2005 hildingsson

ORIGINAL ARTICLE

Number of antenatal visits and women’sopinionINGEGERD HILDINGSSON

1,2, INGELA RADESTAD2

AND ULLA WALDENSTROM1

From the 1Department of Nursing, Karolinska Institutet, Stockholm, and 2Department of Caring and Public HealthSciences, Malardalens University, Vasteras, Sweden

Acta Obstet Gynecol Scand 2005; 84: 248–254. # Acta Obstet Gynecol Scand 84 2005

Background. The national recommendation in Sweden regarding number of antenatalcare visits was reduced in 1996. The aim of this study was to explore the factors associatedwith number of visits made and with women’s own opinions about these visits. Anotheraim was to study associations between the number of visits and satisfaction with antenatalcare overall.Methods. All Swedish-speaking women who came for their first visit to the midwife in 593participating clinics during 3weeks evenly spread over 1 year in 1999–2000 were invited toparticipate in the study. Information was collected by postal questionnaires after thebooking visit and 2months after childbirth. Cases of preterm delivery and intrauterinedeath were excluded.Results. After excluding miscarriages, non-Swedish-speaking women, and women bookedat non-participating clinics, about 69% of all women booked in antenatal care wererecruited. Of these, 2421 (83%) completed the two questionnaires. About 25% followedthe standard visiting schedule for a normal pregnancy, 57% made more visits, and 17%fewer visits. The number of visits made was associated with parity, medical diagnosis,depressive symptoms, level of education, and women’s preferences in early pregnancy.Women’s own opinion that they made too few visits was associated with a preference formore visits in early pregnancy and actually receiving fewer visits than the standardschedule. The view that they made too many visits was associated with a previous negativebirth experience, a wish for fewer visits, having a medical diagnosis, many children, andmajor worries. The vast majority of women (87.6%) were satisfied with antenatal careoverall but less with emotional (76.9%) than with medical (82.3%) aspects. No associationwas found between number of visits made and satisfaction, but women’s own opinion thatthey had too few visits was associated with dissatisfaction with medical as well as emo-tional aspects of care and the opinion that they made too many visits with the emotionalaspects of care.Conclusion. Two-thirds of the women did not follow the standard visiting schedule, themajority of women made more visits. The number of antenatal visits seemed to be fairly welladapted to women’s individual needs and, to some extent, to their own wishes. Very fewwomen were dissatisfied with the number of visits made as well as the antenatal care overall.

Key words: antenatal care; number of visits; preferences; satisfaction

Submitted 6 February, 2003Accepted 21 April, 2004

What constitutes an optimal number of antenatalcare visits during a normal pregnancy has beendiscussed in many countries over the last decade.In Sweden, the recommended number of visitsto the midwife was reduced in 1996 from 11–13to 8–9 for primiparas and 7–8 for multiparas

(1,2). Recent statistics showed that about 74%of all pregnant women were recommended thestandard visiting schedule in early pregnancy,but only 41% of the primiparas and 39% of themultiparas actually followed it (3). In Norway,where the recommended number of visits is rather

# Acta Obstet Gynecol Scand 84 (2005)

Acta Obstet Gynecol Scand 2005: 84: 248--254 Copyright # Acta Obstet Gynecol Scand 2005

Printed in Denmark. All rights reservedActa Obstetricia et

Gynecologica Scandinavica

similar to the Swedish schedule, a similar discre-pancy between recommended and actual numberof visits was observed (4).A review of seven randomized controlled trials

showed that a reduction in the number of ante-natal visits was not associated with any increase ofadverse maternal and perinatal health outcomes(5). However, trials in developed countriesreported higher rates of maternal dissatisfactionwith a reduced number of visits (5). Research onwomen’s own preferences and factors associatedwith a wish for more or fewer visits is limited. Wehave previously reported that 70% of Swedish-speaking women wanted to follow the recom-mended visiting schedule when asked in earlypregnancy, whereas 23% reported they would pre-fer more visits and 7% fewer visits (6). Wantingmore visits was associated with a traumatic obste-tric history, such as miscarriage, infertility, still-birth, and a negative birth experience; whereas, apreference for fewer visits was associated withbeing older (>35years), multiparity, and unfortun-ate timing of pregnancy. Other Swedish studieshave shown that inadequate antenatal care,defined as late booking (after gestational week16) or making fewer than three visits was morecommon in younger women, women with manychildren, and immigrants (7,8).The aim of this study was to identify maternal

