LETTERS
Tailoring antenatal visits: quality over quantity
Marge Berer
Editor, Reproductive Health Matters, 444 Highgate Studios, 5379 Highgate Road, London NW5 1TL, England (email: RHMjournal@compuserve.com)
Editor The article by Lumbiganon et al. (1), which describes Thailand's decision to reduce the number of antenatal visits from approximately eight to five, based on evidence gathered by WHO (2) that fewer visits have no adverse consequences for the woman or her baby, raises several points that require clarification.
First, the article reports that in the original research: "Some women in the studies, especially those in developed countries, expressed dissatisfaction with the reduced number of visits." For Thailand too, Lumbiganon et al. state: "… some women were concerned about the long intervals between visits, particularly women who had been pregnant before and who were familiar with having shorter intervals".
A qualitative study among women and providers of the new model also found some dissatisfaction with fewer visits, including among women and providers in Thailand, but again, few details are offered (3). This raises questions about the nature of women's dissatisfaction with fewer visits and whether pregnant women need more than medical attention from antenatal care. One of the main goals of the new model is to strengthen the information component within fewer visits; however, perhaps this component has not been improved adequately. Perhaps women also want to be able to ask questions more frequently related to the pregnancy and delivery; perhaps they want reassurance that everything is all right or advice on whether something they are experiencing is reason for concern. In the paper by Lumbiganon et al., there were no qualitative data from interviews with the women themselves. There was almost no description of the nature of the women's dissatisfaction, how it could be resolved or how to ensure that the women's informational and other non-biomedical needs could be met in fewer visits.
Second, while the original research notes that in cases of illness or complications an increased number of visits may be required, the paper by Lumbiganon et al. does not mention whether the number of visits recommended will be influenced by the presence of HIV in pregnancy. In Thailand and many other countries, pregnant women are tested for HIV early in pregnancy and should be counselled. If they are HIV-positive and have low immune status they will require antiretroviral drugs throughout pregnancy; or, if their immune status is still high enough, they will require antiretroviral drugs in the latter stages of pregnancy and at delivery to reduce perinatal HIV transmission. In Thailand, women are advised not to breastfeed and should be counselled on how to feed their babies safely. Will this not affect the number and timing of visits and if so, how? 
Conflicts of interest: none declared.
References
1. Lumbiganon P, Winiyakul N, Chongsomchai C, Chaisiri K. From research to practice: the example of antenatal care in Thailand. Bulletin of the World Health Organization 2004;82:746-9.
2. Villar J, Ba'aqeel H, Piaggio G, Lumbiganon P, Miguel Belizan J, et al. WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care. Lancet 2001;357:1551-64.
3. Langer A, Villar J, Romero M, Nigenda G, Piaggio G, Kuchaisit C, et al. Are women and providers satisfied with antenatal care? Views on a standard and a simplified, evidence-based model of care in four developing countries. BMC Women's Health 2002;2:7.
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