Communicating effectively with women experiencing socioeconomic vulnerability during the perinatal period: A systematic review

Abstract

Objective

To assess the evidence on communication interventions designed to support women experiencing socioeconomic vulnerability in the context of perinatal care.

Design

Systematic review based on narrative synthesis.

Data sources

Web of Science Core Collection, MEDLINE (PubMed), CINAHL (Ebsco), and The Cochrane Library.

Study selection

Following PRISMA guidelines, peer-reviewed qualitative, quantitative, and mixed-method studies published between 2013 and 2023 in English, Spanish, Dutch, French, or Turkish were included. Research from all care settings was eligible, except for studies conducted in low-income countries according to the Human Development Index.

Data extraction

Data extraction was performed at least two team members. Studies were analyzed through narrative synthesis. Methodological quality was assessed using the Critical Appraisal Tools developed by the Centre for Evidence-Based Management (CEBMa).

Results

Twelve studies met the inclusion criteria. Interventions included telehealth, home visits, peer-led initiatives, and tailored approaches such as Brief Interpersonal Psychotherapy and Motivational Interviewing. These interventions showed positive effects on breastfeeding, psychosocial well-being, maternal and neonatal health, and satisfaction with care, although outcomes varied in significance. Study quality ranged from moderate to high.

Conclusions

Although the evidence is limited, the findings suggest that communication interventions may improve perinatal care for women facing socioeconomic vulnerability. Further robust research is recommended.

Systematic review registration

The protocol for this review was registered in PROSPERO (registration number: CRD42023406466).

Resumen

Objetivo

Evaluar la evidencia sobre intervenciones de comunicación destinadas a apoyar a mujeres que experimentan vulnerabilidad socioeconómica en el contexto de la atención perinatal.

Diseño

Revisión sistemática basada en síntesis narrativa.

Fuentes de datos

Web of Science Core Collection, MEDLINE (PubMed), CINAHL (EbsCo) y The Cochrane Library.

Selección de estudios

Siguiendo las directrices PRISMA, se incluyeron estudios cualitativos, cuantitativos y de métodos mixtos revisados por pares, publicados entre 2013 y 2023 en inglés, español, neerlandés, francés o turco. Se consideraron elegibles investigaciones de todos los entornos asistenciales, excepto aquellos estudios realizados en países de bajos ingresos según el Índice de Desarrollo Humano.

Extracción de datos

La extracción de datos fue realizada por al menos dos miembros del equipo. Los estudios fueron analizados mediante una síntesis narrativa. La calidad metodológica se evaluó utilizando las herramientas de evaluación crítica desarrolladas por el Center for Evidence-Based Management (CEBMa).

Resultados

Doce estudios cumplieron con los criterios de inclusión. Las intervenciones incluyeron telesalud, visitas domiciliarias, iniciativas lideradas por pares y enfoques personalizados como la Psicoterapia Interpersonal Breve y la Entrevista Motivacional. Estas intervenciones mostraron efectos positivos en la lactancia materna, el bienestar psicosocial, la salud materna y neonatal, y la satisfacción con la atención, aunque los resultados variaron en cuanto a su significación. La calidad de los estudios osciló entre moderada y alta.

Conclusiones

Aunque la evidencia es limitada, los hallazgos sugieren que las intervenciones de comunicación pueden mejorar la atención perinatal para mujeres que enfrentan desafíos de vulnerabilidad socioeconómica. Se recomienda realizar investigaciones más sólidas.

Registro de la revisión sistemática

El protocolo de esta revisión fue registrado en PROSPERO (número de registro: CRD42023406466).

Introduction

In 2023, the World Health Organization (WHO) recommended the development of guidelines for effective communication in maternal, newborn, child, and adolescent health through group counseling and new methods like social media and virtual clubs.¹ The WHO's ‘Framework for the Quality of Maternal and Newborn Health Care’ highlights effective communication as a key pillar of quality care,² aligning with national and international guidelines.^3,4 Effective communication fosters trust, shared decision-making, respect, and dignity, enhancing perinatal care quality and maternal-newborn outcomes.⁵ However, there is still no standardized definition of “effective communication” in the context of maternity care.⁶

Socioeconomic vulnerability refers to the challenges women face—such as limited economic resources, low educational level, unstable housing, or unemployment—that compromise their ability to seek and receive adequate perinatal care.^7–10 Vulnerability is a major determinant of perinatal care processes and outcomes,⁷ as it affects access to healthcare and contributes to health inequalities.^8,9 A recent review by D’haenens et al.¹⁰ identified five care domains for vulnerable women, including healthcare access and continuity of care, highlighting their importance in ensuring quality care. Vulnerable women are more likely to delay the initiation of prenatal care, which increases the risk of care discontinuity and fragmented postnatal follow-up.^11,12 Feijen de Jong¹³ suggests that pregnant women in vulnerable situations strongly desire continuity of care. Communication barriers are a key factor contributing to the delayed uptake of perinatal services among these women,⁴ with a recent review identifying communication as a challenge in the provision of perinatal care to refugee women.¹⁴

Effective communication can enhance continuity of care, support person-centered care, improve healthcare quality, and reduce health disparities.¹³ It is also essential for ensuring safety, facilitating access to services, providing prenatal education and mental health support, and delivering information to vulnerable women.¹⁵ Healthcare professionals can improve service access by using communication methods such as text messaging, sharing service information, and receiving training on the specific needs of socioeconomically vulnerable women.⁴ Innovative tools, including eHealth, can further support these women by improving access to services and communication in perinatal care.^16,17 Moreover, communication skills training programs can enhance the utilization of perinatal services.¹⁴ However, existing research on effective communication during the perinatal period remains limited. A systematic review by Chang et al.⁶ found insufficient evidence regarding the impact of interventions aimed at improving communication between healthy women and maternity care providers during childbirth.

To our knowledge, no systematic review to date has assessed interventions that support communication between healthcare professionals and women experiencing socioeconomic vulnerability in the context of perinatal care. This review aimed to synthesize the literature on interventions designed to improve communication with women experiencing socioeconomic vulnerability during the perinatal period, evaluate their impact on maternal and neonatal health outcomes, and identify best practices to guide care. For clarification purposes, we considered interventions when those were led by healthcare professionals or as part of a team. A preliminary search in March 2023 of PROSPERO, the Joanna Briggs Institute, and the Cochrane Library found no current or ongoing reviews on this topic.

