Hilder et al.

BMC Pregnancy and Childbirth (2020) 20:493

https://doi.org/10.1186/s12884-020-03015-6

RESEARCH ARTICLE Open Access

Communication in high risk ante-natal

consultations: a direct observational study
of interactions between patients and
obstetricians
Jo Hilder1* , Maria Stubbe1, Lindsay Macdonald1, Peter Abels2 and Anthony C. Dowell2

Abstract
Background: Effective communication is crucial to any doctor-patient consultation, not least in pregnancy where
the outcome affects more than one person. While higher levels of patient participation and shared decision making
are recognised as desirable, there is little agreement on how best to achieve this. Most previous research in this
area is based on reported data such as interviews or surveys and there is a need for more fine-grained analysis of
authentic interaction. This study aimed to identify the discourse characteristics and patterns that exemplify effective
communication practices in a high-risk ante-natal clinic.
Methods: We video-recorded 20 consultations in a high-risk ante-natal clinic in a large New Zealand city with
patients attending for the first time. Post-consultation interviews were conducted with the 20 patients and 13
obstetricians involved. Discourse analysis of the transcripts and videos of the consultations was conducted, in
conjunction with thematic analysis of interview transcripts.
Results: Most patients reported high quality communication and high levels of satisfaction; the detailed consultation
analysis revealed a range of features likely to have contributed. On the clinician side, these included clear explanations,
acknowledgement of the patient’s experience, consideration of patient wishes, and realistic and honest answers to
patient questions. On the patient side, these included a high level of engagement with technical aspects of events and
procedures, and appropriate questioning of obstetricians.
Conclusions: This study has demonstrated the utility of combining direct observation of consultations with data from
patient experience interviews to identify specific features of effective communication in routine obstetric ante-natal care.
The findings are relevant to improvements needed in obstetric communication identified in the literature, especially in
relation to handling psychosocial issues and conveying empathy, and may be useful to inform communication training
for obstetricians. The presence of the unborn child may provide an added incentive for parents to develop their own
health literacy and to be an active participant in the consultation on behalf of their child. The findings of this study can
lay the groundwork for further, more detailed analysis of communication in ante-natal consultations.
Keywords: Ante-natal clinic, Health provider – patient interaction, Health communication, Risk communication

* Correspondence: jo.hilder@otago.ac.nz
1
Department of Primary Health Care & General Practice, University of Otago,
Wellington, New Zealand
Full list of author information is available at the end of the article

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Hilder et al. BMC Pregnancy and Childbirth (2020) 20:493 Page 2 of 13

Background study using discourse analysis in antenatal HIV/AIDS

Good communication is crucial to any doctor- clinics in Malawi provided valuable insights into the use
patient relationship and has an important effect on of humour as a communicative strategy [45]. However,
patient outcomes including improved health, satis- there remains a need for more fine-grained interactional
faction, adherence to advice and information recall analysis to examine the detail of how participation and
[1–3], not least in pregnancy where the outcome af- effective communication are manifested or facilitated in
fects more than one person and the process and ante-natal consultations with obstetricians [21, 46].
quality of ante-natal care will always be remem- Additionally, the overall structure of consultations
bered as significant [4–6]. Maternity healthcare and the sequencing of activities within them is an im-
providers agree that listening to women and being portant aspect of effective communication in health
empathetic are important, as is using effective non- contexts. Previous research [47] has analysed the
verbal communication [7], especially when there are structure of surgical appointments compared to those
potentially negative outcomes [8, 9]. Women also in primary care and identified a typically present “re-
value empathy, the opportunity and ability to ask ferral recognition sequence” (RRS) in which the spe-
questions, time, open and respectful communica- cialist acknowledges the referral letter, including the
tion, and informativeness [10–12]. It is also widely reason for referral. This has been shown to be im-
accepted that higher levels of patient participation portant for establishing a shared frame of reference
and shared decision making in ante-natal consulta- and for the smooth progress of the consultation [47].
tions are desirable. However there is little agree- However, the structure and sequencing of specialist
ment on how best to achieve this [11, 13], and antenatal clinic consultations has not previously been
women vary in how much information they want investigated.
and how active or passive they prefer to be in ante- The aim of this study was to identify key discourse char-
natal consultations [14, 15]. acteristics and patterns that exemplify effective communi-
It has been found that the clinical setting and clin- cation practices in consultations in a high-risk ante-natal
ician communication style have more influence on pa- clinic by combining two types of data: direct evidence
tient participation than patient attributes [3]. from consultation recordings, and post-consultation semi-
However, most studies investigating communication structured interviews with participants.
in maternity care have been restricted to aspects of
communication in a narrow range of settings such as Methods
midwife consultations [16–20], genetic counselling This qualitative study used mixed qualitative
[21–28] and women in labour [29–31], and research methods, drawing on the discourse analytic approach
relevant to practitioners may be published outside the of interactional sociolinguistics [48, 49] and using
medical arena [32]. multiple data sources. In contrast to much qualita-
In addition to the need for more research on patient- tive research in this area which often relies on a sin-
provider communication generally in obstetric care [33], gle type of data (frequently interviews), we combine
the specific details of communication style that are most direct observation and discourse analysis of verbal
effective in this setting remain under-investigated. Most and non-verbal communication in video-recorded
studies investigating communication in maternity care consultations with a thematic analysis of post-
rely on reported data such as interviews or surveys. consultation interviews that focused on participant
Where observational methods are used (some with perceptions and experiences of communication in
video- or audio-recordings), consultations are often the same consultations.
coded using a deductive quantitative approach that does Video recordings were made of routine consulta-
not take into account the subtleties of natural inter- tions with consenting patients and obstetricians (ei-
action [34–36]. Current advice for health professionals ther consultants1 or registrars2) in a high-risk ante-
on how to improve communication therefore tends to natal outpatient clinic in a tertiary hospital in a large
be very general in nature, and does not take account of New Zealand city. The hospital has a regional catch-
the complex, dynamic nature of interactions in real-life ment that encompasses diverse socio-economic areas.
consultations, making it difficult for clinicians to imple- Most pregnancies in New Zealand are primarily man-
ment in practice. aged by publicly funded mid-wives or general practi-
Whilst there is a substantial body of work involving tioners, although some women choose privately
analysis of directly observed interaction in primary care, funded obstetric care. These recorded consultations
particularly using video [37–44], there is much less re-
search into the features of effective communication in 1
i.e. fully trained specialists (‘attending physician’ in the USA)
2
other contexts. This is an important gap. For example, a i.e. specialists in training/under supervision
Hilder et al. BMC Pregnancy and Childbirth (2020) 20:493 Page 3 of 13

