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Strategies to improve interpersonal communication along the continuum of maternal and newborn care: A scoping review and narrative synthesis

  • Klaartje M. Olde Loohuis ,

    Roles Conceptualization, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

    Affiliation Julius Global Health, Julius Centre for Health Sciences and Primary Care, UMC Utrecht, Utrecht University, Utrecht, The Netherlands

  • Bregje C. de Kok,

    Roles Conceptualization, Formal analysis, Methodology, Writing – review & editing

    Affiliation Department of Anthropology, University of Amsterdam, Amsterdam, The Netherlands

  • Winter Bruner,

    Roles Formal analysis, Methodology, Writing – review & editing

    Affiliation Department of Genetics, Genomics and Informatics, University of Tennessee Health Science Center, Memphis, TN, United States of America

  • Annemoon Jonker,

    Roles Formal analysis, Methodology, Writing – review & editing

    Affiliation Julius Global Health, Julius Centre for Health Sciences and Primary Care, UMC Utrecht, Utrecht University, Utrecht, The Netherlands

  • Emmanuella Salia,

    Roles Formal analysis, Methodology, Writing – review & editing

    Affiliation Department of Genetics, Genomics and Informatics, University of Tennessee Health Science Center, Memphis, TN, United States of America

  • Özge Tunçalp,

    Roles Conceptualization, Methodology, Writing – review & editing

    Affiliation Department of Sexual and Reproductive Health and Research Including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland

  • Anayda Portela,

    Roles Conceptualization, Methodology, Writing – review & editing

    Affiliation Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland

  • Hedieh Mehrtash,

    Roles Conceptualization, Methodology, Writing – review & editing

    Affiliation Department of Sexual and Reproductive Health and Research Including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland

  • Diederick E. Grobbee,

    Roles Methodology, Writing – review & editing

    Affiliation Julius Global Health, Julius Centre for Health Sciences and Primary Care, UMC Utrecht, Utrecht University, Utrecht, The Netherlands

  • Emmanuel Srofeneyoh,

    Roles Methodology, Writing – review & editing

    Affiliation Department of Obstetrics and Gynecology, Greater Regional Hospital, Accra, Ghana

  • Kwame Adu-Bonsaffoh,

    Roles Methodology, Writing – review & editing

    Affiliation Department of Obstetrics and Gynecology, University of Ghana Medical School, Accra, Ghana

  • Hannah Brown Amoakoh,

    Roles Methodology, Writing – review & editing

    Affiliations Julius Global Health, Julius Centre for Health Sciences and Primary Care, UMC Utrecht, Utrecht University, Utrecht, The Netherlands, Department of Epidemiology, Noguchi Memorial Institute for Medical Research, University of Accra, Accra, Ghana

  • Mary Amoakoh-Coleman,

    Roles Conceptualization, Methodology, Writing – review & editing

    Affiliations Julius Global Health, Julius Centre for Health Sciences and Primary Care, UMC Utrecht, Utrecht University, Utrecht, The Netherlands, Department of Epidemiology, Noguchi Memorial Institute for Medical Research, University of Accra, Accra, Ghana

  • Joyce L. Browne

    Roles Conceptualization, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

    Affiliation Julius Global Health, Julius Centre for Health Sciences and Primary Care, UMC Utrecht, Utrecht University, Utrecht, The Netherlands