Methods

This systematic review adhered to PRISMA guidelines to ensure comprehensive reporting of relevant information¹⁸ (see Supplementary file 1). We used a mixed-methods synthesis approach (see PROSPERO registration CRD42023406466). Below, we outline the review questions, search procedure, and screening process for both qualitative and quantitative evidence sources, in line with our PROSPERO protocol.

Review questions

• (1)

  What are the effective ways to communicate women experiencing socioeconomic vulnerability during the perinatal period?

• (2)

  How can communication be supported for these women during pregnancy and postpartum?

Eligibility criteria

We included primary research studies published between January 2013 and March 2023 in English, Spanish, Dutch, French, or Turkish. Studies focused on communication interventions supporting effective communication between healthcare professionals and women facing socioeconomic vulnerability during the perinatal period. All study designs were eligible, but systematic reviews, editorials, case reports, abstracts, theses, and protocols were excluded to ensure robustness and reliability.

Outcomes of interest

Outcomes included the impact of communication interventions on maternal/neonatal health, breastfeeding, perinatal depression, stress, anxiety, and confidence, along with satisfaction with care and knowledge/attitudes about the interventions. Barriers and facilitators in communication were also assessed.

Setting and population

The study population comprised women experiencing socioeconomic vulnerability during the perinatal period, often compounded by limited support. These factors can create barriers to healthcare access and increase the risk of adverse outcomes.^7,10 Our review specifically focused on women whose vulnerabilities were related to socioeconomic factors, as defined by D’haenens et al.¹⁰ and identified through our search strategy.

The perinatal period was defined as the time from initial pregnancy recognition until one year postpartum.¹⁹ All perinatal care settings—including hospitals, facilities, homes, and community settings—were included, except for those in low-income countries as classified by the Human Development Index.²⁰ Communication interventions can be broadly defined as purposeful, planned and formalized strategies designed to achieve various objectives, such as educating, informing, supporting, skill-building, changing behavior, engaging, or encouraging participation across all aspects of health.²¹ This review followed this view and defined a communication intervention as a planned interaction led by healthcare professionals or conducted as part of a professional team to communicate with women experiencing socioeconomic vulnerability during the perinatal period.

Search strategy

We conducted searches in Web of Science, MEDLINE (PubMed), CINAHL, and Cochrane Library, using relevant keywords and Boolean operators (see Supplementary file 2). Records were managed using Covidence© software,²² and duplicates were removed. Reference lists were reviewed for additional relevant studies.

Study selection and data extraction

Following the search, all studies that potentially met the inclusion criteria were independently screened based on titles and abstracts by at least two team members (STS, FD, AA, JV) using Covidence©. Subsequently, STS, FD, and AA retrieved the full text of all studies deemed potentially relevant and independently assessed their relevance based on the inclusion criteria. The results were then combined, and any discrepancies or disagreements arising during the title and abstract screening or full text review were resolved through discussions among the review team members (STS, FD, AA, JV) until consensus was reached.²³ Data extraction from the included studies was performed by STS, FD, and AA using Covidence©. The data extraction form detailed study objectives, interventions applied, participants, research methodology, and outcomes relevant to the review question and objectives. The review team held ongoing discussions and moderation to ensure consistency during data extraction. A total of twelve papers were retained.

Quality appraisal

At least two review authors (from STS, FD, and, AA) independently assessed the methodological quality and limitations of the twelve included studies, which comprised controlled and qualitative designs, using the Center for Evidence-Based Management (CEBMa) Critical Appraisal Tools.²⁴ The assessment criteria for controlled studies covered study design, subjects, random allocation, inclusion/exclusion criteria, objective outcomes, reliability of measurement tools, effect size, and confounding factors (see Supplementary file 3). For qualitative studies, criteria included study design, context, data collection, data analysis, reliability, credibility of result, and conclusions (see Supplementary file 4). Assessments were reported in a quality appraisal table, using ratings of “Yes”, “No”, or “Cannot tell” (see Supplementary file 5: Tables 1 and 2). Studies were categorized by quality as high (≥70%), medium (40–70%), or low (<40%). Quality scores were calculated, by dividing the number of “Yes” responses by the total number of domains, then converting this ratio into a percentage.²⁵

Table 1.

General characteristics of included studies (n = 12).

Study characteristics	Count (n)	Percentage (%)
Years
2013	2	16.7
2014	1	8.3
2015	2	16.7
2017	2	16.7
2018	3	25
2020	1	8.3
2022	1	8.3
Intervention years
2002–2010	6	50.0
2010–2020	5	41.7
NA	1	8.3
Countries
United States	8	66.6
Canada	1	8.3
France	1	8.3
Ireland	1	8.3
Turkey	1	8.3
Language of intervention
English	7	58.3
English and Spanish	3	25
French	1	8.3
Kurdish	1	8.3
Setting
One center/institution (one country)	6	50.0
National/region level (one country)	1	8.3
Multiple centers/institutions (one country)	5	41.7
Type of center/institution
Public	9	75
Private	3	25
Research design
Quantitative	9	75
Qualitative	2	16.7
Mixed-methods	1	8.3
Sample size
Small (less than 40)	1	8.3
Medium (40–100)	3	25
Large (more than 100)	8	66.7

Table 2.

Data extracted from the included studies (n = 12).