were undertaken in the public system where referral Data analysis

has come from a midwife or general practitioner in The recordings of all consultations and interviews
response to a specific indication of high risk. Referral were fully transcribed and anonymised by the re-
letters are not normally given to patients in the New moval of identifying details such as names of people
Zealand public health system. and places. A log of the activities in each consult-
Patients who were attending the clinic for the first ation was created and proofed by a clinical member
time were asked for consent to participate. This was of the team. The inductive analysis followed an itera-
to ensure a more homogenous sample in that all pa- tive process which alternated between individual
tients would be likely to be meeting the clinician analysis by the main field researcher (a discourse
for the first time. Shortly after the consultation, analyst and the team member with the most intimate
short semi-structured interviews (mostly around 5 knowledge of all the data) and group data sessions
min) were conducted separately with both patients with the wider multi-disciplinary team of clinicians
and obstetricians, and consent to obtain medical and applied linguists. The initial individual analysis
notes for the consultation was requested. The inter- combined a thematic analysis of the interview data
views used open questions to ask participants to (using NVivo software) in tandem with a structural
comment on the communication in their consult- discourse analysis of the consultations which identi-
ation and their level of satisfaction (see appendix 1 fied macro-level features of the interactions includ-
for the interview guides used – in practice many of ing length of consultation, overall structure
the questions to patients about risk were not asked (including the RRS), how openings were managed
due to the sensitivity of the topic and the time and reasons for referral. This was supported by
available). ethnographic information (field notes and medical
notes). Validation (or otherwise) of these initial ana-
lyses was provided by the multi-disciplinary team
Data collection which comprised an obstetrician, and general practi-
Data was collected between June and November tioner and a nurse and two non-clinical health com-
2016. Consent from clinic staff to video some of munication researchers (experienced in interaction
their consultations was obtained ahead of time. Staff analysis and ethnography of communication). These
identified patients attending the clinic for the first data analysis sessions involved viewing and analysing
time and a female researcher approached them in video and transcript data against the analysis, and
the waiting room to seek their informed consent included attention to non-verbal features of the
(full briefing and written consent was then carried interaction including gaze direction, facial expres-
out in a private room). Where consent was granted, sions, nods, body positioning and activities during si-
a single small camera on a slim tripod was dis- lences. Later iterations of this two-stage process
creetly set up in a corner of the consultation room included searching for interactional evidence (or
so that the video captured all participants’ faces and counter-evidence) in the consultation data for each
most of their bodies. A small audio recorder was of the themes emerging from the interview data. Any
also placed on the desk as a backup. This equip- disagreements within the research team were re-
ment was set up and turned on at the beginning of solved through discussion and consensus. Several
the consultation by the researcher who then left the further cycles of individual analysis and group data
room. Interviews after the consultation were audio- sessions resulted in a set of initial findings which
recorded. The patient and any accompanying adults were presented back to the clinical participants in
(often the woman’s partner) were asked for a brief the research, and the rest of the clinic staff. This
interview in a consultation room immediately fol- provided an opportunity for further clinical feedback
lowing the consultation. Obstetricians were inter- on our methods and findings, which then led to fur-
viewed at the end of their clinic, or by email if they ther revision and refinement.
preferred. Medical notes for the consultation were All analysis deliberately followed an appreciative en-
obtained where consent was given to support ana- quiry approach [50–52]. The focus was thus princi-
lysis and interpretation of the consultation record- pally on identifying positive features of the interaction
ings and interviews. The field researcher wrote as well as locating interactional evidence for the
ethnographic field notes to provide additional back- themes from the interviews which represented the
ground information. Participants were also asked for participants’ perpectives. At the same time, other rele-
consent for their data to be added to a permanent vant features that came to light were noted and taken
corpus of health interactions for potential future into account in the analysis and interpretation of the
ethically approved research. data.
Hilder et al. BMC Pregnancy and Childbirth (2020) 20:493 Page 4 of 13

