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Year : 2016  |  Volume : 5  |  Issue : 1  |  Page : 39-45

Written information may not improve factual recall after verbal counseling of mothers in premature labor – a randomized controlled trial

1 Department of Neonatology, Children's National Medical Center; Newborn Services, The George Washington University Hospital, Washington, DC, USA
2 Department of Neonatology, Children's National Medical Center; Newborn Services, The George Washington University Hospital; Department of Obstetrics and Gynecology, The George Washington University Hospital, Washington, DC, USA
3 Department of Obstetrics and Gynecology, The George Washington University Hospital, Washington, DC, USA

Date of Web Publication6-Jan-2016

Correspondence Address:
Mohamed A Mohamed
Newborn Services, The George Washington University Hospital, 900 23rd St., NW, Suite G-2092, Washington, DC 20037
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2249-4847.173268

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Background: Prenatal consultation is an integral step in the care of women at high risk for preterm delivery. Aims: To examine whether the provision of written information regarding prematurity would improve factual recall and satisfaction following prenatal consultation. Methods: We conducted a randomized controlled trial of expectant mothers from 22 to 30 weeks gestational age. Eligible women received routine verbal prenatal consultation prior to enrollment and randomization. Women in the control group received written information about breast feeding. Women in the intervention group received additional written information about prematurity. Later, a survey was administered to elicit their factual recall and satisfaction. Results: A total of 32 women completed the survey. There was no significant difference in mean factual recall score between both groups (control 76%; intervention 71%; P = 0.45) nor in patients' satisfaction (control 4.31; intervention 4.18; P = 0.71). Conclusions: Providing written information about prematurity to mothers in preterm delivery did not improve their factual recall or satisfaction. This suggests that written information may not have added value to verbal communication in delivering key information to women overwhelmed by the stress of preterm labor. The wide range of individual performance on the factual recall test indicates that some women in preterm labor may not be adequately informed by the prenatal consultation, despite their high level of satisfaction.

Keywords: Health communication, patient satisfaction, premature birth, prenatal counseling

How to cite this article:
Kett JC, Mohamed MA, Bathgate S, Larsen JW, Aly H. Written information may not improve factual recall after verbal counseling of mothers in premature labor – a randomized controlled trial. J Clin Neonatol 2016;5:39-45

How to cite this URL:
Kett JC, Mohamed MA, Bathgate S, Larsen JW, Aly H. Written information may not improve factual recall after verbal counseling of mothers in premature labor – a randomized controlled trial. J Clin Neonatol [serial online] 2016 [cited 2020 Jul 15];5:39-45. Available from: http://www.jcnonweb.com/text.asp?2016/5/1/39/173268

  Introduction Top

Despite recent advances in perinatal care, the rate of preterm birth in the United States remains high.[1] For women admitted to labor and delivery who are at high risk of preterm delivery, a prenatal consultation with a neonatologist is often provided. These consultations are generally conducted with one of two goals in mind; for pregnant women carrying fetuses relatively at or above the age of viability, the consultation's purpose is to help the pregnant woman (and her family) to prepare for what might be a long and difficult postnatal course for her infant in the Neonatal Intensive Care Unit (NICU). However, for pregnant women whose fetuses are at an extremely low gestational age (GA), the purpose of the prenatal consultation is to provide them with enough information to enable them take an informed decision.[2] Because delivery room resuscitation of infants who are born extremely preterm may have a low likelihood of success and can carry significant burdens, current guidelines recommend that resuscitation decisions for these infants be guided by the informed preferences of their parents.[3],[4],[5],[6] The exceptionally difficult decisions regarding whether or not to attempt resuscitation for infants at extremely low GA are often made during the prenatal consultation.

Despite the importance of this consultation, it can be uniquely challenging for a number of reasons. Preterm labor often occurs without warning, and women and their families may need to shift rapidly from the experience of a “normal” pregnancy to an imperiled one.[7] It may take significant time for the woman to gather her support system. In addition, a woman admitted to labor and delivery is often a patient herself, and may be under great stress, experiencing significant pain, and receiving numerous medications.[8]

A growing body of research has been focused on the prenatal consultation process. These studies have typically been designed to evaluate the current consultation model: Whether expectant parents recall being given specific information,[9],[10],[11],[12] whether they were satisfied with elements of the consultation,[7],[9],[10],[13] and whether their anxiety level was impacted by the process.[9],[11],[13],[14] Several authors have suggested that the current model might be improved by the provision of written information to expectant parents.[9],[11],[15]