Author(s)YearCountry	Name of the program	Study designPeriod of the intervention	Participants and setting	Type of vulnerability	Mode of intervention delivery	Follow-up time points	Measurements
Coşkun and Karakaya 2013, Turkey	A community-based distribution model	Narrative research Perinatal period	All Kurdis pregnant womenn = 76A regional, 8 primary health care clinics in six districts (public)	Low-income women: poor and mostly illiterate, no health insurance	Face to face (Home visit)	At least twice during pregnancy and postpartum	Follow-up form, Home visits evaluation form, Semi-structured interview form
Doyle et al., 2014, Ireland	Preparing for Life (PFL)	RCTPerinatal period	Unspecified pregnant women from a communityn = 236 (IG: 106; CG: 100)Two maternity hospitals (public)	Socially disadvantaged women	Face to face (Home visit)	Baseline and after birth	A self-constructed questionnaire, Baseline characteristics, Demographic, health and pregnancy factors, Perinatal outcomes (neonatal and maternal)
Evans and Bullock 2017, USA	Baby Behavioral Educational Enhancement of Pregnancy (Baby BEEP)	Descriptive qualitative studyPerinatal period	All Caucasian pregnant women n = 345 (24 phone logs)21 rural Women, Infant, and Children (WIC) clinics (rural) (public)	Low-income women	Remote (telenursing)	Pregnancy and 6 weeks postpartum	Phone call records
Francis et al., 2020, Canada	Canada Prenatal Nutrition Program (CPNP): A novel community lactation support program	Narrative research Postpartum period	Mothers who were mostly born outside of Canadan = 46Community Health Center (public)	Low-income women	Mixed: face to face in-home or at the prenatal program site and remote (telephone, text, or e-mail)	No follow-up	Semistructured open-ended focus groups and individual interview form
Hannan 2013, USA	Advanced Practice Nursing (APN) follow up telephone call	RCTPostpartum period	Mostly Hispanic mothersn = 139 (IG: 70; CG: 69)An inner-city mother-baby unit at a county hospital (public)	Low-income women	Remote (follow up telephone call)	Baseline, post hospital discharge day 3, months 1 and 2 (maternal outcomes), and months 1 and 2 (infant outcomes)	Perceived stress scale, Multidimensional scale of perceived social support, Maternal perception of health scale
Kellams et al., 2018, USA	Better Breastfeeding	RCTPerinatal period	Non-hispanic, white, black and hispanic pregnant womenn = 431 (IG: 211; CG: 220)Four prenatal clinics at research university (public)	Low-income women	Mixed: face to face (viewing of education video in the prenatal clinic) and remote (data collected via follow-up telephone interviews at 1, 3, and 6 months postpartum)	Baseline, 1, 3, and 6 months postpartum	Questionnaires
Lenze and Potts 2017, USA	Brief Interpersonal Psychotherapy (Brief-IPT)	RCTPerinatal period	Black and white pregnant womenn = 38 (IG: 19; CG: 19)A prenatal clinic (urban)	Low-income women	Face to face in the research clinic, participant homes, or other community locations	Baseline and between 37 and 39 weeks gestation	Experiences in Close Relationships-Revised (ECR-R), Client Satisfaction Questionnaire (CSQ), Edinburgh depression scale (EDS), Brief state trait anxiety inventory (Brief-STAI), Social support questionnaire revised (SSQR)
Lewkowitz et al., 2018, USA	LIFE-Moms: Parents as Teachers (PAT) - home based lifestyle intervention	RCTPerinatal period	Black African American pregnant womenn = 118 (IG: 59; CG: 59)A single university based tertiary care institution	Socioeconomically disadvantaged women with overweight or obesity	Mixed: face to face (home visit) and remote (a telephone questionnaire for data collection)	Baseline and within 6–12 months postpartum	A questionnaire modified from the Infant Feeding Practices Study II
Martinez-Brockman et al., 2018, USA	Lactation Advice Through Texting Can Help (LATCH)	RCTPerinatal period	All Hispanic pregnant womenn = 129 (IG: 67; CG: 62)A federally qualified health center, 2 community-based agencies, and a teaching hospital	Low-income women	Mixed: face to face prenatal and postpartum BF education and remote support (BF peer counseling with mobile health technology (text messaging).	Baseline, after the baby was born: (1) immediately, (2) within 48 h, or (3) within 1 or 2 weeks.Exclusive BF: at 2 weeks and 3 months postpartum	A modified version of the Infant Feeding Practices Study II neonatal questionnaire, A potential LATCH benefit score
Srinivas et al., 2015, USA	Breastfeeding peer counseling intervention	RCTPerinatal period	Mostly non-white pregnant womenn = 103 (IG: 50; CG: 53)A hospital-affiliated clinic (urban) (public)	Low-income women	Combining face to face (during clinic visits) or remote (telephone)	After birth, 1 and 6 months postpartum	IOWA infant feeding attitude scale, Breastfeeding self-efficacy scale–short form
Tereno et al., 2022, France	Parental Competences and Attachment in Early Childhood (CEPEDP)	Quasi-experimental NRQPerinatal period	Mostly French pregnant womenn = 114 (IG: 63; CG: 51)Maternity wards in 10 public hospitals (urban) (public)	Psychosocial vulnerability(1) having less than 12 years of education,(2) having a low income	Face to face (home visit)	Baseline and 12 months postpartum	Atypical maternal behavior instrument for assessment and classification (AMBIANCE)
Wilhelm et al., 2015, USA	Home-based Motivational interviewing (MI) intervention	RCTPostpartum period	All Mexican-American mothersn = 53 (IG: 26; CG: 27)A regional acute care hospital (rural) (public)	Rural women with a limited income an education	Mixed: face to face (home visits) Remote (phone assessment)	Baseline, at 3 days, 2 weeks, and 6 weeks postpartum	A demographic and medical history questionnaire, Intent question (intent to breastfeed), Breastfeeding self-efficacy scale-short form, Breastfeeding assessment questionnaire

IG: intervention group; CG: control group.

Data analysis and synthesis

Narrative synthesis was conducted.²⁶ Throughout all stages of data synthesis, the review team held regular meetings to facilitate critical discussions and data interrogation. Peer review of the synthesized findings further enhanced the trustworthiness, coherence, and relevance of the results. We followed the guidelines for combining results.²⁷

Results

Selection of articles

The PRISMA flow diagram in Fig. 1 outlines the steps of the study selection process. The initial systematic search yielded a total of 14,061 publications. Following the removal of duplicates, 13,135 publications remained eligible for screening. After screening titles and abstracts, 43 publications were retained and subsequently evaluated for eligibility through full-text review. Thirty publications were excluded due to the absence of a defined communication component (n = 22), targeting a different population (n = 2) or study design (n = 3), or the publication type (n = 3).