Patients were not involved in the design or analysis of Table 1 Demographic characteristics of patients
the study. n = 20
Ethnicity
Results NZ European 8
Participants
European 2
Thirty two patients were approached to participate, of
whom 7 declined. A further 5 patient consultations Māori 2
were not recorded for logistic reasons. Recordings Pacific 2
were made of 20 patients in consultations, 11 of Asian 6
whom were accompanied by a partner or other family Age
member (18 video and 2 audio only). One consult- 20–24 1
ation was only partially recorded at the doctor’s re-
25–29 7
quest. Sixteen of the 20 patients and those
accompanying them were interviewed (the remaining 30–34 5
patients declined due to time constraints). Two pa- 35–39 7
tients declined consent for their medical notes to be Education
obtained. Thirteen obstetricians were filmed across PhD 1
the 20 consultations, all of whom were interviewed Masters 2
afterwards (one via email).
Bachelors 4

Participant characteristics Polytechnic degree 9

The patients were between 20 and 39 years old, with Professional Qualification 1
more in the older age bracket (12/20 aged 30–39); Secondary School 2
half were of European background (most of whom Other 1
were New Zealand born) and most were well- Parity
educated. More than half (13/20) had given birth be-
0 7
fore. (See Table 1).
The 13 obstetricians in the study included 6 consul- 1 10
tants (11 consultations recorded) and 7 registrars (9 2 1
consultations recorded). Most were female (9/13) in- 3 2
cluding all of the registrars, and included overseas
and locally trained doctors with a range of obstetricians to deal with the main referral issue first
experience. and to back-fill the medical history later in the con-
sultation, while registrars most often began with the
Consultation characteristics medical history.
As background to and context for the analysis of the Most of the doctors (17) read the patient notes prior
quality of the communication that follows, we initially to beginning the consultation, although for three of the
report on several descriptive features of the consulta- patients who saw a consultant, the notes were read dur-
tions: length, structure, reasons for referral and the ing the consultation.
structure of the consultation openings.

Length of consultations Reasons for referral

The length of consultations ranged from about 15 min The reasons for referral to the high-risk antenatal
to nearly an hour. Of the 19 full length consultations re- clinic were varied, and often there was more than
corded, 13 were 15–30 min in length and six were 30– one reason for referral. The most common reasons
60 min. The average length of consultation was 28 min, were previous caesarean delivery - often in combin-
with registrars being more likely to have longer ation with other reasons (7), large or small for
consultations. dates (2), twins (2) and bleeding (3). Other reasons
for referral were: recurrent miscarriage; high BMI3;
Consultation structure threatened pre-term labour; previous infant deaths;
Eleven of the consultations began with a discussion of hip dysplasia; recurrent herpes; low platelets; episode of
the main referral issues while six began with the dizziness/shortness of breath; low thyroid levels;
medical history (three had an unclear structure).
3
There was a tendency for the more experienced Body Mass Index
Hilder et al. BMC Pregnancy and Childbirth (2020) 20:493 Page 5 of 13

