September, 2009 - SUPPORT Summary of a systematic review | print this article |

Do interventions to improve communication between health professionals and women improve maternity care?

The quality of interaction between patients and their carers may impact on a variety of aspects of patient well being. Communication in maternity care between health professionals and women has received much attention at official and professional levels in recent years. There have, however, been few evaluations of the effects of strategies to improve communication between women and their carers during maternity.

Key messages

Providing women with antenatal testing information probably leads them to make more informed decisions about antenatal screening tests;
Antenatal testing information and woman-held maternity re-cords may reduce women’s anxiety during pregnancy, and make them feel more in control of the pregnancy;
Computer assisted history takingmay result in more time be-ing spent on booking interviews, in care providers asking more questions and giving less advice and feedback, and in-more clinical actions being taken by providers;
The interventions (i.e. antenatal testing information, computer-assisted history taking, woman-held maternity records, and provision of informed choice leaflets) may not improve women’s knowledge and understanding, women’s satisfaction, or their health outcomes.
These findings come from studies conducted in high-income country settings having high literacy rates among women, high access to health care, and computer technology in the health services. They may be transferrable to high and middle-income settings in LMIC which have a similar background and backup support, but may not be transferable to many low income settings.

Who is this summary for?

People deciding on strategies to improve maternity care

This summary includes:

Key findings from research based on a systematic review
Considerations about the relevance of this research for low income countries

Not included:

Recommendations
Additional evidence not included in the systematic review
Detailed descriptions of interventions or their implementation

This summary is based on the following systematic review:

Rowe RE, Garcia J, Macfarlane AJ, Davidson LL. Improving communication between health professionals and women in maternity care:a structured review. Health Expectations 2002:5;63-83. See in Pubmed

What is a systematic review?

A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.

SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.

Glossary of terms used in this report

Background references on this topic

Background

Maternity care is an area of health care in which the importance of good communication has received particular attention. Observational studies have suggested that improved communication between health professionals and women attending maternity services, could potentially result in improved satisfaction for women and better health outcomes.

This is a summary of a systematic review published by Rowe et al in 2002 on interventions to improve communication between health professionals and women in maternity care.

How this summary was prepared

After searching widely for systematic reviews that can help inform decisions about health systems, we have selected ones that provide information that is relevant to low-income countries. The methods used to assess the reliability of the review and to make judgements about its relevance are described here

Knowing what’s not known is important

A reliable review might not find any studies from low-income countries or might not find any well-designed studies. Although that is disappointing, it is important to know what is not known as well as what is known.

A lack of evidence does not mean a lack of effects. It means the effects are uncertain. When there is a lack of evidence, consideration should be given to monitoring and evaluating the effects of intervention, if it is used.

About the systematic review underlying this summary

/	What the review authors searched for	What the review authors found
Review Objectives: To assess effectiveness of interventions aimed at improving communication between health professionals and women in maternity care
Interventions	Randomised controlled trials (RCTs), and quasi RCTs which aimed to improve communication between health professionals and women in maternity care	11 RCTs (including 1 cluster RCT). Interventions included information about antenatal testing (5), women held maternity records (3), computer based history taking (2), provision of leaflets and training of staff in their use (1)
Participants	Health professionals and pregnant women	Health professionals and pregnant women
Settings	Maternity services	Maternity services in the UK (10) and Australia (1)
Outcomes	Primary: Women’s clinical and psychologi-cal health outcomes Secondary: compliance with advice or treatment, knowledge or understanding of advice or treatment, satisfaction with care	Clinical: Uptake of tests(4), appointment duration(1), clinical actions(1), clinical outcomes(1), changes in health-related behaviours(1). Psychological: Maternal anxiety(5), women’s satisfaction(6), depression(1), feelings about pregnancy(2), exercising informed choice(1). Other: communication(6), understanding/knowledge of intervention(5), acceptability(2), information needs met(1), amount of information given(1).
Date of most recent search: April 2000
Limitations: This systematic review has major limitations as it was not possible to combine the data from the various studies.

Rowe RE, Garcia J, Macfarlane AJ, Davidson LL. Improving communication between health professionals and women in maternity care:a structured review. Health Expectations 2002:5;63-83. See in Pubmed

About the certainty of the  evidence (GRADE)

High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.

Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.

Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.

Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.

* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.

† Substantially different = a large enough difference that it might affect a decision.

See last page for more information.

Summary of findings

The systematic review included 11 RCTs which described a range of different interventions to improve communication between health professionals and women in maternity services. Most interventions focused on providing information for women in maternity care, and only one focused on health professionals.