Effective interpersonal communication is essential to provide respectful and quality maternal and newborn care (MNC). This scoping review mapped, categorized, and analysed strategies implemented to improve interpersonal communication within MNC up to 42 days after birth. Twelve bibliographic databases were searched for quantitative and qualitative studies that evaluated interventions to improve interpersonal communication between health workers and women, their partners or newborns’ families. Eligible studies were published in English between January 1st 2000 and July 1st 2020. In addition, communication studies in reproduction related domains in sexual and reproductive health and rights were included. Data extracted included study design, study population, and details of the communication intervention. Communication strategies were analysed and categorized based on existing conceptualizations of communication goals and interpersonal communication processes. A total of 138 articles were included. These reported on 128 strategies to improve interpersonal communication and were conducted in Europe and North America (n = 85), Sub-Saharan Africa (n = 12), Australia and New Zealand (n = 10), Central and Southern Asia (n = 9), Latin America and the Caribbean (n = 6), Northern Africa and Western Asia (n = 4) and Eastern and South-Eastern Asia (n = 2). Strategies addressed three communication goals: facilitating exchange of information (n = 97), creating a good interpersonal relationship (n = 57), and/or enabling the inclusion of women and partners in the decision making (n = 41). Two main approaches to strengthen interpersonal communication were identified: training health workers (n = 74) and using tools (n = 63). Narrative analysis of these interventions led to an update of an existing communication framework. The categorization of different forms of interpersonal communication strategy can inform the design, implementation and evaluation of communication improvement strategies. While most interventions focused on information provision, incorporating other communication goals (building a relationship, inclusion of women and partners in decision making) could further improve the experience of care for women, their partners and the families of newborns.


Improving the quality of maternal and neonatal health services would accelerate reductions in maternal and neonatal deaths in low- and middle-income countries (LMICs) [1]. Quality of care, as the 2015 World Health Organization (WHO) quality of care framework identifies, has two major domains: provision of care and experience of care [2]. The experience of care dimension includes effective interpersonal communication, which is also closely linked to mistreatment of women during childbirth [3]. In a multi-country study, almost one in five women felt that health workers or staff did not listen and respond to their concerns, and more than half reported no consent for episiotomies performed during childbirth [4].

Effective interpersonal communication is a cornerstone of medical practice [5, 6]. Effective communication can serve three different goals: facilitating the exchange of information, creating a good interpersonal relationship including building of trust, and enabling the inclusion of patients in decision making [712]. Communication is furthermore an important theme in respectful maternity care, and a way to protect the human rights of women, for example, through ensuring confidentiality, fulfilling the right to be fully informed and allowing for informed consent [9].

Interpersonal communication between health workers and patients can affect health care outcomes, including patients’ satisfaction, knowledge and understanding, adherence to treatment, quality of life and psychological and physical health [8, 10, 11]. Within maternal and newborn care (MNC), good interpersonal communication contributes to better experiences, improved respectful care and reduced mistreatment [7, 8, 13]. This is particularly relevant in low-resource settings where poor communication and mistreatment are common [4], contributing to negative or traumatic birth experiences [12]. To illustrate, in Kenya, person-centred care, which included many interpersonal communication related aspects, was associated with improved MNC outcomes [13].

Various aspects of interpersonal communication processes between health workers and patients have been described. The communication framework of Feldman-Stewart and Brundage is particularly useful to illustrate ‘how’ interpersonal communication works [14, 15], and can thus be helpful in understanding how interpersonal communication could be improved. First, this framework suggests that both health workers and patients have goals in terms of what they want to achieve during the interaction. Second, each participant has certain needs, beliefs, values, skills and emotions that shape ways to interact. Third, each participant receives and sends messages. And finally, the framework underscores that the environment in which the interaction takes place matters for communication, and thus for strategies designed to improve interpersonal communication [14, 15]. Further guidance on effective communication within MNC is emphasized within WHO’s recommendations across the continuum of MNC [1618]. While these recommendations do not provide a definition of effective communication within the context of MNC, they provide guidance to ensure effective communication is prioritized between health workers, women, their partners and families [16].

Despite the increased recognition of the importance of interpersonal communication for MNC there is no clear overview of the different strategies that can be adopted to reduce mistreatment and improve respectful care [19]. Therefore, the objective of this review was to map and categorize implemented strategies to improve interpersonal communication between health workers, women and their partners within MNC up to 42 days after birth.


Protocol and registration

This review was drafted and conducted in accordance with the PRISMA guidelines [20] and the Cochrane Handbook for Systematic Reviews [21]. The study protocol was registered in PROSPERO in July 2020 (CRD42020191622). The protocol was initially developed for a systematic review including a possible meta-analysis on effectiveness. We converted to a scoping review with narrative analysis due to the number and heterogeneous nature of the primary research articles, and because this provided a sufficient basis for answering the research questions.

