The views and anticipated needs of women in early pregnancy


Correspondence: Dr D. Jewell, Division of Primary Health Care, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK.


Objective To assess the expectations of antenatal care of pregnant women at the outset of pregnancy.

Design Questionnaire study within a randomised controlled trial, comparing traditional antenatal care with a more flexible schedule.

Setting Eleven primary care centres providing midwifery care in Avon.

Population Five hundred and ninety-three pregnant women at low risk of obstetric complications presenting for antenatal care.

Methods A questionnaire was completed by women who agreed to participate in the trial shortly after antenatal booking. The questionnaire explored women's views on their attitudes to pregnancy and antenatal care, the locus of control related to pregnancy, the planning of the pregnancy and expectations of care.

Main outcome measures Comparisons between nulliparous and multiparous women in terms of their views of antenatal care, and their stated preference for a particular package of care.

Results There was no difference in their views of pregnancy as an event entailing risk. On a locus of control scale that measured women's perceptions of factors which might affect their babies’ health, nulliparous women rated antenatal care higher than multiparous women (P= 0.0001). However, this was not associated with any difference between the two groups in their stated preference for traditional or flexible care. Approximately half of the women expressed no preference, and of those who did 61% would opt for traditional care. Almost one-fifth of the whole sample welcomed the idea of flexible care.

Discussion These data support the evidence of previous studies that there remains a strong desire among pregnant women to receive a ‘traditional’ pattern of care, even among those who have previously experienced normal pregnancy. However, a minority can be identified at the outset of pregnancy who may welcome a change to a more flexible pattern of care.


The Bristol Antenatal Care Study is a randomised controlled trial comparing traditional and flexible patterns of antenatal care among women at low obstetric risk. The flexible pattern consisted of a minimum number of prescribed visits, with additional visits timed according to the preference of the woman. The main purpose of the study was to measure the change in maternal satisfaction associated with a more flexible approach to antenatal care. Full details of the trial are given in the accompanying paper1.

One prior assumption was that some women would feel confident enough at booking to opt for slightly less antenatal care. For instance, parous women with a history of normal pregnancy may find it more acceptable than nulliparous women to attend for fewer antenatal visits. Thus, women who are likely to need less intensive care could be identified at booking, allowing them to plan a reduced package of care with health professionals. This paper reports on the expectations of pregnancy and antenatal care that women report at booking.


Details of centres, inclusion, recruitment and randomisation are given in the accompanying paper1. Women participating in the trial were asked to complete a questionnaire within one week of recruitment. The questionnaire covered the following areas:

  • 1Basic demographic information: age, occupation, educational achievement, employment and marital status.
  • 2Women's attitudes to pregnancy and antenatal care, in terms of risk, were assessed by means of a scale devised by Schuman and Marteau2. The scale measures attitudes to pregnancy on two subscales, one relating to ‘pregnancy as an event entailing risk’, and the other to ‘pregnancy as a normal event’. Each subscale scores within a range of 3–18, with 3 denoting maximum disagreement and 18 maximum agreement.
  • 3A locus of control scale3. This is an adaptation from a previous scale assessing the extent to which individuals feel that their health is governed by themselves (internal locus), external factors, or chance4. The scale specific to pregnancy measures women's perceptions of what will influence their baby's health. The subscales are: ‘the way you look after yourself in pregnancy’(internal factors); ‘the antenatal care you receive’ (external factors); ‘luck, chance or fate’ (chance); or ‘God’. Each subscale was scored between 0 (no influence at all) and 5 (enormous influence).
  • 4Feelings about pregnancy. All women were asked whether or not the pregnancy was planned and parous women were asked to describe, in free text, any problems they had had in previous pregnancies.
  • 5Expectations of care and carers in this pregnancy. Women were asked to rate, on a scale of 1 to 5, the importance of different elements of antenatal care: ‘wanting reassurance’, ‘an opportunity to talk about worries’, ‘an opportunity to ask questions’ and ‘time to talk about labour and the birth’. As far as their participation in this study was concerned, they were asked whether they had a preference for one study group, and if so, which one. They were also asked how well they thought their general practitioner knew them and with whom they could discuss their feelings during pregnancy.

Data analysis

The principal comparison made, was between nulliparous and parous women in terms of their scores on the attitudinal scales and their stated preference for care. The χ2 test was used for categorical variables and Wilcoxon's test for unpaired samples for analyses involving scale scores. Because of the large number of tests, a 1% significance level was chosen. Data were analysed using SPSS for Windows.


