Pre-post implementation survey of a multicomponent intervention to improve informed consent for caesarean section in Southern Malawi

Abstract

ObjectiveSurgical informed consent is essential prior to caesarean section, but potentially compromised by insufficient communication. We assessed the association between a multicomponent intervention and women’s recollection of information pertaining to informed consent for caesarean section in a low-resource setting, thereby contributing to respectful maternity care.DesignPre-post implementation survey, conducted from January to June 2018, surveying women prior to discharge.SettingRural 150-bed mission hospital in Southern Malawi.ParticipantsA total of 160 postoperative women were included: 80 preimplementation and 80 postimplementation.InterventionBased on observed deficiencies and input from local stakeholders, a multicomponent intervention was developed, consisting of a standardised checklist, wall poster with a six-step guide and on-the-job communication training for health workers.Primary and secondary outcome measuresIndividual components of informed consent were: indication, explanation of procedure, common complications, implications for future pregnancies and verbal enquiry of consent, which were compared preintervention and postintervention using χ2test. Generalised linear models were used to analyse incompleteness scores and recollection of the informed consent process.ResultsThe proportion of women who recollected being informed about procedure-related risks increased from 25/80 to 47/80 (OR 3.13 (95% CI 1.64 to 6.00)). Recollection of an explanation of the procedure changed from 44/80 to 55/80 (OR 1.80 (0.94 to 3.44)), implications for future pregnancy from 25/80 to 47/80 (1.69 (0.89 to 3.20)) and of consent enquiry from 67/80 to 73/80 (OR 2.02 (0.73 to 5.37)). After controlling for other variables, incompleteness scores postintervention were 26% lower (Exp(β)=0.74; 95% CI 0.57 to 0.96). Recollection of common complications increased with 0.25 complications (β=0.25; 95% CI 0.01 to 0.49). Recollection of the correct indication did not differ significantly.ConclusionRecollection of informed consent for caesarean section changed significantly in the postintervention group. Obtaining informed consent for caesarean section is one of the essential components of respectful maternity care.

Health workers’ perspectives on informed consent for caesarean section in Southern Malawi

“…While life-threatening emergencies justify paternalism, educational levels, labour pains or refusal of treatment do not [ 1 , 3 ]. In case of low educational levels and language barriers, a structured informed consent process might still result in significant information recall [ 8 , 47 ]. It was noted that paternalistic views often coexisted with knowledge of benefits of shared decision-making, indicating knowledge alone does not automatically result in corresponding practice.…”

“…The national caesarean section rate was 6% in 2016, but the facility rate was 17% (163 out of 938 births) during the study period with the majority (84%) being unplanned [ 8 , 23 ]. The majority of caesarean sections in the study facility are performed under spinal anaesthesia.…”

“…Staff generally communicate with patients in Chichewa, but the official language during handover and for medical documentation is English. Among women giving birth by caesarean section, one in five were not able to read Chichewa or English, and half solely attended primary school or had not received any formal education [ 8 ].…”

“…Qualitative findings could serve intervention development and assure that interventions are well received by their intended audiences [ 52 ]. The current study may be an example, as the findings aided development and implementation of a consent form, guide and clinical training to improve informed consent for caesarean section [ 8 ]. In the study setting, risk recall by women who gave birth by caesarean section was unsatisfactory, which was partly attributed to partial disclosure of risks and its underlying rationale (Fig.…”

The Quality of Informed Consent in Caesarean Section at a Tertiary Hospital in Addis Ababa, Ethiopia

“…5,6 The information is often shared minutes before the start of a procedure, when patients are vulnerable and less likely to ask questions, leaving little room for informed decision-making. 4,7 Little or no explanation is given regarding the indication for surgery, procedure-related risk, or the postoperative trajectory, leaving patients vulnerable. 7 Informed consent is particularly important in obstetrics as the explanation of procedures and seeking consent is associated with an improved rating of the birth experience, while non-consented care is seen as a deterrent to skilled birth care utilization.…”