Domain and population

The domain of our review consisted of studies that implemented a strategy to improve interpersonal communication between health workers, women, and their partners in care across the continuum of MNC. We also anticipated that experiences to improve interpersonal communication from related domains in sexual and reproductive health and rights (SRHR) would facilitate cross-learning from MNC, and therefore extended the domain to include the reproduction-related SRHR subdomains of safe abortion, family planning and (in)fertility.

The study population included women and their partners as well as newborns and their parents/caregivers/families throughout the continuum of MNC and reproduction-related SRHR subdomains. This included antenatal, intrapartum and postnatal care up to 42 days. In this paper, we used ‘women and partners’ to describe the population. Health workers included different cadres as specified in the WHO recommendations to optimize health workers’ roles within MNC [22]: lay health workers, (auxiliary) nurses and midwives, and (associate) physicians (including obstetricians, paediatricians, general practitioners and residents).

Eligibility criteria

Studies were eligible for inclusion if they were primary, peer-reviewed articles reporting on interpersonal communication quality improvement strategies between health workers and women and partners in MNC and reproductive-related SRHR subdomains. All studies that included health workers who were engaged with in-service training (i.e., not training by students as part of a qualifying degree) were eligible. Studies conducted in any setting within MNC and reproductive-related SRHR subdomains were eligible. Studies that included a paediatric population were only eligible if >50% of participants were newborns (up to 42 days old) or newborns’ parents. Studies published from January 2000 to July 2020 were included to reflect contemporary practices.

We excluded studies that focused on mass communication, group communication, one-way communication, interprofessional communication and communication between mothers and babies. Furthermore, we excluded studies that reported on packages of strategies where communication was not a primary aim, because in these complex intervention studies communication was usually a small part of the intervention, and so difficult to disentangle from other activities. Furthermore, studies that implemented a new communication-based treatment programme (e.g., cognitive behaviour therapy) to treat a specific disease or problem were excluded because these constituted a new form of health service delivery, except when the intervention specifically focused on improving the interpersonal communication within the delivery of the health service. We excluded reviews, but primary studies from relevant systematic reviews were checked for eligibility. We included only English articles, because of language limitations within the team. In total, six studies were excluded in full text screening because of language restrictions.

Information sources

We searched the following information sources: PubMed/Medline, EMBASE, CINAHL, SCOPUS, PsychINFO, Anthropology PLUS, SocioINdex, Cochrane Central Register of Controlled Trials (CENTRAL), Latin American and Caribbean Health Sciences Literature (LILACS), African Journals Online (AJOL), and Global Health Library.


Search terms consisted of MeSH and combined text related to ‘communication’, ‘health workers’, ‘MNC or related SRHR domains’, ‘women and families’ and ‘intervention’. The search was developed with support from a librarian. For the complete search strategy see S1 Appendix. References of included articles were snowballed and checked for eligibility. De-duplication was performed using Endnote (V.X9).

Selection of sources of evidence

First, titles and/or abstracts of studies identified through the search strategy were independently screened to assess whether studies met the inclusion criteria by two of the four reviewers (AJ, ES, WB, KMOL). Next, full texts were screened in the same way. In case a full text article was missing or inaccessible, authors were contacted once through email or ResearchGate and were given the option to respond within a month to provide us with the full text. Rayyan QCRI ( was used to screen articles. Any disagreement that arose was discussed by the persons who screened the articles until consensus was reached, or a fifth review team member was consulted (JLB or BCdK) to resolve the issue through further discussion.

Data charting process including data items

Data were extracted using a standardized pre-piloted form (by AJ, ES, WB, KMOL, BCdK). The data extracted included study characteristics and information for evidence synthesis: first author, year of publication, country, study setting, aims and objectives, study design, study population characteristics, description of intervention and communication goals of the intervention, and the types of outcomes measured. Extracted data were double checked by one of the team members (KMOL).

