Communication is one of the basic human needs. Medical students and health care workers need to be familiar with effective communication skills in order to understand patients’ needs (1). Today, medical education has focused on the human acquisition of communication skills other than only theoretical training. In fact, these skills are considered as determinants of healthcare workers’ qualification and capabilities (2).
The ability to establish effective communication and attain the required skills for
forming and maintaining interpersonal relationships is among the most important skills, introduced by World Health Organization (WHO). The ability to establish effective communication refers to the verbal or non-verbal expression of feelings, needs and personal views. In fact, communication skills for maintaining interpersonal relationships are required for establishing positive interactions with others (3).
Previous research at maternity wards has shown that suitable communication is the key determinant of maternal satisfaction with healthcare services (4). In fact, communication in midwifery is of utmost importance since midwives need to focus on the psychological and emotional aspects of health care. Midwives, as members of healthcare teams, should establish effective communication with patients, families, coworkers and other employees in order to achieve their goals in counseling, health education, health promotion, high-quality care services and providing accurate information.
Therefore, it can be said that communication is an indispensable part of obstetric care (4). However, despite the urgent need to communicate effectively with patients in specific labor conditions, the rate of knowledge, attitude and skills of healthcare workers, particularly midwives, is not desirable (4).
From mothers’ perspective, the major factor for a pleasant childbirth experience is the full support provided by midwives. On the other hand, poor communication skills of midwives have many negative effects on the physical and mental health of mothers, leading to negative socio-economic consequences (5). In addition to clinical care, mothers during labor need attention, understanding, empathy, encouragement, guidance and support. Today, dependence on the use of technology in childbirth care has led to disregard for the human aspects of health care (6).
Effective communication and emotional support of parturient women improve their mental condition and reduce their stress and pain during delivery; moreover, they affect the development and the final outcome of childbirth (6). Studies have shown that communication problems among pregnant women and healthcare workers are the main cause of mothers’ complaints. In fact, most of these women express dissatisfaction with the quantity and quality of received information (7).
A study by Sjojern (1997) in Sweden on labor outcomes in 100 women with severe childbirth anxiety showed that the cause of anxiety in 73% of cases was lack of confidence and effective communication (5). Moreover, Hores et al. (1989) found that midwives’ continuous psychological support of pregnant women during childbirth decreased delivery duration, cesarean rate, use of anesthetics and instrumental delivery and five-minute Apgar score (score < 7). In addition, mothers, who were supported by midwives during labor, had a more positive attitude towards childbirth (4).
A study by Taghizadeh et al. (2006) showed that the use of communication skills (verbal and non-verbal) by midwives was undesirable (68% and 54%, respectively). Moreover, the clients' satisfaction with verbal and non-verbal communication skills of midwives was 50% and 48.4%, respectively. In fact, clients’ satisfaction had a significant relationship with the use of communication skills by midwives (3).
In medical sciences, communication skills are introduced as essential features for all medical groups. In fact, a high level of communication skills in healthcare workers, as a prerequisite for providing high-quality healthcare services, has always been a major challenge for policymakers and executives.
Communication in medical and healthcare professions, especially midwifery, is of high significance. Therefore, considering the fact that midwifery undergraduates are not formally trained on communication skills (at undergraduate and postgraduate levels) (3), the present study aimed to determine the communication skills of midwives, working at the maternity wards of Mashhad teaching hospitals in 2014.
Materials and Methods
In this correlational, descriptive study, 49 midwives, working at the maternity wards of Mashhad teaching hospitals, were evaluated. The sample size was calculated to be 45.92 cases, according to a study by Malekzadeh (2011) (19), which investigated the performance of nurses. The following formula was applied for measuring the sample size (95% confidence interval): Considering the rate of dropout, 49 cases were introduced to the study.
The inclusion criteria were as follows: 1) an academic degree in midwifery (e.g., technician, bachelor’s degree or MSc); 2) being employed at the maternity wards of Omolbanin (s), Imam Reza (AS), Ghaem or Hasheminejad hospitals; 3) having at least one year of clinical experience at maternity wards; 4) written consent to participate in the study; 5) no prior history of participation in training classes or workshops related to communication skills over the last six months (minimum); 6) working different shifts; and 7) no major stressful events over the last six months.
