Antenatal depression is an

important, but neglected phenomenon (Clement 1995), If reduced antenatal visit schedules become the norm, it will be important to ensure that depressed women do not feel alone with their prob- lems. The research also suggests that one way to make reduced schedules more acceptable to women might be to improve the quality of antenatal visits, ensuring, in particular, that caregivers encourage women to ask questions, and are willing and able to sit back and listen when women want to talk about their pregnancies and their feelings.

A C K N O W L E D G E M E N T S

Above all, we would like to thank the women who took part in this research and gave us their views of the care they received. We are also grateful to our secretarial and clerical staff, Maureen Statham and Becky Green, and to the midwives,

128 Midwifery

GPs, obstetricians and administrative staff whose help was invaluable to the running of the Project. The research was funded by the Primary Care Development Fund of South Thames Regional Health Authority.

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