characteristics associated with (1) the number ofantenatal care visits made to a midwife and (2)women’s own opinion regarding number of visitsand (3) to investigate whether the number ofvisits made or the women’s opinion concerningthe number of visits were associated with theiroverall satisfaction with the antenatal care.

Swedish antenatal care

Antenatal care in Sweden is organized in localoutpatient clinics, and the vast majority of theseclinics were public at the time of data collection.According to statistics collected by the SwedishAssociation of Obstetricians and Gynecologists,comprising 80% of all pregnancies in Sweden in2000, the average number of visits by primipar-ous women was 9.3 to a midwife and 1.8 to adoctor and by multiparous women 8.5 to a mid-wife and 1.8 to a doctor (3).

Materials and methods

The study was conducted as a national survey of Swedish-speaking women. The recruitment took place during 3weeksevenly spread over 1 year (1999–2000). Midwives providingantenatal care all over Sweden informed women about thestudy at their first antenatal visit and asked for consent toparticipate in the study. Details of the recruitment have

previously been reported (6). Data were collected by meansof two questionnaires, in early pregnancy and 2monthspostpartum and the Swedish National Birth Register. Thefirst questionnaire asked about women’s socio-demographicbackground, obstetric and medical history, and women’spreferences regarding the number of visits in relation towhat the midwife and/or doctor would recommend (asrecommended, probably fewer than recommended, probablymore than recommended). It also included the EdinburghPostnatal Depression Scale (EPDS) (9), which has beenvalidated in a Swedish context (10), and a Swedish version(11) of the Cambridge Worry Scale (12) including questionsabout common concerns during pregnancy. The secondquestionnaire included questions about different aspects ofcare and care procedures during pregnancy and childbirth.For the purpose of the current study, only the questionsabout number of antenatal visits made to the midwife, andthe doctor, respectively, women’s opinion about these visits(too few, about right, too many), and satisfaction withantenatal care overall were included. Information aboutmedical diagnoses (hypertension, pre-eclampsia, diabetes,intrauterine growth retardation, and twin pregnancies) wasretrieved from the Swedish National Birth Register.Background characteristics of the sample were compared

with data from a 1-year cohort of women giving birth inSweden in 1999, extracted from the Swedish National BirthRegister which includes information on socio-demographicvariables, care procedures, and health outcomes.Statistical analyses were conducted by using SPSS for Win-

dows (SPSS inc. LEAD Technologies, Haddonfield, NewJersey, USA). The number of antenatal visits was categor-ized according to the national recommendations for primi-paras and multiparas (2). Comparisons were made betweenwomen who made fewer visits! 1 versus those who followedthe standard visiting schedule! 0 and between women whomade more visits! 1 versus those who followed the standardschedule! 0. Women’s opinion regarding number of visitswas dichotomized in the same way: number of visits toofew! 1 versus number of visits about right! 0 and numberof visits too many! 1 versus about right! 0. The cut-offpoint for the EPDS was set at 14/15, as suggested when usedduring pregnancy (13). Each of the 16 items of the 5-pointCambridge Worry Scale was dichotomized into minor (0–3)and major (4–5) worries. The dichotomized items were thenadded and classified into four groups (no major worry, 1–2major worries, 3–4 major worries, and 5 or more majorworries). Satisfaction with care was measured on a 5-pointscale ranging from ‘very satisfied’ to ‘very dissatisfied’. Thescale was dichotomized into ‘satisfied’ (very satis-fied" rather satisfied" neither satisfied nor dissatisfied)and ‘dissatisfied’ (rather dissatisfied" very dissatisfied).Bivariable comparisons were made between each explana-tory variable and number of visits made and women’s opi-nion about number of visits, respectively, according toMantel-Haenszel (14). In order to find out which factorscontributed most to the variance, all statistically significantvariables from the bivariable analysis were included in alogistic regression model.The study was approved by the Regional Research and

Ethical Committee at Karolinska Institutet, Sweden (Dnr98-358).