schizophrenia management; malignant hyperthermia; la- Table 2 Patterns of Referral Recognition Sequence (RRS)
tent tuberculosis; and previous HLH4 infant deaths. Type of RRS Example N
1. Immediate explicit RRS 9
Referral recognition sequences a. ‘who from’ and ‘why’ “So your midwife … has asked 5
A clear referral recognition sequence (RRS) was identi- you to come in and see us today
fied in 18 of the 20 consultations.5 Table 2 shows the because baby’s a little bit small?”
(AN-SP25R-01)
patterns for referral recognition sequence (RRS) that
were found. b. Immediate explicit RRS SP: “So you’ve been referred to 4
‘who from’ with delayed ‘why’ us by your midwife right?” … [SP
In half of the consultations, the RRS was explicit and reads notes]
mentioned both who had made the referral and why, al- PT: “So what is this appointment
though in nearly half of these, there was some delay in about today?”
(AN-SP29–01)
relaying the reason for referral. This delay meant that
2. Immediate implicit RRS “So because this is your first visit 6
patients were unclear about some aspects of the referral
… I’ll ask you a few questions
for a time and could result in some discomfort where about yourself and then we’ll talk
patients explicitly asked for the reason for their referral about the twins”
(AN-SP28R-01)
(as in the example for RRS Type 1b), or in other cases
showed increased anxiety. This happened when patient 3. Elicitation of patient 3
perspective
notes were being read during the consultation, which
was more common among the more experienced consul- a. Immediate explicit RRS “So the reason that you’ve been 1
(‘who from’ and/or ‘why’) plus referred was that I understand
tants. Apart from this tendency, there were no other elicitation of PT perspective that you had a bit of bleeding
clear differences between consultants and registrars in when you were in ((COUNTRY)).
the use of RRS patterns. Okay, tell me a little bit about
that”
(AN-SP28R-02)
Quality of the communication in the consultation
b. Immediate elicitation of “So I guess the first thing is, do 2
Analysis of participant interviews and of the con- ‘why’ (with or without ‘who you know why you’re here?”
sultation recordings highlighted a number of fea- from’) (AN-SP36R-01)
tures that contributed to a sense of high quality “alright so i’ve got a referral for
communication and of patient satisfaction. Patient you from the midwife just telling
me a wee bit about you know
interview responses were almost universally positive, why you’re here? obviously you
with all but one of the patients expressing satisfac- guys are pregnant
tion overall with the communication in the consul- congratulations um, but, yeah do
you wanna sort of tell me in your
tations. Comments on communication ranged from own words what’s sort of what’s
“good” (AN-SP34R-01 PT interview), to “he’s very been happening and where
good with his communication skills” (AN-SP29–01 you’re at and, why you’re here”
(AN-SP27–02)
PT interview), through to “amazing…. I think the
best doctor I’ve seen.” (AN-SP36R-01 PT interview).
The following more specific positive features of the
communication emerged from the mixed methods ana- visible (Quote 1.1), while another specifically acknow-
lysis. Tables 3 and 4 contain illustrative quotes from the ledged the difficulty of good communication with
interview data and excerpts from transcripts of the actual someone you have not met before (Quote 1.2). Patients
consultations that are referred to below. also explicitly mentioned thoroughness or described a
thorough approach, as in Quotes 1.3 and 1.4. Within
1. Informative, thorough and clear communication the consultations, this was evidenced by the coverage
of multiple topics and the detailed discussions ob-
Nearly every patient (and/or accompanying adult) who served (the length of which make it impractical to
was interviewed (15/16) mentioned this in their evalua- reproduce an example here). An example of clear and
tions of the communication, as shown in the selection of informative communication is given in Consultation
quotes in Table 3. One patient appreciated the way in Excerpt 1.1 in which the registrar goes to some
which the thought processes of the doctor were made length to explain the reason for the extra concern
with a baby that is small for dates, using an extended
4
Hemophagocytic Lymphohistiocytosis metaphor to make the point.
5
The lack of RRS in the remaining 2 consultations was for clear
reasons: one patient, while technically new to the clinic, was actually
continuing care with the same obstetrician; the other was attending a 2. Explanations delivered in clearly signalled
follow-up to an emergency hospital admission. components
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Table 3 Interview quotations that illustrate the themes from Table 3 Interview quotations that illustrate the themes from
the interactional analysis the interactional analysis (Continued)
1 Informative, thorough and clear communication 7. Good rapport
Quote 1.1: Quote 7.1:
“you could see what was going on in their head a little bit” “[they] made me feel very at ease pretty quickly … [they] seemed very
AN-SP25R-01 (PA) (PT interview) relaxed, and … I guess it made me more relaxed too”
Quote 1.2: AN-SP36R-01 (PT interview)
“For a person that I haven’t met before, [they were] really good with Quote 7.2:
explaining information…it’s hard to find doctors who can actually sit “[they] made me feel very comfortable”
you down and take you through everything.”6 AN-SP28R-02 (PT interview)
AN-SP29–01 (PT Interview)
Quote 1.3: 8. Patient displays of knowledge
“Yeah, I mean [they were] very thorough” Quote 8.1:
AN-SP26–02 (PT Interview) “I think she came in with a good idea about these risks.”
Quote 1.4: AN-SP29–01 (SP Interview)
“[they] definitely addressed everything that we needed to think about.” Quote 8.2:
AN-SP30R01 (PT Interview) “They were a lovely couple that had already done a lot of reading...
which makes it a lot easier. I think it’s difficult when people come in
2 Explanations delivered in clearly signalled components
and they have either done no reading, or have no idea about which
Quote 2.1: way they want to go. And then it becomes a lot more difficult, because
“The way they structure it... instead of jumping from one information to of the clinic... we do kind of pressure them into trying to make a
the other, [they] must have structured the whole entire appointment, decision one way or the other. But then that is difficult to make such a
yeah, which was really good.” big decision in a sort of 15 to 30-min consult. So they were sort of
AN-SP29–01 (PT Interview) already well up-to-date with what they needed to know. So that was
Quote 2.2: helpful.”
“talked point by point... rather than looking at the big, scary picture. Sort AN-SP30R-01 (SP Interview; VBAC clinic)
of broke it down, which made it a lot easier to be able to discuss you Quote 8.3:
know, the little details, and then building up into the... the big “I think they’d come well prepared”
conversations” AN-SP29–03 (SP Interview)
AN-SP36R-01 (PT Interview)
6Note, pronouns referring to obstetricians have been changed to “they” to
3. Feeling listened to and their experience acknowledged further protect anonymity.
(especially anxiety)
Quote 3.1: Informativeness and clarity was enhanced by clearly
“they didn’t just cut me off and dismiss my... concerns”
AN-SP34R-02 (PT Interview) structured communication that patients reported experi-
Quote 3.2: encing in their consultations, as evidenced in Quotes 2.1
“it felt like it’s okay to be worried kind of you know, like it’s okay how and 2.2.
you’re feeling”
AN-SP25R-01 (PT Interview) Clear signalling of topics and agendas was directly
observed in many of the consultations; this made the
4. Feeling able to ask questions and get them answered
structure more obvious, as seen in Consultation Ex-
Quote 4.1:
“Lots of opportunity to ask questions”
cerpts 2.1 and 2.2 in which the doctor first explicitly
AN-SP30R-01 (PT Interview) indicates they are about to deliver an ‘informing’,
Quote 4.2: then numbers off the topics to be discussed in the
“I did ask a lot of questions…. but they were all answered, so yeah.”
AN-SP31–02 (PT Interview)
consultation as a way of signposting the stages of the
explanation.
5. Consideration of patient wishes and provision of options
Quote 5.1: 3. Feeling listened to and feelings/experience
“[they] gave us options”
AN-SP27–02 (PT Interview) acknowledged (especially anxiety)
Quote 5.2:
“Just like, ask me my opinion, what I want to do” While the question was not always specifically asked
AN-SP31–01 (PT Interview)
in the semi-structured interview (depending on how
6. Realistic and honest communication
the conversation went), when 12 patients were expli-
Quote 6.1: citly asked if they felt they were listened to, all
“[they are] quite realistic, so that’s something I like to know. I don’t want
to bat around the bridges.” responded positively for example, in Quote 3.1. One
AN-SP29–01 (PT Interview) patient in particular mentioned feeling that their anx-
Quote 6.2: iety had been legitimised (Quote 3.2).
“it felt it felt very open … and kind of factual and that they weren’t
hiding anything i suppose” Within the consultation, several doctors explicitly
AN-SP25R-01 (PT Interview) acknowledged the worry or anxiety patients may feel,
as shown in Consultation Excerpt 3.1, and also in ex-
cerpt 6.2 (lines 13–20). In excerpt 6.2 (lines 15–16),
the clinician explicitly claims to understand that the
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Table 4 Data extracts from the consultation transcripts that Table 4 Data extracts from the consultation transcripts that
illustrate the interactional analysis illustrate the interactional analysis (Continued)
Hilder et al. BMC Pregnancy and Childbirth (2020) 20:493 Page 8 of 13