Synthesis of results

We initially planned to perform a systematic review including a meta-analysis on interpersonal communication strategies’ effectiveness. However, the number and heterogeneity of designs and interventions among the retrieved articles led us to convert the study to a scoping review with narrative synthesis that focussed on providing an overview and categorization of the various strategies taken to improve interpersonal communication [23]. In this scoping review process, we summarized key findings of articles. We categorized strategies into the three communication goals proposed by Ong et al. [8]: 1) to facilitate the exchange of information, 2) create a good interpersonal relationship, and 3) enable the inclusion of women and partners in the decision making. These categories were pragmatically used as heuristic tools, i.e. functional methods (not necessarily perfect), and studies were assigned to one or more of these categories based on the information available. In addition, we analysed the results to understand ‘how’ interpersonal communication and the communication improvement strategies worked, using the model proposed by Feldman-Stewart and Brundage [14]. This model was updated (and re-visualized) with insights from this review and further deliberations within the review team.


We identified a total of 19956 articles through our search (see flow diagram in Fig 1). After removing duplicates, we screened 16826 articles on title and abstract and 369 articles in full text. Twenty-nine articles were additionally included through snowballing and reference screening of review articles. A total of 138 articles were included, reporting on 128 strategies to improve interpersonal communication.

Study characteristics

Table 1 presents an overview of the included studies. Interventions were implemented in Europe and North America (n = 85), Sub-Saharan Africa (n = 12), Australia and New Zealand (n = 10), Central and Southern Asia (n = 9), Latin America and the Caribbean (n = 6), Northern Africa and Western Asia (n = 4) and Eastern and South-Eastern Asia (n = 2). The majority were in high-income countries (n = 95), compared to 33 interventions in LMICs [24]. The majority of studies were performed within the domain of maternal health (n = 80 studies), with others performed in newborn health (n = 47), family planning (n = 20) and (in)fertility (n = 2). Thirty-seven were randomized controlled trials (RCTs), 73 were non-RCT intervention studies.

Communication goals

Nearly all strategies (n = 126/128) addressed at least one of the communication goals (facilitating the exchange of information, creating a good interpersonal relationship, and enabling the inclusion of women and partners in the decision making [7]). Fifty-eight addressed two goals, and six studies [2530] addressed all three goals. Box 1 provides an elaboration with examples of improvement strategies for each goal. S2 Appendix provides an overview of the communication goals of all studies.

Box 1: Examples of improvement strategies for the three communication goals

Communication goal: Facilitating the exchange of information

  • Example 1. Bakker et al. 2003. Manual, intervention card and training on a counselling protocol on smoking cessation in pregnancy, consisting of 7 steps.
  • Example 2. Maurer et al. 2019. Regular communication through messages/emails with information and tools to support discussions with health workers.

Communication goal: Creating a good interpersonal relationship

  • Example 1. Shao et al. 2018. Simulation based training for NICU nurses to improve their empathic communication skills.
  • Example 2. Bashour et al. 2013. Training for effective communication skills with a focus on the interaction between health workers and patients.

Communication goal: Enabling the inclusion of women and partners/families in MNC decision making

  • Example 1. Muthusamy et al 2012. Written information to receive before counselling including tips about questions to ask.
  • Example 2. Chinkam et al. 2016. Scripted counselling package about birth choices and trial of labour after caesarean using shared decision-making principles.

The goal ‘facilitating the exchange of information’ was present in most strategies (n = 98/128) [25137]. Examples included visual aids [visuals], decision tools, and health worker training focused on the information aspect of communication.

In total, 58 studies aimed to improve the goal ‘creating a good interpersonal relationship’ (n = 58/128) [2530, 38, 39, 73, 75, 7779, 8284, 9094, 104, 106, 109, 110, 112115, 120122, 131, 132, 138164]. These often sought to improve relationships by enhancing verbal and non-verbal communication, including touching the patient, showing empathy and compassion.

