Reviewer's□report 
□ARE□WOMEN□AND□PROVIDERS□SATISFIED□WITH□ANTENATAL□CARE?□Views□on□a□standard□ Title: 
and□a□simplified,□evidence-based□model□of□care□in□four□developing□countries 
Authors: 
Ana□Langer□( alanger@popcouncil.org.mx )
Mariana□Romero□( mromero@cedes.org )
Gustavo□Nigenda□( gnigenda@funsalud.org.mx )
Chusri□Kuchaisit□( CHUSRI-K@medlib2.kku.ac.th )
Georgina□Rojas□( rojas@infomed.sld.cu )
Muneera□Al□Osimi□( mun16@hotmail.com )
Jose□Villar□( villarj@who.ch )
Gilda□Piaggio□( piaggiog@who.ch )
Jose□Belizan□( belizanj@clap.ops-oms.org )
Ubaldo□Farnot□( farnot@infomed.sld.cu )
Yagob□Al-Mazrou□( yalmazrou@hotmail.com )
Guillermo□Carroli□( gcarroli@crep.org.ar )
Hassan□Ba'aqeel□( hassanbaaqeel@hotmail.com )
Pisake□Lumbiganon□( pisake@kk1.kku.ac.th )
Alan□Pinol□( pinola@who.ch )
Per□Bergsjo□( p-bergsj@online.no )
Leiv□Bakketeig□( arosenkrantz@health.sdu.dk )
Jo□Garcia□( jo.garcia@perinat.ox.ac.uk )
□1□ □24□May□2002 Version: Date: 
□Dr□A□Handler Reviewer: 
□not□specified Level□of□interest: 
□Other□(see□below) Advice□on□publication: 
This□study□assessed□women's□and□provider's□satisfaction□with□a□new□evidence-based□prenatal□care□ 
model.□This□assessment□was□part□of□a□larger□randomized□WHO□trial□of□"new"□antenatal□care□(i.e.,□fewer□ visits□with□longer□spacing□between□them□as□well□as□other□changes)□versus□standard□antenatal□care□ 
offered□in□each□of□four□countries.□The□major□result□of□this□study□was□that□women□in□the□new□model□of□ 
prenatal□care□were□generally□as□satisfied□as□women□receiving□standard□care.□Providers□in□the□ experimental□arm□were□concerned□about□visit□spacing,□but□were□also□more□satisfied□with□the□time□and□ information□provided.□ 
The□authors□conclusions□seem□reasonable□given□their□methods□and□approach.□The□major□concern□with□ 
this□study□is□that□it□does□not□recognize□or□build□on□the□work□of□prior□studies□of□satisfaction□with□health□ care□in□general□(i.e.□the□work□of□John□Ware□and□colleagues)□or□many□of□the□studies□of□satisfaction□with□ prenatal□care□(while□a□few□articles□are□referenced□from□this□area,□most□are□not).□The□methods□used□to□ 
measure□satisfaction□have□evolved□such□that□current□satisfaction□researchers□tend□to□use□measures□ 
which□do□not□include□the□words□"are□you□satisfied"□in□the□item□stem□or□"very□satisfied□to□very□dissatisfied"□ 
in□the□response.□In□this□study,□the□authors'□use□"are□you□satisfied□with□the□antenatal□care□you□have□ 
received?"□as□their□general□satisfaction□question.□In□addition,□they□do□not□provide□any□details□about□the□ 
item□stems□or□response□categories□for□the□majority□of□specific□satisfaction□questions□included□in□the□ questionnaires□for□the□providers□or□the□women.□While□the□researchers□cannot□redo□their□study□using□ measures□more□in□keeping□with□the□current□satisfaction□literature,□it□would□be□helpful□to□know□how□the□ 
specific□satisfaction□questions□were□asked□(provision□of□questions□in□a□table□or□appendix□would□be□ 
helpful)□and□the□response□categories□used.□It□would□then□be□useful□for□the□authors□to□critique□the□ 
weakness□of□their□measures□compared□to□more□standard□current□approaches□(e.g.,□acquiescence□bias).□ 
The□authors□make□one□statement□about□courtesy□bias,□but□this□critique□is□discussed□in□the□context□of□ 
using□questionnaires□versus□using□qualitative□methods.□This□critique□instead,□should□be□part□of□a□ 
discussion□of□the□other□methods□currently□in□use□for□developing□satisfaction□questions.□ 
Another□concern□is□that□the□authors□do□not□address□the□issue□of□selection.□Patients□were□interviewed□at□ 
32□weeks□gestation□and□were□at□their□second□or□subsequent□visit□for□prenatal□care.□What□do□we□know□ 
about□the□women□who□dropped□out□of□care?□Was□the□rate□of□drop-out□different□in□the□two□arms□or□were□ 
there□no□drop-outs□in□either□arm?□Are□the□women□interviewed□at□32□weeks□gestation,□the□most□satisfied□ 
women?□Could□this□explain□the□very□high□satisfaction□rates□in□both□groups?□ 
The□analysis□might□also□be□strengthened□by□understanding□what□factors□contribute□to□women's□ 
satisfaction□(in□each□country),□independent□of□women's□personal□characteristics.□The□authors□might□ 
consider□conducting□multivariable□analysis:□what□are□the□characteristics□of□care□(e.g.,□number□of□visits,□ 
waiting□time□to□see□a□doctor□or□midwife,□time□spent□with□the□provider)□that□affect□women's□satisfaction?□ 
Finally,□the□discussion□section□should□make□reference□to□the□numerous□satisfaction□with□prenatal□care□ 
articles□that□examine□characteristics□(e.g.,□time□spent□with□the□provider,□information□received□)□and□ 
discuss□how□the□authors'□findings□support□or□do□not□support□prior□findings.□ 
Competing□interests: 
None□declared.