patient is and will be ‘anxious’ and ‘stressed out’, or caesarean will be considered, quickly checking on
using informal language (such as ‘gonna’ and ‘aren’t whether the patient has received information on the
ya’) that serve to minimise the social distance be- options. At line 5, the clinician asks a completely open
tween clinician and patient, and quiet talk to index question that is not tilted towards either of the available
the sensitivity of this. The clinician also phrases their options. The patient expresses her preference for a
statement so that patient agreement is the ‘preferred caesarean section and the clinician explicitly affirms the
response’ [53] by using a tag question (‘aren’t ya’). importance of the patient’s preferences in lines 16–19, after
The patient does indeed agree (line 17). noting the need for clinical assessments (lines 11–14).
A good example of a patient’s previous experience In another consultation (for which no patient inter-
being acknowledged with empathy is shown in Con- view was conducted), there was a little more negotiation
sultation Excerpt 3.2, where in addition to the min- as to whose wishes might prevail (see Consultation Ex-
imal responses (such as “yeah”), the doctor provides cerpt 5.3). When the obstetrician expressed an opinion
brief but effective acknowledgement of the impact of that was at odds with the patient’s preferences (lines 4–
the experience on the patient at line 6 with a simple 5), there was push-back from the patient in line 6. The
“wow”, and with an explicitly empathic statement at obstetrician went on to explain the risks if a herpes le-
line 15–16. sion was present in labour and that the patient may not
be aware of a lesion, adding:
4. Feeling able to ask questions and get them answered
“as long as you're aware of that situation then you'd
Many patients (9/16) specifically mentioned in inter- be better informed to make that decision, that's
views that they felt comfortable to seek further informa- number one”
tion or explanation, as seen in Quotes 4.1 and 4.2. One
illustration is seen in Consultation Excerpt 4.1 where the While emphasising the importance of medication and
partner of the patient spontaneously asked the doctor to extra scans regarding small gestational size, the obstetri-
provide more information, which was responded to at cian also acknowledged that the patient had a “fair
length. point” on several occasions during the consultation,
In Consultation Excerpt 4.2, the consultant has been which explicitly validated the patient’s perspective. By
giving information at some length, and it is noteworthy presenting information and options and acknowledging
that the patient, at line 6, begins an assertive bid to par- the patient’s perspective, even when being challenged,
ticipate (“so”, just before the consultant has finished the obstetrician succeeded in keeping the interaction on
speaking. The patient here successfully gains the floor at positive terms and negotiations friendly and respectful.
line 8 and asks their question. This illustrates that even
in more challenging interactional contexts such as this, 6. Realistic and honest communication
where a specialist is engaged in an extended informing
sequence (which patients typically do not interrupt), the Two patients particularly appreciated straightforward
patient here indeed had a level of comfort with active and realistic communication from the doctors (Quotes
participation. The doctor, while completing their turn in 6.1 and 6.2). Other patients reported positively on con-
the face of the patient’s bid for a turn, then gives the sultations in which open and realistic talk was observed,
floor to the patient, maintaining mutual gaze and nodding such as Consultation Excerpt 6.1 in which a registrar
as a ‘go-ahead’. comments on the inherent uncertainty in this setting.
Consultation Excerpt 6.2 is another example of plain
5. Consideration of patient wishes and provision of talking that appeared to be appreciated. In line 5, the
options doctor uses very direct, colloquial language to talk about
the possibility of the uterus ‘pulling apart’, albeit soften-
Five of the patients specifically mentioned the fact that ing the words by lowering the volume of talk.
they were given options and that they felt their wishes
were sought and respected, as seen in Quotes 5.1 and 7. Good rapport
5.2. Again there was evidence of this occurring in the
consultations. Consultation Excerpt 5.1 illustrates an ob- Several patients mentioned the way in which doctors
stetrician explicitly telling patients that they aim to in- made them feel relaxed and comfortable, as in Quotes
form them of their options. Consultation Excerpt 5.2 is 7.1 and 7.2.
from a Vaginal Birth After Caesarean (VBAC) clinic con- Simple things like handshakes and small talk that may
sultation with a non-native speaker of English. The clin- elicit laughter contributed to building rapport and mak-
ician makes it clear that patients’ preferences for VBAC ing patients and those accompanying them feel welcome
Hilder et al. BMC Pregnancy and Childbirth (2020) 20:493 Page 9 of 13