The goal ‘inclusion of women and partners in the decision making’ was addressed by 41 strategies (n = 41/128) [2530, 3235, 4345, 6971, 80, 81, 85, 88, 89, 9598, 100, 102, 107, 108, 117, 134137, 140, 141, 160169], for example by asking women about their values and beliefs. Often a decision aid tool was used, such as the WHO Family Planning Care Guidance (FPCG) flipchart decision aid where both women and health workers have information presented on their ‘side’ of a flipchart to support provision of information and shared decision making [35, 70, 96, 170]. Training sessions were regularly used to improve this goal too, for example in Toivonen et al. (2020) [141], where health workers in a neonatal intensive care unit were trained to collaborate with parents using shared decision making and person-centred care principles.

Strategies to improve communication

Two main types of strategy were used to improve interpersonal communication: training of health workers (n = 81) and tools to facilitate interpersonal communication (n = 67), with a few employing other distinct approaches (n = 7). Box 2 provides examples of these two main strategies.

Box 2: Examples of the two main strategies used to improve communication

Training of health workers

Training of health workers to improve their communication.

  • Example 1: Toivonen et al. 2020. An education intervention to increase the quality of family-centred care in different NICU’s.
  • Example 2: Posner et al. 2011. Workshop for residents in obstetrics and gynaecology on disclosing an adverse event.

Tools to facilitate communication

An (electronic) aid that can be used by health workers or women and partners to improve communication

  • Example 1: Langston et al. 2010. WHO decision support tool to structure the family planning counselling session.
  • Example 2: Kakkilaya et al. 2011. Visual aid with visual/graphical information for parents when delivery at the threshold of viability is imminent.

Training of health workers.

The majority of studies (n = 81/128) trained health workers to improve interpersonal communication skills as a single strategy, or as one of their strategies [25, 26, 2830, 3642, 46, 47, 4951, 53, 55, 56, 58, 59, 61, 63, 66, 68, 73, 77, 7981, 8385, 88, 9094, 99, 104106, 108, 110, 112117, 120122, 127, 128, 130, 132, 135, 137143, 145149, 151153, 155159, 161163, 165, 168, 171, 172]. Training programmes had different durations, ranging from 30 minutes [46, 163] to several months [26]. Nineteen studies (n = 19/82) used simulation-based training to teach communication skills [29, 3841, 47, 68, 77, 84, 90, 91, 105, 110, 112, 114, 115, 151, 153, 155, 157, 161]. Some studies employed specific underlying communication theories as a basis of their training, for example the 5-A method for counselling [46, 61, 79, 104] or motivational interviewing techniques [26, 81, 104, 121]. Often, training was combined with communication tools such as scripts or guidelines to provide guidance, structure or reminders [26, 51, 72, 79, 80, 83, 85, 88, 92, 93, 99, 104, 108, 116, 173].

Tools to facilitate interpersonal communication.

Sixty-seven studies (n = 67/128) used tools to improve interpersonal communication between health workers and women and partners: decision aids, visual aids, prompts and scripts, and guidelines based on specific theory-based approaches to communication [25, 26, 3133, 3537, 4345, 48, 5052, 54, 57, 60, 62, 64, 65, 67, 6971, 75, 7880, 82, 83, 85, 8789, 92, 93, 95100, 102104, 108, 109, 116, 117, 123126, 128132, 134136, 144, 154, 160, 164, 166168, 172, 174].

Decision aids (n = 23/67) [32, 33, 35, 4345, 60, 64, 6971, 80, 87, 88, 9597, 108, 123, 124, 126, 134, 136, 167, 168, 174] were often used as tools to support health workers, and/or women and partners in decision making about a health-related issue. Visual aids were used in 17 strategies (n = 17/67) [36, 37, 48, 5052, 62, 65, 75, 80, 83, 92, 103, 108, 117, 128, 135, 136], and supported health workers in their interpersonal communication and explanations. An example of a culturally sensitive visual aid was a cloth embroidery depicting safe maternal practices in pregnancy [62]. Prompts (n = 11/67) were also regularly used [26, 31, 54, 67, 85, 87, 88, 92, 123, 129, 175]. In these studies, health workers (or women [88]) received a (computer-assisted) cue or prompt to deliver or ask for counselling. A fourth type of tool used in studies was a script, or guideline regarding a specific approach to interpersonal communication often based on underlying communication theory (n = 30/67) [25, 26, 31, 54, 57, 67, 78, 79, 82, 85, 89, 92, 98100, 102104, 109, 116, 125, 129132, 144, 154, 160, 164, 166]. This was primarily developed for the health worker, for example a small card with sample questions [166], a more extended script package [102], a checklist [85], or the use of Gamble’s approach to guide counselling [82].