Permission was obtained from the university ethics committee (on 28/06/2014) and the researchers were assured about the cooperation of educational supervisors at the selected hospitals. Among midwives at maternity wards (n=130), who met the inclusion criteria, 49 cases were selected as the study subjects via easy sampling. Overall, 10 midwives from Omolbanin Hospital, 13 midwives from Hasheminejad Hospital, 16 midwives from Ghaem Hospital and 10 midwives from Imam Reza Hospital were selected. The subjects were enrolled in the study after being justified about the study and obtaining written consents.
The data collection tools consisted of a demographic form including age, marital status, educational level and work experience. Also, further information about subjects’ professional interest, workplace satisfaction, childbirth experience, satisfaction with childbirth and marital satisfaction was gathered.
The midwives' communication skills were evaluated, using researcher checklist of communication performance of midwives. This checklist included 26 items and was graded as follows: never (score 0), rarely (score 1), sometimes (score 2), often (score 3), always (score 4) and never (score 5). The total score ranged from 0 to 130. Based on the final score of communication skills, the midwives were divided into three groups: poor (0-43), moderate (44-87) and good (88-130) communi-cation skills.
Content validity was used to determine the validity of the demographic form and the observation checklist of communicative performance. The forms were distributed among ten professors at the School of Nursing and Midwifery for further review. After making revisions, the form and the checklist were used as assessment tools. The reliability of the checklist was determined by internal consistency, using Cronbach's alpha coefficient 83%.
The checklist was completed at the presence of the researcher during various work shifts at the maternity wards. The researcher observed and evaluated midwives' communicative behaviors with parturient women during different stages of labor, childbirth and postpartum period.
The obtained data were entered to SPSS version 16. To analyze the data and determine the level of midwives' communication skills, the subjects were compared, based on age, work experience, professional interest and workplace satisfaction. Mann-Whitney U test was used to compare demographic variables and the level of communication skills. Moreover, Spearman’s correlation coefficient test was applied to evaluate the relationship between midwives' communication skills and age, work experience, professional interest, workplace satisfaction and childbirth experience.
The mean age of midwives was 39.11±9.66 years (range of 23-57 years). The mean work experience of midwives was 15.9±8.77 years (range of 1-29 years). In total, 33 subjects (67.3%) had experienced childbirth and 32 (66.7%) were moderately (or more) interested in midwifery. According to the findings, 7 (14.3%), 40 (81.6%) and 2 (4.1%) cases were single, married and divorced, respectively. Also, one subject (2%) had a high school diploma and 48 (98%) had a bachelor’s degree.
According to the results, 25 cases (51%) were official employees, 9 (18.4%) worked on commission, 4 (8.2%) were contract employees and 11 (22.4%) were project employees. Also, 40 cases (81%) were moderately (or more) satisfied with their workplace. In total, 15 (30.6%), 10 (20.4%), 10 (20.4%) and 14 (28.6%) subjects worked at Ghaem, Imam Reza, Omolbanin and Hasheminejad hospitals, respectively.
Overall, 17 cases (15.5%) had experienced vaginal delivery, 15 (45.5%) had undergone cesarean section and one subject (3%) had experienced both modes of delivery. In total, 51 participants (51.5%) were satisfied with their childbirth experience, 25 (15.2%) were dissatisfied and 11 (33.3%) were almost satisfied. Also, 34 cases (85%) were satisfied with their lives, one (2.5%) was dissatisfied and five (12.5%) were almost satisfied (Table 1).
The mean score of midwives on the observation checklist of communicative performance was 67.9±10.78 out of 130. The communication skills of midwives were moderate and good in 93.9% (44-87) and 6.1% (88-130) of cases, respectively. Kolmogorov-Smirnov test results showed that the data related to communication skills were not normally distributed (P<0.05); normal distribution was obtained by Lisrel software.
The ANOVA test results showed that midwives’ communication skills were not associated with their age, marital status, work experience, professional interest or workplace satisfaction. Independent t-test results showed that the communication skills of midwifes with childbirth experience was not significantly different from those with no childbirth experience (Table 2).
The results showed no significant correlation between independent variables (e.g., age, work experience, professional interest and workplace satisfaction) and communication skills.
This study was performed with the aim to determine the level of midwives’ communication skills, working at Mashhad teaching hospitals in 2014. According to the results, the midwives’ score on communication skills was 67.9 out of 130, which was considered an average score.
In a study by Taghi-Zadeh and colleagues, the use of communication skills (verbal and non-verbal) by midwives was undesirable (63% and 56%, respectively). In their study, there was no relationship between communication skills and midwifes' age, marital status, work experience, professional interest, childbirth experience or life satisfaction.