Although the offer of written information to families makes intuitive sense, it is not known whether such an intervention can have a demonstrable effect on the consultation process. Recently, several investigators have evaluated the use of written decision aids in the setting of simulated or hypothetical prenatal consultations.[16],[17] Others have evaluated the effects of written staff guidelines regarding the performance of the prenatal consult.[14],[18],[19] Only one randomized controlled investigation has been conducted to evaluate whether the provision of written information can improve actual prenatal consultations. Muthusamy et al. demonstrated that the provision of written information to expectant mothers prior to the prenatal consultation improved their recall of some types of medical information.[8] However, these findings have not been replicated, and other models of information provision have not been evaluated.

Given the large proportion of families affected by preterm birth, the uniqueness of the labor and delivery environment, and the high stakes nature of the prenatal consultation, it is important that our consultation practice be guided by the best possible evidence. This investigation was conducted to determine whether a written information packet regarding preterm birth provided after the prenatal consultation could improve factual recall and satisfaction.

  Methods Top


We conducted a randomized controlled trial of expectant mothers at risk for preterm delivery for whom prenatal consultation was requested by the labor and delivery service. The study was conducted at the George Washington University Medical Center, a University Teaching Hospital with a level III NICU, and was approved by its Institutional Review Board. Women were eligible for study participation if they received a prenatal consultation from the neonatology attending or fellow, were between 220/7 and 306/7 weeks gestation, were primarily English speaking, and were legal adults. Women were excluded from the study if they carried a fetus with a known major congenital anomaly.

Expectant mothers received prenatal counseling by attending neonatologists or neonatal perinatal fellows per routine. No attempt was made to alter the consultation session in any way. Following the consultation, mothers were asked whether they wished to enroll in the clinical trial and their informed consent was obtained. Enrolled mothers were randomly assigned to the control group or the intervention group. Randomization was achieved using dark sealed envelopes. Women in the control group received an envelope containing written information about breast feeding. Women randomized to the intervention group received the same breast feeding information, as well as additional written information regarding premature birth and common problems encountered by premature infants. Counselors were blinded as to the group assignments of the participants and did not have access to the informational packets. Within 72 h of this counseling session, expectant mothers in both groups were asked to complete a brief written survey designed to elicit their recall of the factual information contained in the consultation and their satisfaction with the consultation overall.

Informational packet and survey

The informational packet comprised a 7 page pamphlet with approximately 1500 words. The pamphlet included information regarding: (a) The definition of preterm birth, (b) common causes of prematurity, (c) what to expect in the delivery room, and (d) common health problems encountered by preterm infants. The pamphlet was written to be understandable at a 9–10th grade reading level. The survey comprised two parts. First part included 25 multiple-choice questions designed to elicit factual recall and allowed for choosing only one correct answer. Second part included 5 questions designed to elicit parental satisfaction. Each satisfaction questions were scored on a scale from 1 to 5. All survey questions were pretested for readability and face-validity with a small group of NICU parents and clinicians [Appendix 1 [Additional file 1]].

Statistical analysis

Although data is limited, prior investigations have reported that patients appeared satisfied (or very satisfied) with their prenatal counseling approximately 70% of the time.[9],[10] To identify a difference in satisfaction of 15 points, with 80% power, we calculated a sample size of 16 participants per group. Prior investigations have also reported that factual information that parents' recall correlated with physician recall approximately 67% of the time (with regard to neonatal issues).[11] The above sample size would also provide 80% power to identify a 15 point difference in maternal factual recall after counseling. Bivariate analysis for mean, standard deviation, and P value was performed using Student's t-test for continuous variables. Chi-square analysis was used to calculate P value for binomial variables.

  Results Top

Thirty-six women were enrolled in the investigation, of them 32 women completed the survey. There were no significant differences in baseline demographics between the two groups [Table 1]. The age of enrolled women ranged from 19 to 40 years, with a mean age of 30. The gestation age of participants ranged from 22 to 30 weeks, with a mean gestation age of 26 weeks.
Table 1: Characteristics of study groups

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Mean factual recall score in the control group was 76%, (range from 56% to 96%), whereas the mean factual recall score in the intervention group was 71%, with a range from (28% to 100%). This difference was not statistically significant (P = 0.45). When these responses were analyzed by question topic, there was a trend toward more correct responses to questions regarding specific disease processes and treatments (patent ductus arteriosus, intraventricular hemorrhage, respiratory distress syndrome, etc.) from women in the intervention group than in the control group, although this difference was not statistically significant. However, women in the control group provided more correct responses than women in the intervention group in regards to breastfeeding (88.5% vs. 67.7%, P = 0.001).