Other strategies to improve interpersonal communication.

Seven studies used other strategies to facilitate interpersonal communication, including facilitation, women and partner or family empowerment, and multidisciplinary consultations [27, 34, 57, 64, 67, 107, 150]. The strategy of La Rosa et al. [150] consisted of health workers wearing a white coat to increase patients’ confidence or to act as a non-verbal communication facilitator. Peremans et al. 2010 [64] aimed to improve the quality of communication for contraceptive counselling by general practitioners (GPs), who used a decision aid during contraceptive counselling or were confronted with a ‘standardized patient’ who was empowered to ask a few additional questions regarding their contraceptive options. Three of the seven studies used a multidisciplinary approach to improve interpersonal communication, with joint consultations involving various medical specialists, psychologists and/or nurses [27, 67, 107].

Interpersonal communication effectiveness and outcomes

Table 1 includes a narrative overview of key findings of the included studies. Outcomes assessed were diverse, and ranged from health workers’ confidence levels in their communication skills, the participants’ experiences of care, behaviour change (e.g., contraceptive uptake), to impact on health outcomes. Most studies reported a positive effect on at least one of the outcomes measured. One article reported negative consequences after the use of a decision making tool at the NICU [134].

Update of Feldman-Stewart and Brundage communication framework

Based on our findings, the reflections embedded in related articles, and the reflections of the review team, we adapted the communication framework developed by Feldman-Stewart and Brundage [14] to illustrate how interpersonal communication works. We identified four ways in which this framework could be further adapted for the context of respectful MNC (Fig 2). First, we changed the name of ‘patient’ into ‘women and partners’. This is important in MNC communication because it may help remind health workers that they relate to and communicate with not just the women, but also their partners. Second, we reformulated the communication process as the interaction between health workers, women and partners to emphasize its bidirectional nature. This bidirectional nature was already acknowledged in the original papers for the framework by using a double arrow. By explicitly mentioning it in our updated framework we aimed to create awareness that focussing on women and their partners (as well as on the health workers) might be an important alternative strategy to improve interpersonal communication. Third, we included the three communication goals (to facilitate information exchange, create a good interpersonal relationship, and enable the inclusion of women and partners in decision making) to further explain the nature of communication processes or interaction. Including the different goals of communication may remind health workers that these three goals will need different and specific attention in case they need to be improved. Inclusion of these goals in a communication framework will facilitate making deliberate choices when designing interventions to improve interpersonal communication. Fourth, we divided the ‘environment’ into different health system levels (micro, meso, and macro) to emphasize that multiple types of context influence interpersonal communication [176]. Again, for the design of interventions these can result in a more precise conceptualization of the communication process. As such, this can facilitate a better exploration of how environmental aspects at different ‘levels’ of health systems, and the environment beyond, might influence communication.

Fig 2. Updated framework for interpersonal communication in MNC, based on Feldman-Stewart and Brundage [14].


This review identified 128 different interventions to improve interpersonal communication between health workers and women and partners in MNC. We found studies across different thematic areas to facilitate cross-learning for MNC. The majority were in high-income countries. They addressed three main goals of communication: facilitating the exchange of information, creating a good interpersonal relationship, and enabling the inclusion of women and partners in the decision making. The majority of studies focused on facilitation of exchange of information, and only a few incorporated all three goals. Strategies to improve interpersonal communication primarily consisted of health worker training and providing communication tools to facilitate interpersonal communication. We observed substantial heterogeneity in intervention design, implementation and outcome evaluation and measurements. This reduced the opportunities for an evaluation of effectiveness across different interventions within this scoping review.