Figure 1.

PRISMA flow diagram of the study selection process. From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi:10.1136/bmj.n71.

No further publications were found through reference tracking. The data analysis and synthesis for this review included 13 publications. However, one publication was published in 2012²⁸ and therefore removed in accordance with our inclusion criteria, finally, 12 publications comprised communication interventions.

Study characteristics

Table 1 presents the general characteristics of the twelve selected studies. For the years 2013, 2015 and 2017, a total of 6 (50.1%) publications were identified. Most of the publications dated from 2018 (n = 3, 25%). Furthermore, only one publication (n = 1, 8.3%) for each of the years 2014, 2020, and 2022. Half of the studies’ intervention years were before 2010 (n = 6, 50%), covering 2002–2005,²⁹ 2007–2008,³⁰ 2008–2010,^31–32 2009–2012,³³ and 2006–2011.³⁴ Five studies (41.7%) were conducted between 2010 and 2020.^35–39 One publication (n = 1, 8.3%) provided no information on the year of intervention.⁴⁰

Most studies were published in the USA (n = 8, 66.6%),^{32,33,35,36,38–40} one in Canada (8.3%),³⁷ and the remaining three in Europe. The European studies included one conducted in France (8.3%),³⁴ one in Ireland (8.3%),³¹ and one in Turkey (8.3%).³⁰ Most studies (n = 7, 58.3%) were conducted in English.^{29,31,33,35,37–39} Among the other five languages of the interventions, three were in a combination of English and Spanish,^32,36,40 one was in French,³⁴ and one was in Kurdish.³⁰

Three-quarters of the included studies (n = 9.75%) were conducted at public settings.^{29-34,37,38,40} The remaining studies were conducted in private settings.^35,36,39 Six studies were conducted at a center/institution in one country, including a university-based tertiary care institution,³⁵ a “mother & baby unit” at a county hospital,⁴⁰ a community health center,³⁷ a hospital-affiliated urban clinic,³⁸ a regional acute care hospital,³¹ and a prenatal clinic.³⁹ One study was conducted in one country, in a single city (Diyarbakır) in Türkiye at eight primary health care clinics.³⁰ The remaining five studies were conducted at multiple centers within a single country, including a health center, two community-based agencies, and a teaching hospital,³⁶ ten public hospitals,³⁴ two maternity hospitals,³¹ and four prenatal clinics.³³

The used study designs (n = 9) were mostly quantitative, consisting of randomized controlled trials (RCTs; n = 8, 89%) and one nonrandomized quantitative (NRQ) study (n = 1, 11%). Three studies (16.7%) had a qualitative study design; one of them was a descriptive qualitative study (n = 1, 33.3%) and the others were narrative studies (n = 2, 66.7%). The analyses included a total of 2467 participants. The median sample size was n = 205, with the largest sample size being n = 431 and the smallest being n = 38.³⁹ Most studies included exclusively pregnant women (n = 5, 42%), or women during perinatal period (n = 4, 33%). However, three studies (25%) included mixed samples of pregnant women and women during the perinatal period.

Used measurements

The general characteristics of included studies are completed in Table 2. A wide range of validated questionnaires were used (namely the IOWA Infant Feeding Attitude Scale, Breastfeeding Self-Efficacy Scale–Short Form, Multidimensional Scale of Perceived Social Support, Maternal Perception of Health Scale, Perceived Stress Scale, Brief State Trait Anxiety Inventory (Brief-STAI) Edinburgh Depression Scale (EDS), Client Satisfaction Questionnaire, and Atypical Maternal Behaviour Instrument for Assessment and Classification (AMBIANCE). Additionally, several non-validated, self-constructed questionnaires were employed, such as those for breastfeeding assessment, intent to breastfeed, and home visits evaluation. Semi-structured interview forms were also used in the studies.

Type of vulnerability

Eight studies defined participants’ vulnerability simply as “low-income women”.^{29,30,33,36–40} The remaining four studies defined vulnerability in the following ways: one study focused on “rural women with limited income and education”,³² while another defined it as “socially disadvantaged women,” characterized by “higher-than-national-average rates of unemployment, early school leavers, lone-parent households, and reliance on social housing”.³¹One study addressed “psychosocial vulnerability”, defined by participants having less than 12 years of education and a low income,³⁴ and one study focused on “socioeconomically disadvantaged women with overweight or obesity”.³⁵

Description of the intervention and interaction

Face to face interventions

Regarding the nature of the intervention and various modes of interaction, this systematic review revealed that four studies examined interventions conducted “face to face”.^30,31,34,39

In the study by Coşkun and Karakaya,³⁰ peer trainers conducted an intervention focusing on education and counseling techniques for pregnant and postpartum women. This intervention featured a program utilizing educational materials prepared by peers during their training. The peer trainers, maintained follow-up records on the women, documenting socio-demographic information, obstetric details, and healthcare service utilization during home visits. Educational materials included a pamphlet for peer trainers with illustrated content on safe motherhood, a Counseling Atlas covering physical and psychosocial changes during perinatal periods, an illustrated booklet for pregnant and postpartum women, and 3-D models demonstrating birth processes. Breast models demonstrated breastfeeding techniques, while a poster provided a visual representation of the different types of lochia. On the other hand, Tereno et al.³⁴ described their intervention as “care as usual” without detailed explanation but mentioned implementing the “Parental Competences and Attachment in Early Childhood (CAPEDP)” home-intervention program. Doyle et al.³¹ outlined a specific program called “Preparing for Life” (PFL), which involves bi-monthly home visits focusing on “socio-ecological development, human attachment, and social learning”. It was compared to the standard antenatal education classes typically provided in maternity hospitals, referred to as ‘care as usual’. Finally, Lenze and Potts³⁹ utilized Brief Interpersonal Psychotherapy as the mode of program delivery, comparing it to Enhanced Treatment as Usual (ETAU) for perinatal depression.