The mean satisfaction score in the control group was 4.31, with a range from 3.2 to 5.0. In the intervention group, the mean satisfaction score was 4.18, with a range from 0.0 to 5.0. The difference in mean satisfaction score was not statistically significant between the groups (P = 0.71). An analysis of individual questions revealed a trend toward higher satisfaction with written information provided in the intervention group as compared to the control, although this difference was also not statistically significant (control 3.31 vs. intervention 3.88, P = 0.37).

  Discussion Top

In this investigation, providing written information about prematurity to expectant mothers at high risk for preterm delivery did not improve their factual recall (within 72 h) or satisfaction with the prenatal consultation. This finding suggests that written information may not be a reliable way to deliver key information to women in this context. These findings may be due to the unique nature of the labor and delivery environment. Women are often patients themselves at the time of the consultation. They may be experiencing significant emotional stress, physical pain, and the effects of a range of medications.[8] They may be required to undergo numerous tests and procedures. As such, these mothers may not have adequate time, opportunity, or ability to read and absorb written information given to them on a timely fashion.

The most noteworthy finding in our investigation is the extremely wide range of individual performance on the test of factual recall. Although the average factual recall score was 74%, the individual scores ranged from 28% to 100%. In fact, 16 of the 32 (50%) women who completed the test scored <70% and 3 of the 32 (9%) scored <50%. Despite a low level of factual knowledge about prematurity, these women might still be required to make life and death decisions regarding their infants. Although factual information is the only one component of medical decision making,[12],[20] this level of factual knowledge may be unacceptably low.

Despite the poor performance of many participants on the test of factual recall, participants indicated a high level of satisfaction with the consultation process overall, with the average satisfaction score being 4.24 of 5.0. This may indicate that women and their providers have different goals for the consultation process, and that information transfer may not be of key importance to patient satisfaction in this context. Qualitative investigations have demonstrated that factual information about survival and disability may not play a central role for expectant parents during the prenatal consultation.[12],[20] The opportunity to meet team members, voice concerns about preterm birth, or obtain reassurance and emotional support may be more important to expectant parents than information transfer.[7],[21]

The results of our investigation differ from the findings of Muthusamy et al.[8] In their study, patients who received written information 1 h prior to the prenatal consult were significantly more knowledgeable about long-term outcomes of prematurity and numerical data than those who received verbal counseling only. A significant improvement in the knowledge of short-term outcomes was not demonstrated. It is possible that the difference in the timing of the provision of written information (before versus after the consultation) is partially responsible for the differences seen, or that the nature or quality of the written material was dissimilar. It is also possible that differences in patient populations in different regions of the country could account for this difference. Understanding of breastfeeding behavior and techniques were the main significant differences between both groups. This may be attributed to that nature of written information given to both groups. Mothers in the control group were given pamphlets only on breast feeding. This may allowed for better absorption of the information and higher recall scores. Mothers in the intervention group were given pamphlets on both risks of prematurity and breast feeding. Too much information and level of stress associated with reading about complications of prematurity may attributed to the insignificant improvement in recall.