and comfortable. A simple example is shown in Consult- able to meet women’s need for effective communication
ation Excerpt 7.1 where the patient’s partner, who arrived [54]. Some of the consultations were quite long (up to 1
late, was explicitly made welcome with introductions hour), and the length of consultations may have contri-
and small talk that elicited laughter. buted to high satisfaction levels.
The overall structure of the consultations varied ac-
8. Patient displays of knowledge cording to the level of experience of the doctors, with
more experienced consultants able to “cut to the chase”
In addition to the opportunities patients had to ask by not exhaustively following medical checklists. While
questions and participate, patients and those accom- most of the existing literature about consultation length
panying them were also able to display their knowledge, comes from General Practice [55], this study aligns with
with many of them having experienced childbirth before. hospital outpatient findings in which registrars took
Such patients spontaneously used clinically appropriate more time with patients than consultants [56]. Registrars
technical terms such as “placenta praevia” (AN-SP31– sometimes completed a medical history before moving
02) or “breech” (AN-SP36R-01). The patient in Consult- to the referral and this may have contributed to their
ation Excerpt 4.2 (discussed above) displayed her confi- longer consultations. The importance of the opening of
dence in her knowledge with an interruption (line 6) the consultation and of the referral recognition sequence
that treats the doctor’s partial utterance (‘if it’s not going (RRS) in specialist practice, as reported elsewhere, was
well’) as sufficient (indicating that she doesn’t need to confirmed in this data set; when there were delays in the
hear the rest of the explanation). Her following turn full RRS being completed, the smooth progression of the
(lines 8–9) further displays her understanding by her use consultation was disrupted with patients sometimes ask-
of the term ‘induction’ in a way that links back to the ing explicitly why they were there or showing signs of
doctor’s discussion of triggering labour by breaking wa- increased anxiety in the face of this uncertainty.
ters (i.e. displaying her understanding that this is a form Generally patients reported that their feelings were
of induction). heard, anxieties acknowledged and questions answered.
In interviews, the obstetricians explicitly valued pa- Again this was reflected in observations of the recorded
tients being well-informed, especially in view of the lim- consultations, which also showed high levels of partici-
ited consultation time available (see Quotes 8.1–8.3), pation and invitations for shared decision making. Many
and were observed in consultations giving patients op- patients displayed fluency in many aspects of the discus-
portunities to display their knowledge, thus also ascer- sion in the consultations, including familiarity with clin-
taining their current understanding. Even those without ical terminology and a biomedical framing of the
previous childbirth experience were given opportunities conditions contributing to the high risk state, especially
to display recently acquired knowledge, as shown in where they had previous experience of complications in
Consultation Excerpt 8.1 in which the patient is a pregnancy and childbirth. This is not to say that the
young first time mother. Here the doctor initially talked communication observed was uniformly positive, but
in non-technical terms (line 1) and asked a question at our appreciative inquiry stance provides a constructive
line 3 which opened up the floor to the patient to basis for recommending strategies and practices that are
answer with a narrative that led up to her attempting to likely to enhance quality of communication.
provide the technical term herself. The patient also later
displayed her familiarity with the type of twins in line Strengths and limitations
11. We are not aware of other studies that have directly
observed the detailed interactional processes at work in
Discussion a generic high risk ante-natal clinic, and that correlate
Main findings these direct observations with interview data from both
This study explores the quality of communication in patients and clinicians. Limitations of the study are the
routine obstetric ante-natal care using methodology that small size of the data set, possible skewing in the patient
combines direct observation techniques with experiential sample towards older and more highly educated women,
data from patient interviews, and with a specific focus and the observer effect (the communication in the con-
on identifying specific features of consultation discourse sultations may have been affected by the presence of the
that contributed to patient-reported satisfaction and recording devices, with participants perhaps inclined to
quality of communication. show themselves in the best light). The interviews were
Overall, patients’ reports on the communication in also limited by their short length (to minimise impos-
their consultations were very positive, and these reports ition on participants). Some patient responses in inter-
were confirmed by researchers’ analysis of the recordings views may have been affected by a reluctance to criticise
which indicates that the clinicians in this setting were their clinicians.
Hilder et al. BMC Pregnancy and Childbirth (2020) 20:493 Page 10 of 13