Face to face and remote interventions

Six articles reported interventions that combined both face-to-face and remote components.^{32,33,35–38}

These interventions encompassed various approaches, including lifestyle therapies,³⁵ breastfeeding peer counseling along with text messaging before and after birth,³³ in-person consultations,³⁷ peer counseling,³⁸ motivational interviewing,³² and prenatal video education.³³

Remote interventions

This systematic review also identified interventions that exclusively utilized remote methods. For instance, an American study suggested a weekly telephone social support intervention.²⁹ Similarly, Hannan⁴⁰ utilized advanced practice nurse-led follow-up calls as a preferred intervention method.

Type of technology used

The technology devices integral to the interventions predominantly included telehealth through telephone calls. The studies of Francis et al.,³⁷ Hannan,⁴⁰ Srinivas et al.,³⁸ Evans & Bullock²⁹ and Tereno et al.³⁴ utilized telephone calls for the intervention itself. In contrast, Lenze and Potts,³⁹ Lewkowitz et al.,³⁵ and Wilhelm et al.³² employed phone calls solely for administering questionnaires. Others used text messaging³⁶ or video viewing.³³ The remaining two studies did not use any technology.^30,31

Follow-up of the intervention and the period receiving the intervention

Ten studies provided a follow-up of their intervention. Lenze and Potts³⁹ delivered a follow-up intervention two times during the prenatal period (baseline: 23–26 week; follow-up: 37–39 week). Four of them offered a follow-up intervention during the postnatal period, ranged from immediately to six months after birth.^32,33,36,40 Finally, the follow-up intervention of four studies were planned during the prenatal period as well as after the birth of the child, extending to the child's 24th month of age.^29,34,38 One study³⁷ provided no follow-up during the postnatal period, while another³⁵ provided no follow-up during the entire perinatal period.

Focus of the intervention

The detailed information of included intervention programs is reported in Table 3. Half of the selected studies (6/12) focused on breastfeeding in general, with some of them focusing on the effect of breastfeeding interventions on breastfeeding initiation rates,³⁵ promoting breastfeeding³⁷ or exclusive breastfeeding (EBF) status.^33,36,38 Another intervention focused on increasing breastfeeding behaviors.³² The other six interventions focused various aspects, including encouraging women to receive healthcare with a focus on safe motherhood, enhanced knowledge and skills in self-care and satisfaction with care provided,³⁰ providing emotional, social, and/or personalized informational support tailored to each woman's specific needs to foster trust and build relationships with healthcare providers,²⁹ perinatal depression and satisfaction with the communication program,³⁶ maternal and neonatal health outcomes,^31,40 psychological support to reduce disruptive maternal communication.³⁴

Table 3.

Related measurements and the main findings of the included studies (n = 12).

AuthorYear	Focus of the intervention	Intervention description	Control description	Outcomes measured	Key findings
Coşkun and Karakaya 2013	Safe motherhood	A community-based distribution model involves home visits by peer trainers who provide education and counseling	No control group	Knowledge and skills in self care and receiving health care	Enhanced knowledge and skills in self-care, the rate of utilizing health care services from primary health care centers, and satisfaction with care provided.
Doyle et al., 2014	Healthy prenatal behaviors and the birthing experience	A community-level intervention involves bi-monthly prenatal home visits by trained mentors from various professional backgrounds, including education, psychology, and childcare (averaging six visits between program entry and birth).	Care as usual: standard antenatal education classes offered in maternity hospitals	Neonatal and maternal outcomes for infants and mothers	No significant differences in any of the neonatal outcomes or the majority of the maternal outcomes, however IG improved birth preparation, reduced cesarean rates, and increased spontaneous labor onset.
Evans and Bullock 2017	Social, emotional and/or informational support	Telenursing involves weekly telephone psychosocial support provided by six research nurses	No control group	Characterizing nursing care and the relationships between patients and providers.	Meaningful nursing care, therapeutic nurse–patient relationships and foster trust between patient and provider during pregnancy.
Francis et al., 2020	Breastfeeding	A community breastfeeding and lactation support provided in-home by an International Board-Certified Lactation Consultant (IBCLC)	No control group	Infant feeding experiences and experiences with the lactation support.	Lactation support helped to address breastfeeding challenges with the provision of an electric breast pump if needed.
Hannan 2013	Infant and maternal health	A routine hospital discharge care plus Advanced Practice Nursing (APN) follow up telephone call for the first 2 months post birth (on posthospital discharge days 3, 7, 14, 21, months 1 and 2)	Routine hospital discharge care: 1–2 h of maternal and infant care instructions on feeding, bathing, sleep positions, signs and symptoms of urgent health conditions prior to discharge by the nursery nurse; written instructions on infant care to take home; and a pediatrician appointment in 2 months’ time	Maternal health (stress, social support, physical health), infant health (routine medical visits, immunisations, weight gain), morbidity (urgent care visits, emergency room visits, re-hospitalisations), and health care charges	IG had significantly lower perceived stress, greater perceived maternal health and social support; infants had healthier weight gain, fewer emergency room visits; significantly lower total health care charges.
Kellams et al., 2018	Breastfeeding	A single viewing of a prenatal breastfeeding video education	Prenatal nutrition video	Primary outcome: duration of breastfeeding up to 6 months, secondary outcome: duration of exclusive breastfeeding up to 6 months.	No significant differences in breastfeeding duration or exclusivity.While not adequate on their own, educational videos could be valuable as part of a broader program to encourage breastfeeding.
Lenze and Potts 2017	Perinatal depression	Brief Interpersonal Psychotherapy (Brief-IPT) by therapists, including a clinical psychologist with 15 years of experience supervising IPT, and two master's level clinicians	Enhanced Treatment as Usual (ETAU): The assessments of depressive and anxiety symptoms by telephone every two weeks, along with encouragement or facilitation of depression treatment.	Treatment feasibility, acceptability, and clinical outcomes (satisfaction, depression, anxiety and social support)	IG clinically significantly improved depressive symptoms and social support and reported high satisfaction with the program.
Lewkowitz et al., 2018	Breastfeeding	Parents as Teachers (PAT) plus additional content on breastfeeding intervention, with 1-hour home visits by trained parent educator every week during pregnancy (during 16 weeks)	Parents as Teachers (PAT): A home-based parenting support and child development educational intervention	Breastfeeding initiation and reasons for not initiating or not continuing breastfeeding	IG increased breastfeeding initiation rates compared to the national average.No significant differences perceived importance of factors for non-initiation or discontinuation of breastfeeding.
Martinez-Brockman et al., 2018	Breastfeeding	Standart of care plus 2 way text messaging by 3 IBCLCs and 7 Breastfeeding Peer Counselors (BFPCs) (prenatally and up to 3 months postpartum)	Standart of care: WIC Loving Support BFPC program	Time to contact with BFPC and EBF status.	IG significantly promoted early contact between participants and BFPCsNo significant differences EBF rates at 2 weeks and 3 months postpartum.
Srinivas et al., 2015	Breastfeeding	Care as usual plus peer counseling on breastfeeding within 3–5 days after delivery, weekly for 1 month, every 2 weeks up to 3 months, and once at 4 months (between 28 weeks’ gestation and 1 week prior to delivery, with additional contacts at the mother's request).	Care as usual: Access to IBCLCs in the hospital, as well as outpatient lactation support from clinic pediatricians and the WIC nutritionist	Breastfeeding initiation, exclusive breastfeeding, breastfeeding self-efficacy	No significant difference in the rates of breastfeeding initiation, exclusive breastfeeding before hospital discharge, or breastfeeding to 1 month or 6 months.Both IG and CG improved breastfeeding rates up to 1 month.Peer counseling assisted women with low self-efficacy in achieving their breastfeeding goals.
Tereno et al., 2022	Mental health	Care as usual plus the CAPEDP (Parental Competences and Attachment in Early Childhood), a perinatal home-visiting psychological support program focused on the mental health of children, provided by four psychologists 6 times during the prenatal period (starting from the 27th week of pregnancy), 8 times during the first 3 months of the child's life, 15 times when the child was between 4 and 12 months of age.	Care as usual: Community-based mother–child support and prevention services	Disruptive caregiver behavior	IG significantly reduced disruptive communication.
Wilhelm et al., 2015	Breastfeeding	Motivational interviewing (MI) on continue breastfeeding during home visits at 3 days, 2 weeks, and 6 weeks postpartum by nurses certified and experienced in delivering MI interventions	Education about infant safety	Breastfeeding outcomes: intent to breastfeed for 6 months, breastfeeding self-efficacy, and duration of breastfeeding	No significant differences in any outcome variables, including intent to breastfeed for 6 months, breastfeeding self-efficacy, and duration of breastfeeding.The program was not found to be significantly effective.