Results

Of all the 608 antenatal clinics in Sweden operat-ing at the time of recruitment, 593 chose to partici-pate in the study. Based on figures from theSwedish National Birth Register, approximately

Antenatal visits and women’s opinion 249


5500 women booked for antenatal care duringthe 3 recruitment weeks, and 4259 were eligiblefor this study after the exclusion of miscarriages(275), non-Swedish speaking women (550),women from 15 non-participating clinics (75),and 341 women who were excluded because of apreterm delivery (<38weeks), perinatal death ormissing information in the National Birth Regis-ter. Of the 2952 (69%) women who consented toparticipate in this study, 2421 filled in both thequestionnaires (83% of those who consented toparticipate and 57% of all women eligible).

Socio-demographic characteristics

The women were on average 29.4 years (range15–46) at recruitment, and the proportion of pri-miparas was 43.4% (n! 1050) and multiparas56.6% (n! 1371). The sample characteristicswere similar to those of the 1-year cohort of allwomen giving birth in Sweden in 1999 regardingprimiparity (43% versus 44%), mean age(29.4 years versus 29.5 years), and marital status(95% versus 95% being married/cohabiting). Themain difference was country of birth (90% versus83% born in Sweden), which is explained by theexclusion of non-Swedish speaking women in thecurrent study (6).

Number of visits and satisfaction with number ofvisits made

The primiparas reported on average 11.1 visits tothe midwife [standard deviation (SD) 4.5] and themultiparas 9.2 visits (SD 3.6). More than half(57%) of the women saw the midwife more oftenthan specified in the standard visiting schedulefor a normal pregnancy, whereas a minority(17%) saw the midwife less often. The majorityof women were satisfied with the number of visitsto the midwife (87%), and more women thoughtthey made too few visits (11%) than too many(2%). The mean number of visits to the doctorwas 2.9 in primiparas (SD 3.0) and 2.7 in multi-paras (SD 2.9). The majority was satisfied withthe number of visits to the doctor (79%), but 13%said they had too few visits and 4% too many.

Factors associated with number of visits made

Table I shows the distribution of the number ofvisits made to the midwife during pregnancyin relation to explanatory variables, such aswomen’s socio-demographic background, obste-tric history, having a medical diagnosis, emo-tional well-being, and preferences regarding

number of visits in early pregnancy. The bivari-able analyses showed that making fewer visitswas only associated with high educational level.The logistic regression analysis did not contributeto any additional information. Making morevisits than the standard schedule was associatedwith: primiparity, age less than 25 years, having amedical diagnosis, depressive symptoms, andhaving five or more major worries. Women whopreferred fewer visits had a decreased risk ofsubsequently having more visits than the stand-ard schedule. In the logistic regression model, thefollowing variables remained: having a medicaldiagnosis [odds ratio (OR) 2.7; 1.8–3.8], a wishfor fewer visits (OR 0.4; 0.3–0.6), primiparity(OR 1.6; 1.3–1.9), five or more major worries(OR 1.6; 1.0–2.7), and depressive symptoms(OR 1.5; 1.0–2.4). Age <25 years was no longerstatistically significant.

Factors associated with women’s own opinionabout number of visits made

The same explanatory variables as listed inTable I, with the addition of number of visitsmade (fewer or more than standard schedule oras standard schedule), were analyzed in relationto women’s opinions about number of visits.Women who had the opinion that the number

of visits was too few were more likely to be multi-paras, and they were more worried in early preg-nancy. The higher the number of major worries,the greater the risk of finding the number of visitstoo few. A preference for more visits in earlypregnancy and having made fewer visits thanthe standard schedule were also associated withthe opinion that the visits were too few. Whenthese factors were taken into account in the logis-tic regression analysis, the following remainedstatistically significant: a preference for morevisits in early pregnancy (OR 4.6; 3.5–6.2), andsubsequently making fewer visits than thestandard schedule (OR 1.6; 1.1–2.4). A preferencefor fewer visits during pregnancy (OR 0.1; 0.1–0.5)and making more visits than the standard schedule(OR 0.5; 0.4–0.8) reduced the risk of finding thenumber of visits too few. Multiparity and majorworries did not contribute to the final model.The opposite view, assessing that the number

of visits were too many, was associated withhaving many children, not being born in Sweden,low educational level, having a medical diag-nosis, a previous negative birth experience, andanxiety (five or more major worries), and a pre-ference for fewer visits in early pregnancy. In thelogistic regression analysis, the following factors