Interpersonal communication within health care settings is a broad and diversely defined concept. Our comprehensive approach, in which we incorporated studies about interpersonal communication within pregnancy-related reproductive health domains, facilitated learning from related domains. This helped us to build on insights from other more specific reviews of interpersonal communication improvement strategies for care during antenatal care [177], and labour and childbirth [19]. Furthermore, we added value for future communication improvement activities by exploring how different communication goals were addressed. Finally, we further improved understanding of how interpersonal communication works within the MNC context by updating the previously developed framework. As such, in the absence of a clear definition of what ‘effective communication’ is, our classification and adapted model can contribute to developing such a clearer definition.

Although arguably the principles of patient-centred care date back to the ancient Greeks [178], the concept has recently received more attention in a push to transform health care into a more individually-tailored and rights-based approach instead of the traditional paternalistic (bio)medical model. These principles are embedded in midwifery and are related to optimal outcomes for maternal and newborn care [179]. This shift to focus on the experience of care [2] and patient-centred care [7] is reflected by the growing attention to the communication goals of ‘creating a good interpersonal relationship’ and ‘enabling the inclusion of women and families in the decision making’. However, our review found that information provision was still the dominant goal used in interventions (75%), suggesting there is scope for improvement to address the other domains relevant for patient-centred care and shared decision making. The importance of this shift to patient-centred care is illustrated by a review of women’s satisfaction with maternity care in LMICs [180]. This review demonstrated that aspects of relational communication such as listening and kindness could improve maternal satisfaction [180]. Similarly, a review on the effect of patient-provider communication on health outcomes in diverse medical settings and specialisms showed that involvement of patients in decision making could lead to improved psychological and somatic health outcomes [10].

Communication is a cornerstone of healthcare [5]. Most strategies in our review focused on health workers and their interpersonal communication skills through training or tool provision, and emphasized information provision. However, interactive communication by default includes and affects women and partners as participants, and yet only a few studies in our review specifically targeted women (and their partners) in their strategies [57, 181, 182]. Therefore, a deliberate effort to address this gap and include women, partners or newborns’ families in the design of strategies could be beneficial, especially for strategies that aim to include women and partners in decision making. Such a deliberate effort could address potential factors that affect interpersonal communication and shared decision making, such as health literacy challenges or language preferences. In addition to benefits for the individual women and partners, this can also mitigate the risk of increased health inequities that arise as a consequence of interventions that are (more) easily taken up by more wealthy, educated or literate patients [183, 184]. A number of equity and inclusion-promoting communication approaches have been previously identified. These include the use of culturally appropriate and less complex language without medical jargon, messages of short duration, and clear layouts or formats. A deliberate effort to include equity promoting approaches in communication improvement interventions presents an opportunity for health workers to engage, include and empower women and partners otherwise at (high) risk of being disengaged or marginalised, and to tackle a widening health equity gap [184186].

Effective interpersonal communication is a core principle of respectful MNC, and all three goals of communication support this [187]. The recently documented unacceptably high number of women experiencing mistreatment and (verbal) abuse in maternity care worldwide [4, 188191] stresses the need to implement and test strategies to improve respectful communication [189]. A recent multi-country study showed for example that many obstetric procedures were performed without the adequate informed consent of women, including caesarean section (among 10.8% of women), episiotomy (56.1%), induction of labour (26.9%) and vaginal examinations (58.9%) [4, 192]. This lack of consent could be greatly reduced by improved interpersonal communication. More generally, better interpersonal communication could lower the occurrence of mistreatment, and has been emphasized in global guidelines as a way to improve quality of care [2, 18, 193, 194] and respectful maternity care [16, 195198].

The importance of an enabling environment, however, needs to be recognized. The health care setting at all levels (micro, meso and macro) impacts the ability of individual health workers to effectively communicate [199]. Enabling factors can include a non-excessive workload (and thus time to communicate), availability of adequate space and resources, [183, 200] and a work atmosphere where team work and good communication are the norm [199]. The enabling environment should also include the consideration of culture, which can impact understandings and expectations of what ‘good communication’ is between the health worker and women and partners [201].