One of the strengths of our investigation is that it is one of only two randomized controlled investigations aimed at improving the prenatal consultation. In addition, our findings call into question the oft-made assumption that the provision of written information is critical to improving the prenatal consultation. The limitations of our study are its small sample size and its limitation to one clinical setting. There is a great deal of variation in the practice of prenatal counseling across different centers and some practices being more effective than others. In addition, we did not assess whether study participants read the written material provided to them. Our goal was to determine whether providing written information was helpful to expectant mothers at high risk for preterm delivery. To most closely mimic what would happen in the clinical context, no attempt was made to ensure that the material was read or to determine who had read the material provided. It is possible that no significant difference was found between the groups because few women in the intervention group read the material. However, even if this is the case, providing written information to all expectant mothers in this setting would not be a reliable way to improve factual knowledge about prematurity, as women would be equally unlikely to read the material outside of the study scenario. This is not to say that written information should ever be withheld from patients, rather that it should not be relied upon to convey key information or to significantly improve knowledge about prematurity in this setting. The prenatal consultation remains an important part of the care of women at risk for preterm delivery and their families. Although a growing body of literature has been aimed at improving this critical process, much remains to be done.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Griswold KJ, Fanaroff JM. An evidence-based overview of prenatal consultation with a focus on infants born at the limits of viability. Pediatrics 2010;125:e931-7.  Back to cited text no. 2
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International Liaison Committee on Resuscitation. The International Liaison Committee on Resuscitation (ILCOR) consensus on science with treatment recommendations for pediatric and neonatal patients: Pediatric basic and advanced life support. Pediatrics 2006;117:e955-77.  Back to cited text no. 4
Nuffield. Critical Care Decisions in Fetal and Neonatal Medicine: Ethical Issues. Nuffield Council on Bioethics; 2006.  Back to cited text no. 5
Harrison H. The principles for family-centered neonatal care. Pediatrics 1993;92:643-50.  Back to cited text no. 6
Gaucher N, Payot A. From powerlessness to empowerment: Mothers expect more than information from the prenatal consultation for preterm labour. Paediatr Child Health 2011;16:638-42.  Back to cited text no. 7
Muthusamy AD, Leuthner S, Gaebler-Uhing C, Hoffmann RG, Li SH, Basir MA. Supplemental written information improves prenatal counseling: A randomized trial. Pediatrics 2012;129: e1269-74.  Back to cited text no. 8
Yee WH, Sauve R. What information do parents want from the antenatal consultation? Paediatr Child Health 2007;12:191-6.  Back to cited text no. 9
Keenan HT, Doron MW, Seyda BA. Comparison of mothers' and counselors' perceptions of predelivery counseling for extremely premature infants. Pediatrics 2005;116:104-11.  Back to cited text no. 10
Zupancic JA, Kirpalani H, Barrett J, Stewart S, Gafni A, Streiner D, et al. Characterising doctor-parent communication in counselling for impending preterm delivery. Arch Dis Child Fetal Neonatal Ed 2002;87:F113-7.  Back to cited text no. 11
Boss RD, Hutton N, Sulpar LJ, West AM, Donohue PK. Values parents apply to decision-making regarding delivery room resuscitation for high-risk newborns. Pediatrics 2008;122:583-9.  Back to cited text no. 12
Paul DA, Epps S, Leef KH, Stefano JL. Prenatal consultation with a neonatologist prior to preterm delivery. J Perinatol 2001;21:431-7.  Back to cited text no. 13
Sobczak-Hoeft S, Finer N. Standardizing perinatal consults to improve trainee physician competency and decrease maternal anxiety. J Neonatal Perinatal Med 2008;1:181-7.  Back to cited text no. 14
Grobman WA, Kavanaugh K, Moro T, DeRegnier RA, Savage T. Providing advice to parents for women at acutely high risk of periviable delivery. Obstet Gynecol 2010;115:904-9.  Back to cited text no. 15
Koh TH, Casey A, Harrison H. Use of an outcome by gestation table for extremely premature babies: A cross-sectional survey of the views of parents, neonatal nurses and perinatologists. J Perinatol 2000;20 (8 Pt 1):504-8.  Back to cited text no. 16
Guillén Ú, Suh S, Munson D, Posencheg M, Truitt E, Zupancic JA, et al. Development and pretesting of a decision-aid to use when counseling parents facing imminent extreme premature delivery. J Pediatr 2012;160:382-7.  Back to cited text no. 17
Kaempf JW, Tomlinson M, Arduza C, Anderson S, Campbell B, Ferguson LA, et al. Medical staff guidelines for periviability pregnancy counseling and medical treatment of extremely premature infants. Pediatrics 2006;117:22-9.  Back to cited text no. 18
Kaempf JW, Tomlinson MW, Campbell B, Ferguson L, Stewart VT. Counseling pregnant women who may deliver extremely premature infants: Medical care guidelines, family choices, and neonatal outcomes. Pediatrics 2009;123:1509-15.  Back to cited text no. 19
Payot A, Gendron S, Lefebvre F, Doucet H. Deciding to resuscitate extremely premature babies: How do parents and neonatologists engage in the decision? Soc Sci Med 2007;64:1487-500.  Back to cited text no. 20
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  [Table 1]

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