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Knowledge of family planning and the levonorgestrel intrauterine system

patient was the most popular, followed by mother and then pregnant woman, but definitely not client, consumer or customer. Perhaps sensitivity to women’s wishes concerning the manner of their address is the first step to resolving tensions in antenatal care. Another area which has been inadequately researched is women’s expectations of antenatal care. This was studied by David Jewell and his colleagues (pages 1237-1240) as a prelude to a randomised trial of flexible and traditional antenatal care. There was moderate agreement with the statement that ‘Pregnancy was a normal event’, but also moderate agreement that ‘Pregnancy is an event entailing risk’. The women felt that the health of their infant was largely governed by the way they looked after themselves in pregnancy and less by antenatal care or by the effect of chance. They regarded wanting reassurance as the most important element of antenatal care, followed by the opportunity to ask questions and to talk about worries. Women who planned their pregnancy were more likely to prefer traditional antenatal care. Previous randomised trials of reduced antenatal visits have shown no difference in obstetric or perinatal outcome but dissatisfaction with the reduced schedule due to a perception of not being looked after properly. Jewell and colleagues (pages 1241-1247) suggest that the reduced schedule in these trials was too strict, and tested the hypothesis that a flexible pattern of antenatal care allowing the woman to determine her own number of antenatal visits above a minimum would result in no loss of satisfaction. With the flexible arrangement the number of visits were reduced and the maximum number of weeks between visits increased, with greater continuity of antenatal care. There was no difference in the degree of satisfaction with care provided by general practitioners and hospital doctors, but less satisfaction with care provided by midwives, compared with traditional care. Small for gestational age was suspected more often in the flexible care group. The women may have been unable to adapt to the extra responsibility of determining the pattern of their antenatal care, despite being worried about complications of pregnancy which may have passed unrecognised in the long interval between visits. During the flexible schedule the women may have been more reassured by visits to general practitioners and hospital obstetricians rather than midwives, whom they may regard as less able to identify complications of pregnancy. On the other hand, the anxiety felt by midwives, general practitioners and hospital obstetricians with the flexible schedule may have conveyed itself to the women, resulting in less reassurance; evidence for this notion is that twice as many women were thought to be small for gestational age with flexible care. The truth is that we really do not know what women want from antenatal care. Probably we should not carry out any more randomised trials of reduced schedules of antenatal care, for the differences are likely to be marginal. What is certain is that serious medical complications are rare, anxiety is common. The conceptual conflict between pregnancy as a potential illness and pregnancy as a natural phenomenon is no longer relevant. Research in antenatal care must be more fundamental; there should be qualitative research in a variety of settings to understand women’s whole experience of pregnancy and its attendant anxieties. We can make a start by addressing pregnant women in the manner they desire.