1) Antenatal Testing Information

Four studies provided pregnant women with information about antenatal tests, and assessed outcomes related to the women. The fifth study targeted health professionals, and assessed their knowledge and communication of antenatal screening. Overall, the studies show that:

Providing pregnant women with antenatal testing information-probablyincreases uptake of antenatal tests.
Providing women with antenatal testing informationprobably reduces anxiety levels during pregnancy.
It is not known whether providing women with antenatal testing information improves their knowledge, understanding, or satisfaction.

Antenatal Testing Information
Patient or population: Pregnant women Settings: Maternity services in high income countries Intervention: Antenatal Testing Information provided to pregnant women Comparison: Routine information
Outcomes	Impact	No of Participants (studies)	Quality of the evidence (GRADE)
Uptake of Tests	Three studies showed a positive impact on uptake of tests (HIV, anomaly testing, and Downs syndrome screening); one study did not show any difference, and one found a decrease in testing (cystic fibrosis testing)	7126 (4 studies)
Anxiety levels	Two studies found a reduction in anxiety levels, two found no additional effect.	7126 (4 studies)
Knowledge/Understanding	One study found that the intervention improved women’s understanding; two studies showed no additional benefit to women’s knowledge and/or understanding; the HIV testing information intervention improved specific knowledge such as vertical transmission, but not general HIV knowledge.	7126 (4 studies)
Women's satisfaction	Three studies found that women’s satisfaction was not affected by the intervention, and one found that women who received information were more satisfied.	7126 (4 studies)
p: p-value GRADE: GRADE Working Group grades of evidence (see above and last page)

2) Computer assisted history taking

Two studies assessed the effectiveness of computer based questionnaires to assist midwives in taking the booking history, compared to a standard manual history taking checklist. Results show that:

Computer assisted history taking may result in more time being spent on booking interviews, and in midwives asking more questions and giving less advice and feedback;
It is not known whether computer assisted history taking leads to any difference in women’s understanding of the information and advice given by care providers;
Computer assisted history taking probably generates more clinical actions by care providers.

Computer assisted history taking
Patient or population: Pregnant women Settings: Maternity services in high income countries Intervention: Computer assisted history taking Comparison: Routine information
Outcomes	Impact	No of Participants (studies)	Quality of the evidence (GRADE)
Process measures	More time spent on booking interview (p < 0.001); midwives asked more questions (p<0.01) and gave less advice and feedback (p < 0.01).	95 (1 study)
Patient outcomes	No significant difference in women’s understanding of information or advice	95 (1 study)
Other outcomes	Structured methods of taking history generated more clinical actions (p < 0.05)	2373 (1 study)
p: p-value GRADE: GRADE Working Group grades of evidence (see above and last page)

3) Provision of informed choice leaflets and staff training

In one study pregnant women were provided with informed choice leaflets which summarised research evidence on topics about which decisions are made in maternity care. In addition, staff received training on the use of the leaflets in practice. The results of this study indicate that the intervention:

May not improve the exercise of informed choice by women, women’s anxiety or de-pression, their level of knowledge, or their satisfaction.

4) Woman-held Maternity Records

The three trials which provided women with their full maternity records found that the intervention:

Probably improves communication between women and health professionals, and women’s decisions about labour companions;
Probably reduces women’s anxiety, and makes them feel more in control of their pregnancy;
Probably leads to little or no difference in health outcomes, with the exception of assisted deliveries.

Women-held full Maternity Records
Patient or population: Pregnant women Settings: Maternity services in high income countries Intervention: Woman-held full maternity records Comparison: Women held standard co-operation card
Outcomes	Impact	No of Participants (studies)	Quality of the evidence (GRADE)
Process outcomes	Women found it easier to talk to health professionals antenatally (RR 1.73, CI 1.16 – 2.59) (1 study), that professionals had explained everything in the records ( 1 study), and were able to have a companion of choice during labour (1 study). The intervention did not improve women’s understanding of what was happening nor their feeling that the record helped communication (1 study)	713 (3 studies)
Health outcomes	The intervention did not impact on most clinical outcomes, with the exception of more assisted deliveries occurring (29% vs. 16%, p<0.05)	563 (2 studies)
Other patient outcomes	Women reported feeling less anxious (1 study), more informed during labour and pregnancy (1 study), and more in control of their pregnancy (2 studies). Overall women’s satisfaction did not change (2 studies), and there were no differences in health related behaviours (2 studies).	713 (3 studies)
p: p-value GRADE: GRADE Working Group grades of evidence (see above and last page)