IG: intervention group; CG: control group.

Effects of interventions on breastfeeding outcomes

The most frequently reported outcome in the included studies was breastfeeding. Lewkowitz et al.³⁵ demonstrated that the Parents as Teachers (PAT) program—“a home-based parenting support and child development educational intervention”—when supplemented with breastfeeding content, enhanced breastfeeding initiation rates in an at-risk population, exceeding those expected based on national averages. However, incorporating breastfeeding education into the curriculum did not affect women with overweight or obesity regarding the perceived importance of factors contributing to breastfeeding non-initiation or discontinuation compared to a standard home-visit program.

Martinez-Brockman et al.³⁶ reported no significant effect of the “Lactation Advice Through Texting Can Help (LATCH)” intervention, which used two-way text messaging to facilitate early contact between mothers and “Breastfeeding Peer Counsellors (BFPCs)”, on EBF rates at 2 weeks or 3 months postpartum. Francis et al.³⁷ found that the Canada Prenatal Nutrition Program, which included breastfeeding and lactation support, improved breastfeeding outcomes among women. The study highlighted that providing in-home support from a skilled, non-judgmental lactation consultant, along with access to an electric breast pump when needed, effectively addressed breastfeeding challenges. Srinivas et al.³⁸ reported that peer counseling effectively supported women with low self-efficacy, aiding them in achieving their breastfeeding goals. The study found that breastfeeding attitudes were more strongly linked to breastfeeding behavior than peer support. Overall, breastfeeding rates among all participants improved during the study period, but no significant differences in rates were observed between the groups. However, peer counseling significantly improved breastfeeding rates up to 1 month. In a trial examining the impact of a breastfeeding education video, Kellams et al.³³ reported that a single viewing of the video during a prenatal clinic visit did not affect breastfeeding duration or exclusivity among low-income women. While insufficient on its own, educational videos could serve as a valuable element of a broader, multifaceted program aimed at promoting breastfeeding. Finally, Wilhelm et al.³² reported that at six months postpartum, mothers who received motivational interviewing breastfed for an average of 90 days, while those in the attention control sessions breastfed for an average of 82 days. Additionally, 22% of mothers in both groups were still breastfeeding to some extent—whether exclusively, partially, or occasionally—at six months postpartum. High attrition rates by week six limited the evaluation of the motivational interviewing intervention's potential. The groups showed no significant differences regarding intent to breastfeed for six months, breastfeeding self-efficacy, or breastfeeding duration. Although mothers expressed their intentions and confidence in breastfeeding for six months, most did not continue breastfeeding for the full period.

Effects of interventions on maternal/neonatal health outcomes

Hannan⁴⁰ found that follow-up telephone calls from advanced practice nurses to low-income, first-time mothers with full-term, healthy infants, were low-cost, protected, effective, and easy to implement. The intervention improved health outcomes for both mothers and infants and contributed to reduced healthcare costs. However, Doyle et al.³¹ found that the PFL home visiting program, which provided tip sheets on social support, healthy prenatal behaviors, and the birthing experience, did not affect neonatal outcomes such as Apgar scores, prematurity, weight at birth, or age of gestation. Nevertheless, preliminary evidence suggested that this intervention helped prepare women for childbirth, potentially increasing the incidence of spontaneous labor and decreasing the rates of cesarean section.