250 I. Hildingsson et al.


TableI.Num

bero

fantenatalvisits

Madefewer

visits

visitingschedule

n!393(17.4%

)[n

(%)]

Followed

the

standard

schedule

n!568(25.1%

)[n

(%)]

Mademorevisitsthan

instandard

schedule

n!1298

(57.4%

)[n

(%)]

ORforfewer

visits

versus

standard

(95%

CI)

ORformorevisits

versus

standard

(95%

CI)

Parity

Primiparas

132(33.6)

205(36.1)

632(48.7)

0.9(0.8–1.1)

1.7(1.1–1.2)

Multiparas

261(66.4)

363(63.9)

666(51.3)

1.0(Ref.)

1.0(Ref.)

Num

berof

previous

children

One

child

165(64.2)

227(63.9)

437(67.1)

1.0(Ref.)

1.0(Ref.)

Twochildren

69(26.8)

101(28.5)

169(26.0)

0.9(0.6–1.3)

0.9(0.8–1.1)

Threeor

morechildren

23(8.9)

27(7.6)

45(6.9)

1.2(0.6–2.1)

0.9(0.5–1.4)

Agegroups

<25

54(14.0)

96(17.1)

302(23.6)

0.8(0.5–1.1)

1.4(1.1–1.8)

25–35

282(73.0)

402(71.8)

873(68.3)

1.0(Ref.)

1.0(Ref.)

>35

50(13.0)

62(11.1)

103(8.1)

1.1(0.8–1.7)

0.8(0.5–1.1)

Singlestatus

13(3.5)

18(3.5)

53(4.3)

1.0(0.5–2.1)

1.3(0.7–2.2)

Married/cohabiting

354(96.5)

502(96.5)

1171

(95.7)

1.0(Ref.)

1.0(Ref.)

Not

born

inSw

eden

38(9.7)

47(8.3)

112(8.6)

1.2(0.8–1.9)

1.0(0.7–1.5)

Born

inSw

eden

355(90.3)

521(91.7)

1186

(91.4)

1.0(Ref.)

1.0(Ref.)

Educationallevel

Low

11(3.1)

24(4.6)

67(5.8)

0.8(0.4–1.6)

1.5(0.9–2.4)

Middle

179(50.9)

303(57.9)

659(5.9)

1.0(Ref.)

1.0(Ref.)

High

162(46.0)

196(37.5)

433(37.4)

1.4(1.1–1.8)

1.0(0.8–1.3)

Residentialarea

Largecity

96(25.2)

153(27.5)

332(26.3)

1.0(Ref.)

1.0(Ref.)

Middle-sizedcity

81(21.2)

115(20.6)

230(18.2)

1.1(0.8–1.6)

0.9(0.9–1.1)

Smallcity

78(20.5)

118(21.2)

280(22.2)

1.0(0.7–1.5)

1.1(0.8–1.4)

Ruralarea

126(33.1)

171(30.7)

421(33.3)

1.2(0.8–1.6)

1.1(0.9–1.5)

Smokinginearly

pregnancy

36(9.4)

52(9.3)

128(10.1)

1.0(0.6–1.6)

1.1(0.8–1.5)

Not

smokinginearly

pregnancy

345(90.6)

505(90.7)

1142

(89.9)

1.0(Ref.)

1.0(Ref.)