Interpretation Ante-natal and maternity care is a clinical environ-

Our results show that communication in the high risk ment where health literacy can have an important im-
ante-natal context studied here differs from that docu- pact on outcomes [69]. We observed examples where
mented in other health settings in a number of ways, patients displayed knowledge and were willing to ask
notably the high levels of patient participation and the questions in often complex areas of care such as choices
ways in which risk is discussed. regarding operative intervention or the type and timing
Given the challenges that clinicians in all disciplines of imaging, indicative of high levels of health literacy.
often face in achieving effective interaction with patients, The presence of the unborn child as an unseen and un-
the results portray a positive picture of doctor patient heard additional patient who needs to be cared for by
communication and a relatively empowered and well- the mother (and partner) may provide an added incen-
informed cohort of patients [57–59]. Our results accord tive for patients to further develop their own health liter-
with survey studies that found an association between acy and to be an active participant in the consultation
‘high quality’ interactions with realistic and clear infor- on behalf of their child.
mation and reassurance [60, 61]. The high level of pa- The explicit way that risk is talked about was notice-
tient satisfaction is consistent with a 2008 review of able in the interactions and reported by patients as being
maternity services in this region of New Zealand which appreciated. Risk was framed in ways that were clearly
found low levels of dissatisfaction among 115 partici- articulated and understood. Explicit orientation to risk
pants [62]. The specific elements that were highly rated seems acceptable in this context where patients have
in our interviews and observed in the consultation data been referred to a high risk antenatal clinic, a finding
are largely consistent with more high-level descriptions that is congruent with other research [70]. For example,
in other studies of what patients want from maternity in this study doctors opted to manage the potential for
care generally [10–12, 54]. causing anxiety by explicitly addressing clinical risks, ra-
Previous research on surgeon communication has ther than avoiding such talk which may then prolong
emphasised the need to make sure that patients are en- uncertainties and worry [70]. Focus group studies with
abled to present their problems fully, despite the surgeon women on topics such as gestational weight gain also in-
already having another source of information (achieved dicate that women prefer these issues to be addressed
through the RRS) [47]. This ensures that patient and explicitly but sensitively [71–74].
doctor are aligned about the purpose of the consultation.
Attending to this by getting the topic of ‘risk’ on the Conclusion
table early in the consultation is also a way to reduce This study provides detailed information about com-
anxiety for patients who, by definition, know they have munication in ante-natal care, and has identified a
been referred for some reason. Our analysis of the ways number of features of interaction in consultations
in which the specialists in our data achieve the referral which may explain high levels of satisfaction by pa-
recognition sequence provides detail about the commu- tients (and those accompanying them). In contrast to
nication that underpins overall perceptions of effective much of the literature which emphasises the chal-
communication, and this can inform training in medical lenges of appropriate communication and shared deci-
communication. sion making in maternity care, this case study has
The high level of patient participation observed in provided many examples of good communication
this study contrasts with earlier studies which found practice. Previous research has identified a need for
that many women undergoing antenatal care did not better training in obstetric communication [75], espe-
actively participate and were uncomfortable with deci- cially in handling psychosocial issues and in convey-
sion making responsibility [15], rarely asked questions ing empathy, which have been shown to be teachable
and were not encouraged to do so [63], and often did [76, 77]. The findings of this study can inform com-
not share in decision making [34]. The increased munication training for medical students and other
‘agency’ that we observed may be due to recent efforts less experienced health professionals and lay the
to develop more ‘patient-centred’ care [64–66] and groundwork for further, more detailed analysis of
shared decision making [67, 68]. The high participa- such communication.
tion levels may also have been influenced by the pa-
tients feeling that they were being given options and Appendix 1:Interview guides for patients and
their choices respected, an endorsement of the com- clinicians
munication styles of the study doctors. The fact that Interview guide - Patients.
patients felt that the doctors were informative, clear Preamble. Thank you again for agreeing to be part of
and realistic with the information they provided also this study. I’m going to ask you now about the consult-
contributes to shared decision making. ation you have just had. We are especially interested in
Hilder et al. BMC Pregnancy and Childbirth (2020) 20:493 Page 11 of 13