Effects of interventions on maternal psychosocial well-being

Regarding the psychosocial outcomes, in Lenze and Potts³⁹ study, low-income women found Brief Interpersonal Psychotherapy (IPT) for perinatal depression to be acceptable, with improvements observed in depressive symptoms and social support. Nevertheless, the treatment's feasibility was constrained by a relatively low rate of session attendance, even though efforts were made to enhance treatment engagement. Evans and Bullock's²⁹ study illustrates the acceptability, feasibility, and potential of telephone social support interventions (telenursing) in providing meaningful nursing care and fostering trusting relationships between patients and providers during pregnancy. Furthermore, Tereno et al.³⁴ showed that a secondary analysis of the CAPEDP program, which provides psychological support for first-time mothers, was effective in decreasing maternal disruptive communication.

Effects of interventions on other outcomes (knowledge, skills, receiving health care, and satisfaction)

Coşkun and Karakaya³⁰ found that a community-based distribution model, using peer trainers for education and counseling on safe motherhood, increased women's knowledge, Self-care behaviors and the frequency of healthcare utilization in primary healthcare facilities. The women reported high satisfaction with the visits and guidance offered by peer trainers. Additionally, Lenze and Potts³⁹ reported high satisfaction with the Brief-IPT program.

Barriers and facilitators in communication

Coşkun and Karakaya³⁰ reported that the peer trainers were effective in persuading women to seek healthcare in regions where health staff struggled to establish contact due to geographical constraints and language barriers. They were particularly helpful in primary healthcare centers with a shortage of nurses and midwives. Lewkowitz et al.³⁵ highlighted the physiologic challenges and sociodemographic barriers about breastfeeding disparities. Furthermore, Wilhelm et al.³² highlighted that maintaining up-to-date contact information can be challenging. In their study, some participants experienced loss of phone service or were only able to top up minutes when their finances allowed. Attempts to visit these mothers without initial contact were unsuccessful, and some participants were lost to follow-up when they moved without providing updated contact details.

Methodological quality of the studies

Overall, almost all studies (n = 11, 91.6%) obtained scores ranging from medium to high quality. Of the nine controlled studies, all were evaluated as medium to high, with two studies scoring 83%, two scoring 75%, three scoring 66% and two scoring 58%. Among the three qualitative studies, two were evaluated as medium to high, with one scoring 100%, and the other scored 70%. The one qualitative study with a lower score obtained 30%, indicating several methodological limitations.

Discussion

This systematic review synthesized the available evidence on communication programs designed to support women experiencing socioeconomic vulnerability during the perinatal period, with the quality of evidence assessed as medium to high. We found that face-to-face, remote, or combined face-to-face and remote modes of intervention were used to evaluate four main types of communication interventions: educational programs, peer counseling, professional support, and tailored approaches—such as Brief Interpersonal Psychotherapy and motivational interviewing—delivered at various stages throughout the perinatal period. These interventions mostly focused on promoting breastfeeding practices, while others aimed to enhance maternal and neonatal health, improve maternal psychosocial well-being, and increase overall satisfaction with care.

In this review, we identified that communication interventions utilized various modes of delivery, which are crucial to the success of the communication program. Martinez-Brockman et al.³⁶ conducted an RCT, and the results showed that mothers who had received BFPCs plus 2-way text messaging (mobile health technology) showed more improvements in early contact between participants than those receiving BFPCs only. Similarly, breastfeeding and lactation support by an IBCLC at the prenatal program site or in-home, along with additional consultations by telephone, text, or email helped mitigate breastfeeding challenges.³⁷ Furthermore, participants appreciated the convenience of ongoing contact with IBCLCs via text message, telephone, or e-mail following the initial home visit. These findings suggested that providing mobile health technology support enhances the effectiveness of traditional interventions by facilitating more frequent and timely communication and enhanced the flexibility and reach of the healthcare. Furthermore, the mixed modes of delivering the intervention may be superior to providing in-person peer counselors alone. Other included studies that used mixed-mode intervention delivery^32,33,35,38 did not find significant differences in any breastfeeding outcomes. These results may have resulted from the utilization of mobile health technologies to collect longitudinal data rather than for delivering targeted interventions. Furthermore, face-to-face home visit interventions were mostly found to be effective.^30,34,39 Remote interventions, such as telephone follow-ups and telenursing, were shown to be feasible and cost-effective.^29,40 These results align with a review that reported in-person modes include better engagement of participants in communication, prevention of attrition, and sustained motivation through ‘real’ person contact. Furthermore, remote delivery offers greater access in terms of place and time, reduced costs and the ability to privately engage with the intervention.⁴¹

Pregnant women and new mothers have heightened sensitivity to non-verbal communication and may be less receptive to large amounts of verbal information. Developing strategies that transition from a directive approach to a more person-centered approach in information sharing allows practitioners to better address the needs of the mothers in their care.⁴² Half of the included studies in this review focused on optimal breastfeeding practices including breastfeeding initiation continued breastfeeding, exclusive breastfeeding, and breastfeeding behaviors. Breastfeeding and lactation support at home by IBCLCs helped address breastfeeding challenges to promote breastfeeding.³⁷ Similarly, peer-based support at home increased breastfeeding initiation rates.³⁵ Another study suggested that peer counseling, with its personalized and interactive support, may be more beneficial than traditional lactation support in improving breastfeeding rates up to 1 month.³⁸ These findings are consistent with those reported in a Cochrane review, which highlighted positive effects of empathetic, proactive, and predictable in-person postnatal breastfeeding support in overcoming practical, physical, and self-efficacy challenges, as well as improving breastfeeding outcomes over six months.⁴³ Furthermore, two-way text messaging promoted initial contact between BFPCs and participants; however, it did not have a significant impact on exclusive breastfeeding rates at 2 weeks and 3 months postpartum.³⁶ Similarly, a single viewing of prenatal video education did not result in significant differences in breastfeeding duration or exclusivity.³³ One study also adopted motivational interviewing to help new mothers to continue breastfeeding; the results showed no improvements in breastfeeding outcomes, including the breastfeeding self-efficacy, intention to breastfeed for 6 months, and breastfeeding duration.³² These findings suggest that while communication interventions may enhance initial engagement, they might not be sufficient to impact long-term outcomes, such as sustained breastfeeding. Thus, further studies should employ a longitudinal design to deliver targeted interventions that may contribute to significant effects on communication outcomes with socioeconomically vulnerable women.