Five hundred and ninety-three women formed the cohort of women eligible to return completed questionnaires and 562 of these completed them (92% of those who agreed to participate).

The characteristics of the sample are shown in the accompanying paper1. The data suggest that this was a predominantly privileged sample: the majority were living with their partners, were in employment and were nonsmokers. However, the limited amount of data describing the pregnant women in one of the NHS Trusts (Southmead) suggests that the study population is broadly representative.

Attitudes to pregnancy

Mean scores for the whole sample were 11.3 on the ‘pregnancy as a normal event’ scale and 11.2 on the ‘pregnancy as a risky event’ scale. There was no difference between scores for nulliparous or parous women on either scale (‘pregnancy as a normal event’P= 0.98; ‘pregnancy as a risky event’P= 0.85).

‘The way you look after yourself in pregnancy’(i.e. internal control) was felt to have greatest influence by both nulliparous and parous women, with mean scores of 4.7 for nulliparous women and 4.6 for parous women (P= 0.27). Antenatal care (i.e. external control) was viewed as the next most important influence. Nulliparous women felt that this would have a greater influence on their pregnancy outcome than parous women, mean scores 3.4 and 3.0, respectively (P= 0.0001). Chance or fate was deemed to be less important with mean scores of 2.2 and 2.4, respectively, for nulliparous and parous women (P= 0.38). ‘God’ was viewed as having least influence, with mean scores 1.5 and 1.4, respectively (P= 0.43).

The question about planning the pregnancy allowed four responses: hoping to become pregnant as soon as possible; hoping to become pregnant, but not as soon as they did; not hoping to become pregnant; and unsure how they felt. The results are shown in Table 1. More parous women (66.3%) than nulliparous (56.2%) had been hoping to become pregnant as ‘soon as possible’. More nulliparous women (70 [30%]), than parous, (54 [17.8%]) reported that they were ‘hoping to become pregnant, but not as soon as they did’. There were more parous women than nulliparous not sure or hoping not to become pregnant (χ2= 11.1, df 3, P= 0.01).

Table 1.  Planning of pregnancies. Were you hoping to become pregnant? Values are given as n or n (%).
 Nulliparous womenParous womenTOTAL
  1. χ2= 11.1; df 3; P= 0.01.

Yes, as soon as possible131 (56.2)201 (66.3)332 (61.9)
Not just yet70 (30.0)54 (17.8)124 (23.1)
No23 (9.9)34 (11.2)57 (10.6)
Unsure9 (3.9)14 (4.6)23 (4.3)

Out of a maximum of 5, scores on the different items for what women wanted to get out of their antenatal care were as follows: ‘wanting reassurance’(4.8); ‘an opportunity to talk about worries’(4.4); ‘an opportunity to ask questions’(4.4). There were no differences between nulliparous and parous women. However, ‘time to talk about labour and the birth’ was rated more important by nulliparous than by parous women (mean scores 4.3 and 3.8, P < 0.001).

When asked what pattern of care they had hoped they would receive (traditional or flexible), 267 (47.5%) reported that they did not have a preference. Nulliparous women were less likely to express a preference than parous women (55% not having a preference vs 46% of parous women; P < 0.01). Unfortunately, the study design did not allow this question to be asked before women were actually randomised, and Table 2 shows that there is a strong influence (among those who expressed a preference) of women stating a preference for their allocated group. Of the 268 women who did express a preference, 164 (61%) preferred traditional care. There was no significant difference (at the 1% level) between the numbers of nulliparous and parous women preferring traditional care (56% of nulliparous women expressing a preference, compared with 69% of parous women, P= 0.03).

Table 2.  Preference for care type. Which group did you hope to join? Values are given as n or n (%).
 Randomised to traditional careRandomised to flexible careTOTAL
  1. This table only includes women expressing a preference.

Traditional care115 (72.8)49 (44.5)164
Flexible care43 (27.2)61 (55.5)104
χ2= 21.7; df 1; P < 0.001.   

Among women who expressed a preference, those who had been planning to become pregnant were more likely to prefer traditional care than women whose pregnancy was unplanned (67% compared with 48%, P= 0.006).

