Effective Communication in Perinatal Care

ComPARE (effective COMmunication in Perinatal cARE) is a cross-sectional observational study investigating the clarity, accessibility, and effectiveness of communication between healthcare professionals and pregnant individuals during prenatal consultations concerning vaginal birth after caesarean (VBAC).

Doctor-patient communication is an integral component of clinical care and is essential for establishing trust, supporting patient autonomy and shared decision-making, and promoting patient safety and quality of care. In clinical communication, misunderstandings may arise not only from the explicit content of what is said, but also from implicit assumptions, contextual cues, presuppositions, and non-literal meanings. The TouCAN Codebook (Textual misUnderstanding Codebook ANalysis) provides a structured linguistic framework for identifying markers of potentially problematic communication that may hinder mutual understanding. The present study applies this approach to perinatal care, with a specific focus on consultations concerning VBAC.

The study addresses the need for research specifically examining communication practices in VBAC counselling. These consultations involve the communication of complex and risk-sensitive information concerning pregnancy and birth and require information to be conveyed in a clear and accessible manner to support informed and autonomous decision-making.

The study population consists of 50 pregnant individuals considering VBAC and 12 healthcare professionals from IRCCS Ospedale San Raffaele, including 6 obstetricians and gynaecologists (OB-GYNs) and 6 midwives with expertise in VBAC. Eligible pregnant participants are Italian-speaking individuals aged 18-44 years with a singleton pregnancy between 33 and 37 weeks of gestation, a history of caesarean section in a previous pregnancy, and a scheduled VBAC counselling consultation at IRCCS Ospedale San Raffaele. Participants must provide written informed consent and plan to deliver at San Raffaele Hospital.

The study is non-interventional and does not involve medicinal products, medical devices, diagnostic procedures, or therapeutic interventions outside routine clinical practice. The clinical consultation is conducted according to standard care, and participation in the study does not influence the healthcare professional's clinical decisions or the diagnostic or therapeutic pathway.

The study procedures include three main components. First, the participant attends the scheduled outpatient prenatal consultation with an OB-GYN or midwife experienced in VBAC. The consultation is audio-recorded to allow subsequent linguistic analysis. Second, following the consultation, the participant takes part in the SSI-CLAR semi-structured interview, lasting approximately 30 minutes, which assesses the participant's perceived clarity of communication, tone, accessibility of language, and subjective understanding of the information received. The interview is also audio-recorded and subsequently analysed using thematic analysis. Third, after delivery, information is collected concerning the method of delivery, specifically whether the participant underwent VBAC or caesarean section and, in the case of caesarean section, the clinical indication.

The primary objective is to evaluate the clarity and effectiveness of communication between healthcare professionals (OB-GYNs and midwives) and pregnant individuals during prenatal consultations concerning VBAC. The primary endpoint is the level of misunderstanding in clinician-patient conversations, measured through systematic analysis of consultation transcripts using the TouCAN Codebook. Coded misunderstandings will be quantified as counts and, where appropriate, as rates per consultation. Inter-rater reliability will also be assessed.

A secondary objective is to assess whether there is a match or mismatch between patterns of misunderstanding identified in clinical conversations and patients' own perceptions of communication as reported in the post-consultation interviews. The secondary endpoint is the degree of convergence or divergence between the level and types of misunderstandings identified through TouCAN Codebook coding and patients' perceived clarity and understanding as assessed through the semi-structured interviews.

The study will also explore the association between communication characteristics, perceived clarity, and the participant's subsequent decision regarding VBAC or a new caesarean section. Quantitative analyses will include descriptive statistics and exploratory Spearman correlations. A linear mixed-effects model will be used to explore the relationship between communication characteristics and perceived clarity, accounting for clustering at the clinician level. A logistic regression model will explore the association between communication characteristics and delivery outcomes. These quantitative analyses are exploratory and hypothesis-generating and are not intended to establish causal or predictive relationships.

The qualitative analysis of consultation transcripts will focus on identifying and characterising linguistic markers of misunderstanding using the TouCAN Codebook. Interview data will be analysed through thematic analysis, following a six-phase approach involving independent coding and collaborative synthesis. The combination of linguistic analysis and participants' subjective accounts is intended to capture both observable features of communication and patients' own perceptions of clarity, understanding, and communication quality.

All study data are collected in connection with the routine prenatal consultation and the subsequent assessment of communication and understanding. Participant involvement lasts approximately two hours. No additional clinical risk or therapeutic intervention is introduced by the study.

The study has a total duration of five years, with participant enrolment lasting two years. The study is sponsored by IRCCS Ospedale San Raffaele and co-sponsored by Università Vita-Salute San Raffaele. The Principal Investigator is Prof. Massimo Candiani.