The communication programs aimed at supporting socioeconomically vulnerable women during the perinatal period revealed mixed results on maternal and neonatal health outcomes. Hannan⁴⁰ underscores the effectiveness of integrating standard hospital discharge care with low-cost follow-up calls, revealing promising improvements in both maternal and infant health outcomes. This approach not only emphasizes the feasibility of implementing straightforward and scalable strategies but also highlights their potential to positively influence health outcomes. Conversely, Doyle et al.³¹ showed mixed results of a bi-monthly home visiting program in average six times, with no impact on neonatal outcomes but potential benefits in reducing cesarean section rates and promoting spontaneous labor. These discrepancies suggest the complex interplay of factors influencing perinatal health outcomes and underscore the importance of tailored interventions that consider the multifaceted aspects of maternal and neonatal care, specifically addressing the needs and contexts of the target population.

Three studies in this review focused on maternal psychosocial well-being. Lenze and Potts³⁹ found improvements in depressive symptoms, social support, and high satisfaction with the Brief-IPT program for perinatal depression, although engagement continued to be a challenge. Similarly, Evans and Bullock²⁹ highlighted the acceptability and feasibility of telephone-based social support, emphasizing the role of trust and meaningful patient-provider relationships. Moreover, Tereno et al.³⁴ highlighted the impact of a usual care plus psychological support program in mitigating maternal disruptive communication among first-time mothers, underscoring the importance of early intervention strategies. These results highlight the potential of tailored psychosocial interventions to positively impact mental health and well-being as well as foster crucial supportive networks, despite varying implementation challenges and contexts. Future interventions should consider tailored approaches that prioritize early engagement and sustainable support mechanisms to optimize maternal psychosocial well-being.

Finally, based on our review, a community-based distribution model that targets education and counseling through peer trainers at home can empower individuals with essential knowledge and skills, and the rate of utilizing health care services.³⁰ A recent systematic review reported that interventions most valued by particularly vulnerable women were those utilizing a community-based peer support approach, as these interventions offered the most comprehensive way to address the women's needs.⁴⁴ These findings underscore that community-based peer counseling approaches significantly enhance self-care capabilities and promote the utilization of primary healthcare services and specialized support systems, fostering maternal well-being and enhancing healthcare access.

Regarding the identified methodological aspects, the current review found that three-quarters of the studies were RCTs. Although some studies had small sample sizes, the majority of the studies included in the review had adequate sample sizes. Overall, the methodological quality of the studies ranged from medium to high, with the exception of one qualitative study. This was primarily due to underreporting and not clearly describing the context, procedures for data analysis, and results.

Limitations

To the best of our knowledge, this systematic review is the first to offer insights into the current evidence supporting communication between healthcare professionals and women experiencing socioeconomic vulnerability during the perinatal period. However, this review has some limitations that should be addressed. First, we excluded publications in languages other than English, Spanish, Dutch, French, and Turkish, which may have restricted the scope of our investigation. Second, the included studies were mainly conducted in the US and other Western countries. Therefore, the findings of this systematic review may not be generalizable to other populations. Third, a notable limitation of this review is the broad inclusion criteria, which resulted in the inclusion of interventions that were quite heterogeneous. Additionally, the scope of our search strategy was limited to categories of vulnerability and related socioeconomic factors during the perinatal period. This limitation may have excluded some populations who could also benefit from communication interventions, highlighting the need for future research to explore this aspect further. It should be acknowledged that eight of the twelve selected studies were conducted in the United States, which may limit the generalizability of the findings, as the socio-economic variables examined are likely to be shaped by the specific characteristics of that context. Finally, as the last search was conducted in March 2023, more recent studies may not have been included.

Conclusion

This systematic review contributes to the evidence on communication interventions that support effective communication between healthcare professionals and women experiencing socioeconomic vulnerability during the perinatal period. The review identified a diverse range of interventions, including telehealth, home-based, and peer-based approaches. These interventions primarily focused on improving breastfeeding practices, maternal and neonatal health, maternal mental well-being and utilization of healthcare services. Characteristics of effective communication support include being provided by trained professionals during antenatal or postnatal care and ensuring accessibility to healthcare services. It also involves addressing challenges faced by socioeconomically vulnerable women—such as difficulties making appointments, limited operating hours, and inadequate financial and transportation resources—and tailoring support to the specific needs of the vulnerable group and care setting. Support may be provided by professional counselors, peer counselors, or a combination of both. Communication interventions that combine both face-to-face and remote support are more likely to succeed with vulnerable women. In our opinion, interventions should be more widespread and standardized across countries so that women can benefit from better support throughout their pregnancies and the entire perinatal period.

Problem or issue

Women experiencing socioeconomic vulnerability face heightened risks during the perinatal period, worsened by communication challenges in healthcare.

What is already known

Communication interventions such as telehealth, peer-based support, and Motivational Interviewing (MI) strategies showed some benefits for maternal and neonatal outcomes, breastfeeding, psychosocial well-being, and satisfaction with care, but robust evidence is limited.

What this paper adds

This systematic review highlights positive effects of communication interventions but identifies gaps in evidence. It calls for more rigorous studies to determine which strategies effectively improve communication between healthcare providers and women experiencing socioeconomic vulnerability during perinatal care, aiming to reduce risks and enhance outcomes.

Author contributions

Ayse Akalin: Conceptualization; Methodology; Investigation; Data Curation; Validation; Formal analysis; Visualization; Writing-original draft; and Writing-review & editing.

Florence D’haenens: Conceptualization; Methodology; Investigation; Data Curation; Validation; Formal analysis; Visualization; Writing-original draft; and Writing-review & editing.

Joeri Vermeulen: Investigation; Validation; Formal analysis; Writing-review & editing.

Sandra Tricas-Sauras: Conceptualization; Management; Methodology; Investigation; Data Curation; Validation; Formal analysis; Visualization; Writing-original draft; and Writing-review & editing.

Ethical statement

Ethical approval is not required as this is a review of studies.

Funding

No funding was obtained for this research.

Conflict of interest

None declared.

Acknowledgements

The team wishes to acknowledge the advice and kind eye of Dr Yan Shing Chang at the Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care (Division of Methodologies). King's College, London during this process.