communication; in how information is exchanged 3. Do you think the video recorder being there
between patients and doctors. changed the communication in any way?
1. Have you met this doctor before?
Abbreviations
2. Is this your 1st pregnancy? (specify if not).
RRS: Referral recognition sequence; VBAC: Vaginal Birth After Caesarean
3. Tell me briefly what this consultation has been
about. Key to transcription
I would like to ask you now a bit more about your SP: Specialist; RG: Registrar; PT: Patient; PA: Patient’s partner; [ ]: indicates
simultaneous speech; more: emphasis; ((loudly)): indicates how the following
pregnancy and how you think things are going. words in italics are spoken; or non-verbals; ((NAME)): name removed for
CHOOSE FROM FOLLOWING AS APPROPRIATE confidentiality; (1): pause of 1 second
FOLLOWING INITIAL CONVERSATION
Acknowledgements
We would like to thank the women, their family members, and the
 Has the doctor indicated there are any things to be physicians who participated in this project, and the clinic staff who helped
looking out for in your pregnancy, or any things that to facilitate recruitment. We would also like to thank Rachel Tester, ARCH
are going to be monitored or checked during the Data Manager, for her contribution to the project.
pregnancy?
Availability of data and material
 How do you feel about those things? The datasets generated and analysed during the current study are not
 Do you think they make your pregnancy more risky publicly available since they were collected on a confidential basis. The data
than it might be otherwise? are part of the ARCH Corpus at the University of Otago (https://www.otago.
ac.nz/wellington/research/arch/corpus/).
 Has the doctor talked to you about risks?
 What do you understand about those risks? Authors’ contributions
 Overall do you think there are particular things All authors contributed to the research design and data analysis, and
critically reviewed the final manuscript. JH conducted most of the fieldwork,
which make your pregnancy more risky than in undertook the initial data analysis, and drafted the manuscript. MS
your previous pregnancy (or compared to other contributed to writing of the manuscript, providing advice from an
women having a baby if this is the first interactional linguistic viewpoint. TD contributed to the writing of the
manuscript, providing advice from a clinical point of view. LM contributed to
pregnancy) the fieldwork and initial data analysis. PA contributed clinical oversight from
 Do you think these risks are mainly to the baby and a specialist point of view to the fieldwork and data analysis. All authors have
or to you? read and approved the manuscript.
 In what way?
Authors’ information
 Do you think the risks would be mainly affecting you All authors are members or associates of the Applied Research on
/ your baby before, during or after the baby’s birth? Communication in Health Group (ARCH), a multidisciplinary group of
 How well do you think the doctor explained those researchers based in the Department of Primary Health Care and General
Practice, University of Otago, Wellington. The ARCH Group studies all aspects
risks to you? of communication in health care, with a special focus on analysing how
 Do you feel reassured about things as a result of people interact in real-life health care interactions. Members and associates
what the doctor has said? have a range of clinical and social science backgrounds in the fields of pri-
mary health care, public health, sociolinguistics, sociology, psychology and
 Are there any other things that have reassured you conversation analysis.
or that would reassure you?
Funding
4. Did you understand everything that the doctor This study was funded by a University of Otago Research Grant (UORG 2016).
The funding body did not have any involvement in the design or conduct of
talked about? this study or in the publication of its findings.
5. Do you think the doctor listened to you and heard
what you had to say? Ethics approval and consent to participate
This study was approved by the University of Otago Human Ethics
6. Are there any other challenges or difficulties? Committee (Health) - Ref: H16/012. Written consent was obtained from all
7. What other comments would you like to make participants (patients, accompanying adults, and clinicians).
about communication in this setting?
8. Were you satisfied with the outcome of the Consent for publication
The participants gave consent to publish data from this study on condition
consultation? that no material which could identify an individual would be used in any
9. Do you think the video recorder being there chan- publications without explicit consent. All data used in this paper have been
ged the communication in any way? de-identified to maintain confidentiality.
Interview guide - Clinicians
Competing interests
The authors declare that they have no competing interests.
1. Quick summary of content and outcome of the
consult Author details
1
Department of Primary Health Care & General Practice, University of Otago,
2. Any comments on how the communication went (any Wellington, New Zealand. 2Department of Obstetrics and Gynaecology,
challenges or why it went particularly well or not)? University of Otago, Wellington, New Zealand.
Hilder et al. BMC Pregnancy and Childbirth (2020) 20:493 Page 12 of 13

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