Women in the new ANC model clinics were, in general, as satisfied as their counterparts in the standard model. Furthermore, women in both arms were equally satisfied with waiting time and information provided about their health, tests during pregnancy, and treatment they might need. There were also no significant differences regarding what women worried about and whether the caregiver reassured them. Yet, women in the new ANC model were more satisfied with the time spent with the provider and with the information they received. Providers were more satisfied with the new ANC model with regards to number of visits, time spent with the patient, and information provided, but they were less satisfied with the spacing between visits. More providers rated the overall care provided under the standard model as good or very good than under the new ANC model.
Overall, these results show that both ANC models were equally well accepted by women and providers, suggesting that the adoption of the new antenatal care model would not face major obstacles derived from women or providers' perception of ANC and their satisfaction with it.
Within this framework, specific issues deserve special attention. In terms of the number of visits and spacing, the qualitative stage findings of our study  and those of several previous trials conducted to evaluate ANC models that reduced the number of visits [15, 20, 23–26] showed that more women in the intervention groups reported dissatisfaction with a reduced number of visits and longer spacing between them [20, 25]. However, our study only demonstrated a trend towards patients' dissatisfaction with the changes introduced by the new ANC model, as no statistically significant differences between the trial arms were found. In another study conducted in a developing country results were similar to ours: there was no change in patients' satisfaction with a smaller number of ANC visits and longer spacing between them .
Still, our study findings suggest that number of visits and spacing are potential areas of concern for women. Providers could address these concerns by giving women information on the safety of these protocol changes, as was demonstrated by the results of the large WHO trial  and the systematic review of all randomized controlled trials . Other needs that work as incentives for women to attend ANC clinics, such as socialization and social support, should be addressed through other activities that do not necessarily involve formal encounters with medical providers.
Regarding time spent with the provider, women in the new model had a higher level of satisfaction with the time spent with the provider than those in the standard model clinics, although the actual duration of the clinical encounter was similar. This positive impression may have resulted from an improvement in the quality of the patient-provider interaction. It is interesting to highlight that although waiting time was effectively reduced, women's satisfaction did not reflect the difference (Table 2).
One of the main goals of the new model was to strengthen the information component . The fact that a larger proportion of women in these clinics perceived that their information needs were satisfactorily met even if there were only five visits to the clinics reveals that the new model was effective in reinforcing this aspect of care. In the Sikorski et al trial conducted in London, which achieved only a small reduction in number of visits, provision of information was also stressed; however, they did not find any difference in satisfaction among women in both arms of the trial .
The summary questions used to explore overall women's satisfaction with ANC showed surprisingly high levels among patients in both models, especially considering that women from the same clinics had expressed concerns about the quality of care during the focus groups and personal interviews conducted during the first stage of this study . A hypothesis to explain this difference is that qualitative techniques capture the feelings of few more outspoken women and may provide a biased perception of the group. This could also be due to a "courtesy bias", which usually affects the answers to inquiries about satisfaction with care received, especially when women are asked in clinical settings . In our study, qualitative techniques allowed to discriminate better among women with different levels of satisfaction than close-ended questions, especially the summary ones. This may be due to the wording of questions meant at exploring overall satisfaction; in fact, those that addressed specific issues (such as number of visits, spacing between them, information provided, etc) received answers with more variability.
There is another interesting hypothesis to consider as well. One study in Scotland found that pregnant women are fairly uncritical of health care, accepting whatever care they receive as appropriate.  The authors suggest that it would not be surprising to see high levels of overall satisfaction in a controlled study comparing two ANC models, and that it would be important to examine the differences between the two groups studied in their expressed preferences rather than the absolute magnitude of the expressed satisfaction. This was the case with our study, where we were able to differentiate women's satisfaction between the two models. However, women in the clinics of both models of ANC seemed to be equally uncritical.
Another difficulty in interpreting our findings derives from the variability in views and expectations originated by various cultural and socio-economic settings. In a study conducted in Chile, for instance, low-income urban women defined high quality as "being treated as a human being"; technical quality was not even mentioned . Village women in Thailand identified inequalities of power fundamental to gender, class and ethnic relations as dimensions that crucially affect the client-provider interaction . This was an important challenge in our study. The satisfaction questionnaire we used in each country was standardized with adaptations of terminology only and therefore did not provide any detailed clues about what aspects of ANC women of different cultural backgrounds appreciated more.
Women's satisfaction is a sensitive indicator that responds to changes in quality of care, even before changes in health status are detected,  but its measurement remains an important challenge. Qualitative methods allow women to reveal their feelings in greater depth than survey research methods . In fact, most studies aimed at exploring women's views about quality of reproductive health care resort to interviews and focus groups . However, results obtained with these techniques cannot be extrapolated and have low external validity. Yet, although data collected through questionnaires usually offer more superficial insights and do not reflect cultural nuances, when administered to a representative and large sample they can be safely extrapolated to the population from which the sample was obtained. In an attempt to overcome these limitations, we combined both methodologies .
Although our study makes important contributions to the area of users' perception on changes introduced into ANC models, it does not address methodological issues involved in the measurement of clients' satisfaction, which other authors have extensively addressed in observational studies [35, 36]. In fact, we analyzed the differences between the perspectives of women in the intervention and control clinics, focusing only on those specific aspects that changed as a result of the introduction of the new ANC model (number and spacing of visits, information provided, etc.) Our study did not explore women's satisfaction with any other aspects of ANC such as technical quality, physical environment, access and continuity of the provider [37, 38] that were not modified with the intervention, or the differences in users' satisfaction associated with ANC received in different types of facilities (i.e. private or public.) 
While users' perspective of quality of care has been assessed relatively often, the perspective of health professionals has been assessed occasionally at best [27, 40]. In our study, while some degree of resistance to the new ANC model was expected, doctors and midwives did not have strong views against it. For instance, providers' satisfaction with the number of antenatal visits was similar in clinics of both arms of the trial. The reason for this may be that all providers worked at public health institutions, where the number of visits does not have a serious impact on their workload or income. Similar results were obtained in the study conducted in public hospitals in Harare, where the assessment showed that staff wished women made fewer visits to ANC clinics . In the Sikorski trial  doctors were in favor of a reduced number of visits, but the average number under routine circumstances was much higher than in the four countries that participated in the WHO trial.
Regarding the information, our study confirmed an imbalance between women's expectations and providers' responses: providers scored themselves higher than their patients did in relation to the information they provide during antenatal check-ups. There appears to be a mismatch between doctors and nurses' perception of the quality and quantity of the information they provide and the users' needs. Furthermore, providers should be aware of the importance of meeting women's information needs during ANC visits, and thus be prepared to satisfy them.
In matters of overall satisfaction with ANC, although the proportion of providers that said care offered in their clinics was good or very good was high in both arms of the trial, those working in the standard ANC model clinics were more satisfied. This difference could be interpreted as a sign of discontent with the new ANC model.