Moreover, in the mentioned study, no significant relationship was found between most demographic characteristics and use of communication skills; this was consistent with the results reported in our study. In the mentioned study, there was only a significant relationship between marital status and use of non-verbal communication skills, which was inconsistent with the present study (3). This discrepancy is probably due to the difference in midwives’ working hours at maternity wards and those working at healthcare centers only in the morning.
Similar to a study by Hooker (1997), application of communication skills was not significantly correlated with age or work experience in the present study (15). However, Cortez (2005) believed that experience plays an important role in strengthening communication skills. Zraick (2011) suggested that increased work experience alone is not effective for improving communication skills, whereas experience, following a model and training can together contribute to the formation of communication skills (2).
A study by Peyman (2013) in Ilam, which evaluated the interpersonal communication skills of university professors, showed that age, educational level and academic status were not associated with interpersonal skills. This finding was consistent with the present results as the level of communication skills was not related to age or work experience (1).
In a study by Barati (2012), which evaluated the level of students’ communication skills at Hamadan University of Medical Sciences, a significant association was observed between the mean score of communication skills and variables such as sex, marital status, educational level and field of study. In their study, female students and midwifery and paramedical students showed more communicative competence, compared to others; also, PhD, married and GPA students had a higher level of communication skills (14).
The mentioned study was not consistent with the present research in terms of the effect of marital status on communication skills. This discrepancy is probably due to the difference in the marital status of participants in Barati’s study (over 90% of students were single), compared to the present research (more than 90% of participants were married).
Moreover, Zaeifi Mohammadi (2008) reported that the use of communication skills among nurses working at hospitals in the city of Karaj was undesirable in 32% and desirable in 68% of cases; this categorization (i.e., desirable and undesirable) was inconsistent with the method of classification and the results of this study (13). Also, in the mentioned study, the relationship between nurses and physicians was assessed, while in our study, the communication between midwives and service recipients (parturient women) was evaluated.
Additionally, Salimi (2012) in Tehran showed that the mean score of communication skills in paramedical students was 99.8, which was unfavorable and lower than the average score of the questionnaire (i.e., 102); also, students educating at higher levels obtained higher scores. However, no relationship was found between students’ communication skills and gender, average grade, field of study or attending communication skill courses (10).
Also, in a study by Hemati Maslakpak et al. (2013) on senior students of nursing and midwifery, 77.2% of subjects in the seventh semester and 88.1% in the eighth semester had moderate communication skills, which was similar to the present study. They concluded that by improving students’ educational experience, their ability to communicate increases. The results of the mentioned study were not consistent with the present findings in terms of the positive effect of experience on improving communication skills (12). In their study, students' educational experience was assessed, while in the present study, midwives' work experience was evaluated.
In addition, the results of a study by Baker et al. (2001) showed that the majority of patient complaints and incorrect application of instructions by patients are not due to healthcare workers’ incompetence, but rather the result of communication problems (17).
Finally, despite the selection of samples from all teaching hospitals, affiliated to Mashhad University of Medical Sciences, small sample size was considered as a limitation of this study. Also, different physical and psychological conditions of midwives at the time of performance evaluation were among the shortcomings of this study, which could not be controlled by the researchers.
This study showed that the level of communication skills among midwives was not favorable. No significant relationship was observed between communication skills and demographic variables such as age, marital status, work experience, professional interest, workplace satisfaction, childbirth experience or life satisfaction. Communication is an important part of midwifery care. Considering the insufficient communication skills of midwives, which can be also a factor for mothers' dissatisfaction with delivery care, communication skill training should be incorporated in midwifery courses until post-graduation period in form of in-service courses by using modern teaching methods.
It can be said that communication is a basic element in providing obstetric care. Hence, considering the importance of communication in midwifery and communication with parturient women, it is recommended that training courses (by the use of modern teaching methods and active participation of midwives) be held in order to overcome the insufficiency of midwives’ communication skills. Also, in future studies, the use of verbal and non-verbal communication skills by midwives should be evaluated at various stages of hospital admission, labor, childbirth and postpartum period.
This article was extracted from the corresponding author’s M.Sc. thesis project (code: 922887), approved by the Research Committee of Mashhad University of Medical Sciences. We would like to thank Mashhad University of Medical Sciences for the financial support. We also extend our gratitude to the participants, training supervisors and maternity personnel at Ghaem, Imam Reza (AS), Hasheminejad and Omolbanin (R) hospitals.
Conflict of Interest
The authors declare no conflicts of interest.