How power and knowledge hierarchies affect communication in intrapartum care: findings from public health facilities in two southern Indian districts.

Abstract

Background: Effective communication is a key element of medical care; it can foster a warm interpersonal relationship, facilitate the exchange of information, and enable shared decision-making. In the context of obstetric care, it is associated with a range of positive clinical and social outcomes for mother and baby. Extant communication frameworks and respectful maternity care (RMC) guidelines emphasize the importance of effective communication during intrapartum care. Yet, studies conducted in Indian public health settings suggest that there are gaps in the implementation of RMC guidelines.

Methods: As part of a larger study on disrespect and abuse in Indian public hospitals, we studied the nature of communication in the intrapartum context and the extent to which it is respectful. The study is based on interviews with 29 providers across different levels of public health facilities. Interviews were translated, transcribed, and thematically coded. We examined codes related to communication to understand what kinds of communication occur during intrapartum care and the role played by knowledge and power hierarchies. We then considered their implications for RMC.

Results: We identified four types of communication that occurred in the context of intrapartum care: (a) compassionate, to comfort and support the laboring woman, (b) factual, to obtain or provide information or updates, (c) prescriptive, to obtain consent and cooperation from the woman and her family members, and (d) defensive, to protect against accusations of poor care. Knowledge and power hierarchies operated differently in each type of communication, with prescriptive and defensive communication more likely to be disrespectful than others.

Conclusions: Our findings suggest that successful implementation of RMC guidelines requires greater attention to knowledge and power hierarchies, and an understanding of the ways in which they operate in a clinical setting. Integrating this understanding into guidelines, medical education, training programmes, and interventions will facilitate effective and respectful communication during maternity care.