This review highlights the importance of interpersonal communication between health workers and women and partners. There are other aspects of communication within MNC that can be possible anchors of quality improvement as well. These include interprofessional communication between health workers, which can be improved by simulation training [202] or ‘time outs’, deliberate interprofessional communication moments during labour [203]. Similarly, other quality improvement strategies have aimed to increase the frequency of contact moments between health workers and women, often through mobile-health [204214]. Improved information provision by health workers can also occur without an interpersonal component, for example through an information video [215] or leaflets [216]. Finally, in addition to the targeted communication improvement strategies within the scope of this review, several successful multi-component or complex interventions have been reported, that take a comprehensive approach and target various interpersonal communication aspects simultaneously. An example is the multi-component strategy of Abuya et al. [217] which covered many respectful maternity care elements including interpersonal communication between health workers and women [217]. If, how, and in what way these intervention packages work (better), is relevant to include in future studies. Because of the complex interactions between strategies and local contexts, this requires implementation research with a learning agenda on how to design to make these interventions more context specific, and what the underlying mechanisms of action are.

Strengths, limitations and future considerations

Our broad domain and systematic search enabled us to capture a large number of intervention studies and thereby to incorporate a broader perspective of effective interpersonal communication in different domains of SRH and MNH. Due to the large number of included studies, we may not have done full justice to complexities and nuances because we were only able to summarize limited information from each intervention. Language limitations may have resulted in the exclusion of relevant studies or reduced the diversity of study settings (six non-English articles were excluded). Exclusion of grey literature prevented review of potentially relevant reports from (non-governmental) organizations and other projects.

Although our search deliberately included databases that indexed journals from LMICs, the vast majority of studies were conducted in high-income settings. More research and better documentation of strategies to improve interpersonal communication in LMICs is therefore necessary, given both the need to develop culturally-tailored strategies in general and the greater health system constraints in these settings [218, 219]. Contextualized strategies appear especially relevant when targeting communication goals such as ‘building a relationship’, and ‘inclusion of patients in decision making or shared decision making’. Importantly, we believe communication strategies should always be adapted to local settings irrespective of their high- or low-income status. Because of the broad domain and inclusion of many studies from diverse settings, we believe our classification could serve well as a basis for designing strategies, measurement tools and implementation studies that can be further shaped and tailored to local settings.

Finally, our review also points towards the need to develop guidance for the reporting of communication interventions’ implementation and evaluation. We observed often a lack of detail on the exact design of a communication intervention and heterogeneity in reported outcomes, which reduces the opportunities for others to learn and adapt these strategies elsewhere. Such reporting guidance would ideally reflect the value of mixed methods designs to ensure evaluation studies report both what has been done, its effectiveness and an understanding of how the strategies worked, and whether they are sustainable over time. Existing tools [220, 221] can be used to start documenting these processes.


This scoping review provides a classification of strategies to improve interpersonal communication between health workers and women and partners. This classification can be used as the foundation to inform the design and further tailoring of strategies to improve interpersonal communication, measurement tools and evaluation studies at local settings. While most communication strategies focus on the facilitation of information exchange, incorporation of the other goals of communication (creating a good interpersonal relationship, and including women and families in decision making) are essential to ensure optimal improvement of patient-centred communication in MNC. A learning agenda on how to do this especially in low-resource settings could provide concrete and actionable guidance for settings where the burden of maternal and newborn mortality is highest, and quality of care improvements are urgent.

Supporting information

S1 Appendix. Complete search strategy for different databases.



We would like to acknowledge the contributions of Sasha Kruger to the development of the protocol, the support of Pauline Wiersma and Janneke Staaks in developing the search strategy, and Giulia Ensing and Gina Melis in references management. We thank Rio Withall for the framework visualization design. Furthermore, we would like to extend our appreciation to Action on Preeclampsia Ghana (APECGH), and especially APECGH’s CEO Mrs Koiwah-Koi Larbi Ofosuapea, for feedback on the protocol and reflections on the role of communication in care for women with hypertensive disorders of pregnancy in Ghana. Finally, we thank Linda McPhee and Steve Russell for providing input in editing this manuscript.


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