Pre-post implementation survey of a multicomponent intervention to improve informed consent for caesarean section in Southern Malawi

Siem Zethof, Wouter Bakker*, Felix Nansongole, Kelvin Kilowe, Jos Van Roosmalen, Thomas Van Den Akker

*Corresponding author for this work

Research output: Contribution to JournalArticleAcademicpeer-review


Objective: Surgical informed consent is essential prior to caesarean section, but potentially compromised by insufficient communication. We assessed the association between a multicomponent intervention and women's recollection of information pertaining to informed consent for caesarean section in a low-resource setting, thereby contributing to respectful maternity care. Design: Pre-post implementation survey, conducted from January to June 2018, surveying women prior to discharge. Setting: Rural 150-bed mission hospital in Southern Malawi. Participants: A total of 160 postoperative women were included: 80 preimplementation and 80 postimplementation. Intervention: Based on observed deficiencies and input from local stakeholders, a multicomponent intervention was developed, consisting of a standardised checklist, wall poster with a six-step guide and on-the-job communication training for health workers. Primary and secondary outcome measures: Individual components of informed consent were: indication, explanation of procedure, common complications, implications for future pregnancies and verbal enquiry of consent, which were compared preintervention and postintervention using χ2 test. Generalised linear models were used to analyse incompleteness scores and recollection of the informed consent process. Results: The proportion of women who recollected being informed about procedure-related risks increased from 25/80 to 47/80 (OR 3.13 (95% CI 1.64 to 6.00)). Recollection of an explanation of the procedure changed from 44/80 to 55/80 (OR 1.80 (0.94 to 3.44)), implications for future pregnancy from 25/80 to 47/80 (1.69 (0.89 to 3.20)) and of consent enquiry from 67/80 to 73/80 (OR 2.02 (0.73 to 5.37)). After controlling for other variables, incompleteness scores postintervention were 26% lower (Exp(β)=0.74; 95% CI 0.57 to 0.96). Recollection of common complications increased with 0.25 complications (β=0.25; 95% CI 0.01 to 0.49). Recollection of the correct indication did not differ significantly. Conclusion: Recollection of informed consent for caesarean section changed significantly in the postintervention group. Obtaining informed consent for caesarean section is one of the essential components of respectful maternity care.

Original languageEnglish
Article numbere030665
Pages (from-to)1-10
Number of pages10
JournalBMJ Open
Issue number1
Early online date6 Jan 2020
Publication statusPublished - Jan 2020


  • caesarean section
  • informed consent
  • maternal medicine
  • medical ethics
  • quality in health care
  • tropical medicine


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