Relevance of the review for low-income countries

Findings	Interpretation*
APPLICABILITY
The studies were conducted in high income countries.	Most of the interventions depend on high literacy rates among women, education about pregnanacy, accessibility to health care, and to some extent to access to computer technology in the health services. These interventions may be transferrable to middle-income settings with high literacy rates and access to technology, but may not be transferable to many low-income settings.
EQUITY
The review did not provide data regarding differential effects of the interventions for disadvantaged populations.	Increased involvement by women can potentially improve equity by better equiping women to make informed decisions about accessing testing and care. However, this depends on the relevant tests and care being available in the health system and other barriers not existing. In low- and midde-income countries such barriers may include costs of health care, distance, and societal attitutes towards women’s involvement in decision making about their health care.
ECONOMIC CONSIDERATIONS
The review did not provide information on economic evaluations	Good communication requires additional staff time as well as other resources e.g. production of leaflets, access to computers, copies of maternity records. The costs and benefits should therefore be assessed in future studies, as well as in implementation settings in LMIC.
MONITORING & EVALUATION
The number of studies included was small, and provided information about very few aspects of care.	The evidence of effectiveness is not strong, and any implementation should be accompanied by a monitoring and evaluation programme to continually assess whether the processes are adequate and the desired outcomes achieved.
*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low- and middle-income countries. For additional details about how these judgements were made see: http://supportsummaries.org/support-summaries/how-support-summaries-are-prepared/

Additional information

Related literature

Brown HC, Smith HJ. Giving women their own case notes to carry during pregnancy. Cochrane Database of Systematic Reviews 2004. Issue 2, Art.No:CD002856. DOI: 10.1002/14651858.CD002856.pub2.See in Cochrane Library

This summary was prepared by

Lilian D Dudley, Charles Shey Wiysonge, South African Cochrane Centre, Medical Research Council, Cape Town, South Africa

Conflict of interest

None known. For details, see: Conflicts of interest

Acknowledgements

This summary has been peer reviewed by:Rachel Rowe, UK; Pisake Lumbiganon, Thailand; Lelia Duley, UK; Rukhsana Gazi, Bangladesh; Gabriel Bastías, Chile; Cristian Herrera, Chile

This summary should be cited as

Dudley LD, Wiysonge CS.Do interventions to improve communication between health professionals and women improve maternity care? A SUPPORT Summary of a systematic review. September2009

This summary was prepared with additional support from:

The South African Medical Research Council aims to improve health and quality of life in South Africa through promoting and conducting relevant and responsive health research.www.mrc.ac.za/

The South African Cochrane Centre, the only centre of the international Cochrane Collaboration in Africa, aims to ensure that health care decision making in Africa is informed by high quality, timely and relevant research evidence. http://www.mrc.ac.za/cochrane/cochrane.htm

Norad aims to contribute to effective use of funds for development aid and to be Norway’s innovative professional body in the fight against poverty, in near cooperation with other national and international professional groups. http://www.norad.no/

GLOBINF is a thematic research area focusing on "Prevention of major global infections - HIV/AIDS and tuberculosis" at the Medical faculty, University of Oslo in collaboration with the Norwegian Institute of Public Health, Norwegian Knowledge Centre for the Health Services and Ullevål University Hospital.

About certainty of evidence (GRADE)

The “certainty of the evidence” is an assessment of how good an indication the research provides of the likely effect, i.e. the likelihood that the effect will be substantially different from what the research found. By “substantially different” we mean a large enough difference that it might affect a decision. These judgements are made using the GRADE system, and are provided for each outcome. The judgements are based on the study design (randomised trials versus observational studies), factors that reduce the certainty (risk of bias, inconsistency, indirectness, imprecision, and publication bias) and factors that increase the certainty (a large effect, a dose response relationship, and plausible confounding). For each outcome, the certainty of the evidence is rated as high, moderate, low or very low using the definitions on page 3.

For more information about GRADE

SUPPORT collaborators:

The Cochrane Effective Practice and Organisation of Care Group (EPOC) is part of the Cochrane Collaboration. The Norwegian EPOC satellite supports the production of Cochrane reviews relevant to health systems in low- and middle-income countries . www.epocoslo.cochrane.org

The Evidence-Informed Policy Network (EVIPNet) is an initiative to promote the use of health research in policymaking in low- and middle-income countries. www.evipnet.org

The Alliance for Health Policy and Systems Research (HPSR) is an international collaboration that promotes the generation and use of health policy and systems research in low- and middle-income countries. www.who.int/alliance-hpsr

Norad, the Norwegian Agency for Development Cooperation, supports the Norwegian EPOC satellite and the production of SUPPORT Summaries. www.norad.no

The Effective Health Care Research Consortium is an international partnership that prepares Cochrane reviews relevant to low-income countries. www.evidence4health.org

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