TableI.Co

ntinued

Madefewer

visits

visitingschedule

n!393(17.4%

)[n

(%)]

Followed

the

standard

schedule

n!568(25.1%

)[n

(%)]

Mademorevisitsthan

instandard

schedule

n!1298

(57.4%

)[n

(%)]

ORforfewer

visits

versus

standard

(95%

CI)

ORformorevisits

versus

standard

(95%

CI)

Medicaldiagnosis

24(6.1)

39(6.9)

224(17.3)

0.9(0.5–1.5)

2.8(2.0–4.0)

Nomedicaldiagnosis

369(93.9)

529(93.1)

1074

(82.7)

1.0(Ref.)

1.0(Ref.)

Previous

miscarriage

92(23.4)

122(21.5)

257(19.8)

1.1(0.8–1.5)

0.9(0.7–1.1)

Noprevious

miscarriage

301(76.6)

446(78.5)

1041

(80.2)

1.0(Ref.)

1.0(Ref.)

Previous

stillbirth

4(1.5)

3(0.8)

13(1.9)

1.9(0.4–8.4)

2.4(0.7–8.4)

Noprevious

stillbirth

257(98.5)

360(99.2)

653(98.1)

1.0(Ref.)

1.0(Ref.)

Previous

birthexperience

Positive

155(60.5)

223(62.5)

375(57.8)

1.0(Ref.)

1.0(Ref.)

Mixed

feelings

62(24.2)

77(21.6)

164(25.3)

1.1(0.8–1.7)

1.3(0.9–1.7)

Negative

39(5.8)

57(15.9)

110(16.9)

1.0(0.6–1.5)

1.1(0.8–1.6)

Pregnancyless

welcome

19(5.4)

28(5.3)

57(4.9)

1.0(0.5–1.8)

0.9(0.6–1.4)

Pregnancywelcome

336(94.6)

498(94.7)

1106

(95.1)

1.0(Ref.)

1.0(Ref.)

Depressivesymptom

sinearly

pregnancy

20(5.2)

28(5.0)

106(8.3)

1.0(0.6–1.9)

1.7(1.1–2.6)

Nodepressive

symptom

sinearly

pregnancy

366(94.8)

532(95.0)

1172

(91.7)

1.0(Ref.)

1.0(Ref.)

Cambridge

Worry

Scale

Noworries

181(46.9)

254(47.1)

537(42.0)

1.0(Ref.)

1.0(Ref.)

1–2major

worries

137(35.5)

194(34.6)

451(35.3)

1.0(0.7–1.3)

1.1(0.9–1.4)

3–4major

worries

45(11.7)

79(14.1)

202(15.8)

0.8(0.5–1.2)

1.2(0.9–1.6)

5or

moremajor

worries

23(6.0)

23(4.1)

88(6.9)

1.4(0.8–2.6)

1.8(1.1–2.9)

Preferencesinearly

pregnancy

Fewer

visits

35(9.1)

60(10.7)

58(4.6)

0.8(0.5–1.3)

0.4(0.3–0.6)

Standard

visitingschedule

275(71.6)

393(70.2)

914(71.8)

1.0(Ref.)

1.0(Ref.)

Morevisits

74(19.3)

107(19.1)

301(23.6)

1.0(0.7–1.4)

1.2(0.9–1.5)

OR,o

ddsratio;C

I,confidence

intervals;Ref.reference

cattegory.



remained statistically significant: a negative birthexperience (OR 10.3; 2.9–36.2), a wish to havefewer visits (OR 9.8; 3.0–31.5), having a medicaldiagnosis (OR 4.8; 1.6–14.3), three or more pre-vious children (OR 4.4; 1.3–15.7), and five ormore major worries (OR 6.2; 1.4–11.6). Whenprimiparas were analyzed separately, only prefer-ence for fewer visits was statistically significant(OR 6.5; 2.2–19.2).

Overall satisfaction with antenatal care

Only 1.5% of the women were dissatisfied withantenatal care overall, 3% with the medicalaspects, and 4% with the emotional aspects.Women rated the medical aspects of care morepositively than the emotional aspects. Therewas no association between the actual numberof visits women made and satisfaction. However,women who were dissatisfied with the numberof visits were less satisfied with antenatal careoverall, especially if they felt the number of visitswere too few.