Apart from parity and whether the pregnancy was planned, other factors examined (e.g. age, educational attainment, feelings concerning the previous pregnancy, attitudes to pregnancy as a normal or a risky event and locus of control) were not associated with differences in women's preferences for a particular pattern of care.

A small number of women, both nulliparous and parous in both groups, commented spontaneously on a lack of care and information in early pregnancy and felt that this was an aspect of antenatal care in need of improvement.

Table 3 shows how well women thought their general practitioners knew them as individuals. The data showed a predictable effect that women feel better known the longer they have been registered with a general practitioner. The proportion reporting that they felt they were well known was 11.2% if registered for less than two years, compared with 25% if registered for more than 10 years. Parous women did not report feeling better known than nulliparous women (Table 3). How well they felt known by their general practitioner did not influence their preference for a particular pattern of care.

Table 3.  Relationship with general practitioner. How well do you think your general practitioner knows you? Values are given as n or n (%).
 Nulliparous womenParous womenTOTAL
  1. χ2= 1.18; df 2; P= 0.55.

Not at all39 (17.1)46 (15.2)85
Know a little about me144 (63.2)186 (61.4)330
They know me well45 (19.7)71 (23.4)116

As stated above, women were randomised to flexible or traditional groups before completing the first questionnaire. In order to ensure that allocation had not influenced questionnaire responses, a stratified analysis was carried out, comparing the responses given by the two groups. Apart from the effect on preference for type of care, the stratified analysis showed no differences between the traditional and flexible groups in terms of attitudes to pregnancy, locus of control, planning of pregnancy and expectations of care.


Apart from an association with planned pregnancies, we were unable to identify other factors to predict acceptability of a flexible pattern of antenatal care: neither parity, nor the expectation that pregnancy was an event entailing risk, nor the perceived relationship with general practitioners, nor the belief that antenatal care made a difference to the outcome of pregnancy. At the outset of pregnancy, women appear to feel that a fixed pattern of care will do no harm, will provide more reassurance and is therefore to be preferred. The only spontaneous comments made reflected a desire for more care in the early part of pregnancy. The lack of association with the belief that antenatal care makes a difference suggests that this belief holds good even among those women who doubt the effectiveness of antenatal care. The one significant association found was between having planned a pregnancy and preferring traditional care. Possibly the two factors together identify women who favour structure in their lives. Overall, these results go some way to explaining the problems that previous studies have reported in successfully reducing the number of antenatal visits5,6.

Parous women are no more likely to opt for flexible care than nulliparous women. Comparing their views on the other scales showed strikingly few differences. Parous and nulliparous women had similar responses to questions about the degree of risk entailed in pregnancy, the extent to which the outcome of pregnancy depended on themselves or chance, and how well they felt they were known by the general practitioners. There were, however, differences in three particular areas: parous women were more likely than nulliparous women to have planned to become pregnant; less likely to regard antenatal care as having an important influence on the outcome of pregnancy; and more likely to express a preference about the pattern of antenatal care they received. It is perhaps not surprising that parous women viewed antenatal care as less important than did nulliparous women. Because of inclusion criteria, they had all had at least one normal pregnancy. Parous women who were excluded because of an adverse obstetric event in a previous delivery might be expected to have different views about the importance of antenatal care in determining outcome. The results suggest that parous women with a history of normal pregnancy do not, as a result, feel any less at risk than nulliparous women. Either professionals are not assuring them that this is the case, or their own experience of modern obstetrics may confirm feelings of risk. In either case, it helps to explain why so many of them favour a traditional pattern of antenatal care.

The findings on the numbers of planned and unplanned pregnancies are consistent with previously reported figures, with the figure for planned pregnancies of 62% close to figures reported in two previous studies from the UK7,8. While the parous women were more likely to describe their pregnancies as planned, the differences are small, and there were a significant number of unplanned pregnancies among parous and nulliparous women.

While a more flexible approach to care does not appear to be linked to any of the attitudes measured, it was welcomed in this study by 19% of the total and may be acceptable to some of the 50% who did not express a preference. Nevertheless, the predictable structure of a traditional antenatal care pattern seems to remain the preference for most women.


The authors would like to thank Dr T. Peters for advice with statistical analysis, Ms C. Cutlan for her part in data collection, and all the patients, their midwives and general practitioners who took part in the study. The project was supported by a grant from the NHS Executive South and West Research and Development Directorate.