To have more women who attend ANC and attend early, promotion should be targeted at high-risk groups of women. However, to improve the number of ANC visits and overall utilization, the quality of ANC services should be improved.

Vietnam has high numbers of maternal and infant mortality and morbidity. Each year, 1,500 women die and 45,000 others become disabled as a result of pregnancy and childbirth complications. 1 There were 37,700 neonatal deaths in Vietnam in 1999. 2 The maternal mortality rate is 165 per 100,000 live births 3 and the infant mortality rate is around 30 per 1,000 live births. 4,5 Antenatal care (ANC) has been proven to be effective in preventing pregnancy adverse outcomes. 6 For ANC to be effective, women should have enough visits at appropriate times, with sufficient ANC content. The World Health Organization (WHO) recommends four visits at the 4th, 6th or 7th, 8th, and 9th month for women in developing countries. 7 The Vietnamese government recommends three visits, one during each trimester. 8 WHO recommends three basic components of ANC content: (1) biomedical assessment based on medical history, physical examination, and laboratory tests; (2) health promotion; and (3) care provision. 7 To measure ANC adequacy, many indicators and indices have been developed in the world. Single indicators are any ANC, number of ANC visits, and duration of pregnancy at entry to ANC. Complex indices that combine number of ANC visits and duration of pregnancy at first visit are the Kessner index, 9 the Graduated Index of Prenatal Care Utilization, 10 the Adequacy of Prenatal Care Utilization Index, 11 and the Prenatal Care Evidence-Based Index. 12 These indices are suitable for developed countries because of the high cutoff points. There has been a modified index in the Philippines with the lower cutoff point of five visits and initial visit within the first three months, 13 but this index might not be suitable for other less developed countries like Vietnam. Editor's note: This paper by Drs. Trinh, Dibley, and Byles shows with clarity the benefit of antenatal care and improved outcomes in maternal and infant morbidity and mortality. The data set used, which goes up to 1999, also suggests an improving trend in infant mortality as the economy grows and the GDP increases. These rates of improvement are at a rate of about 7% annually. In fact, infant mortality rates have changed dramatically in the last two decades in Vietnam.

Incorporating combination vaccines, such as the measles-mumps-rubellavaricella (MMRV) vaccine, into immunization schedules should be evaluated from a benefit-risk perspective. Use of MMRV vaccine poses challenges due to a recognized increased risk of febrile seizures (FSs) when used as the first dose in the second year of life. Conversely, completion by age 2 years of measles, mumps, rubella, and varicella immunization may offer improved disease control.OBJECTIVE To evaluate the effect on safety and coverage of earlier (age 18 months) scheduling of MMRV vaccine as the second dose of measles-containing vaccine (MCV) in Australia.DESIGN, SETTING, AND PARTICIPANTS Prospective active sentinel safety surveillance comparing the relative incidence (RI) of FSs in toddlers given MMRV and measles-mumpsrubella (MMR) and a national cohort study of vaccine coverage rates and timeliness before and after MMRV vaccine introduction were conducted. All Australian children aged 11 to 72 months were included in the coverage analysis, and 1471 Australian children aged 11 to 59 months were included in the FS analysis, with a focus on those aged 11 to 23 months. MAIN OUTCOMES AND MEASURESMMRV vaccine safety, specifically, the RI of FSs after MMRV vaccine at age 18 months, compared with risk following MMR vaccine and vaccine uptake for 2-dose MCV and single-dose varicella vaccine, focusing on timeliness. RESULTSOf the 1471 children, the median age at first FS was 21 months (interquartile range [IQR], 14-31 months). Three hundred ninety-one children were aged 11 to 23 months and had at least 1 FS included in the analysis; of these, 207 (52.9%) were male. A total of 278 children (71.1%) had received MMR followed by MMRV vaccine, 97 (24.8%) had received MMR vaccine only, and 16 (4.1%) had received neither vaccine. There was no increased risk of FSs (RI, 1.08; 95% CI, 0.55-2.13) in the 5 to 12 days following MMRV vaccine given as the second MCV to toddlers. Febrile seizures occurred after dose 1 of MMR vaccine at a known low increased risk (RI, 2.71; 95% CI, 1.71-4.29). Following program implementation, 2-dose MCV coverage at age 36 months exceeded that obtained at age 60 months in historical cohorts recommended to receive MMR vaccine before school entry, and on-time vaccination increased by 13.5% (from 58.9% to 72.4%). Despite no change in the scheduled age of varicella vaccine, use of MMRV vaccine was associated with a 4.0% increase in 1-dose varicella vaccine coverage. CONCLUSIONS AND RELEVANCETo our knowledge, this is the first study to provide evidence of the absence of an association between use of MMRV vaccine as the second dose of MCV in toddlers and an increased risk of FSs. Incorporation of MMRV vaccine has facilitated improvements in vaccine coverage that will potentially improve disease control.

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