Discussion

Data on number of antenatal visits in this studywere based on women’s recall at 2months afterthe birth. Primiparas reported 11.1 visits to amidwife and 2.9 to a doctor, and multiparas 9.2and 2.9, respectively. The Swedish National BirthRegister which includes information on the totalnumber of antenatal visits collapses visits to mid-wives and doctors; and according to this register,which included 94% of the current sample, ourprimiparas made on average 11.3 visits and multi-paras 10.7 visits. These figures are very close tothose reported by the Swedish Association ofObstetricians and Gynecologists (3). One explan-ation of the larger number of visits reported inthis study could be that women may havereported some visits twice, because they also metthe midwife during the medical check-up with thedoctor. We do not believe that this overestima-tion of the number of visits to the midwife alteredthe major findings of this study. We acknowledgethat it may be difficult to remember the exactnumber of visits in retrospect, even if studies ofmaternal recall of events around childbirth sug-gest that their memories are fairly accurate andthat medical records are not necessarily betterthan women’s own reports (15–17).In this study, only 25% of the women followed

the recommended visiting schedule for a normalpregnancy, and this is 15% less that reported byrecent national statistics (3). Initially, our samplewas fairly representative for all pregnant women

in Sweden, with the exception of native language.The exclusion of preterm deliveries and adverseoutcomes, such as perinatal deaths, made thesample more low-risk. However, we cannotfrom our data exactly estimate the proportion ofwomen who were at low-risk and thereforeshould have followed the standard visiting sched-ule, but we know that 17.2% of the primiparasand 9.6% of the multiparas had a medical diag-nosis, either at onset of pregnancy or during itscourse, which would have been associated withmore visits.Our finding about the actual number of visits

differs significantly from our previously reporteddata on women’s expectations which showed that70% of the women wanted to follow the recom-mended visiting schedule when asked in earlypregnancy, whereas 23% said they would prob-ably prefer more visits and 7% fewer visits (6).This discrepancy may be explained by the diffi-culty of anticipating the appropriate number ofvisits in early pregnancy, especially when expect-ing the first baby. The fact that only 13% of thewomen were dissatisfied with the number of visits(too few 11% and too many 2%) at 2 months afterbirth suggests that their expectations in earlypregnancy were less important for this outcome.The number of antenatal visits seemed to be

reasonably well adapted to women’s individualneeds, as first-time mothers and women with amedical diagnosis made more visits than the stand-ard schedule. Also women with major worriesand depressive symptoms in early pregnancymade more visits, suggesting that women’s emo-tional well-being was taken into account, which isin line with the national recommendations (2).Women’s own preferences regarding the numberof visits were also considered. Making fewer visitswas associated with high education, suggestingthat the care was not biased by favoring morevocal consumer groups.A surprising finding of this study was that a

previous negative birth experience and maternalanxiety were associated with the view that num-ber of antenatal visits was too many. One expla-nation of this finding may be that antenatal carewas not sensitive enough to these women’s needs,a problem that would not be solved by offeringmore visits. This interpretation is supported by astudy which showed that one of the predictors ofnegative birth experience was insufficient timeallocated to women’s own questions at theantenatal visits (18) and the finding that a nega-tive experience of the latest birth was associatedwith a wish for more visits when asked in earlypregnancy (6). Another explanation may be ablunting coping style. Two main psychological



coping styles have been identified when a personis faced with potentially threatening information:monitoring (attending to) and blunting (avoid-ing) (19). Women may have preferred avoidingthe antenatal visits because they triggered theirfear of the approaching birth.

Conclusions

The majority of the women made more visits thanrecommended in the standard schedule for a nor-mal pregnancy. The number of antenatal visitsseemed to be fairly well adapted to women’s indi-vidual needs and, to some extent, to their ownwishes. The majority of women were satisfiedwith number of visits made as well as antenatalcare overall. The actual number of visits did notaffect satisfaction but affected women’s opinionabout the visits.

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Address for correspondence:Ingegerd HildingssonGamla Karlebyvagen 22 ES-87133 HarnosandSwedene-mail: [email protected]



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