New Zealand College of Midwives Journal • Issue 58 • 2022 11

LITERATURE REVIEW

Exploring the ways communication technology is used

by midwives and pregnant women/people: An
integrative review
Karen WakelinA,B PhD (Cand), MA, GradDipTertEd, BSc (Hons), RM • Judith McAra-CouperC PhD,
BA, DipMid, RM, RGON • Tania Flemingc PhD, MHSc, BM, RM • Gwen Erlamc DHSc, MA, BSN, RN

A
Corresponding
author: karen.
[email protected] ABSTRACT
B
Otago Polytechnic,
Aotearoa New Background: Pregnant women/people globally are increasingly using digital technology such as
Zealand texting, emailing, instant messaging, pregnancy applications, social media and the internet to access
C
Auckland University information about their pregnancy. There is little information, however, on how the technology is
of Technology, used to enable midwives and pregnant women/people to communicate with each other and what
Aotearoa New effect this may have on the quality of maternal and newborn health within Aotearoa New Zealand.
Zealand
Aim: To explore the literature on how communication technology has been used to enable midwives
and pregnant women/people to connect with each another.
Method: An integrative literature review of peer reviewed studies between 2010 and 2021 was
undertaken to explore how communication technology was used to enable midwives and pregnant
women/people to connect with each another. The initial search elicited 450 articles, of which
five met the inclusion criteria. These were then assessed using the Critical Appraisals Skills
Programme checklist.
Results: The five relevant studies were summarised using an evidence table to enable comparison
of themes or relationships between the studies. Four main themes were identified: (1) connecting,
(2) access to healthcare, (3) privacy and confidentiality, and (4) lack of skills and knowledge. Using
communication technology appeared to provide a safe space for information sharing within which
pregnant women/people and midwives could connect. A feeling of connection was important,
in supporting the pregnant woman/person in their access to maternity services. This emotional
connection was enabled regardless of whether the pregnant person and midwife were known to each
other. However, concerns were identified relating to issues of privacy, and the skills pregnant women/
people and midwives needed to access and use the technology.
Conclusion: Gaps in the published literature were highlighted through undertaking this integrative
literature review. The first was in the understanding of how midwives and pregnant women/people
use communication technology when communicating with one another, and the second was in how
communication technology is used within a midwifery continuity of care model.
Keywords: communication technology, midwives, pregnant women

INTRODUCTION there is a delay in the sending and/or receiving of a message).

Effective communication which is responsive to a person’s needs and Living in a “digital society” or being a “digital citizen” are
preferences has been identified by the World Health Organization terms used to describe ways in which people communicate with
(WHO) as being one of five key categories for improving quality one another using digital technology (Zwimpfer et al., 2017).
of care during childbirth (Bohren et al., 2017; WHO, 2016). There are expectations that communication technology users are
Communication practices that utilise digital technology such as interacting, collaborating, sharing and connecting with others
short message service (SMS), emailing and instant messaging have through online platforms or messaging services (Zwimpfer et
been increasingly used over the last 30 years. (SMS is a system al., 2017). These expectations are noted within Aotearoa New
for sending text messages between mobile phones [Cambridge Zealand (Aotearoa NZ) where 91% of adults aged between 18-
Dictionary, n.d.] and will be referred to as texting throughout 34 years own a smartphone (Research New Zealand, 2015) and,
this integrative review.) Interactions take the form of being either in 2018, 89% of Aotearoa NZ’s population were active internet
synchronous (occurring at the same time) or asynchronous (when users (Hughes, 2019). This compares similarly to smartphone use
12 New Zealand College of Midwives Journal • Issue 58• 2022

(Granwal, 2021; O’Dea, 2021) and internet use (Keats, 2021; women/people and midwives are living in areas with poor internet
Statista Research Department, 2021) by adults in Australia and connectivity or mobile phone signal access, such as in rural or
the United Kingdom (UK) respectively. How communication remote rural locations (White et al., 2019). Further barriers can
technology is used by pregnant women/people and midwives is also exist for pregnant women/people where there are financial
the focus of this integrative literature review. constraints or literacy concerns which can make it difficult to
access and interpret health information (Dalton et al., 2018;
BACKGROUND Fleming et al., 2014; McAra-Couper et al., 2020).
Use of communication technology within Concerns around unsafe care have been identified by midwives
maternity care where they feel they are competing with mobile phones when
trying to communicate or connect with women during labour or
The use of communication technology within healthcare globally
shortly after birth (Dahl et al., 2017; Lewis et al., 2019). Midwives
takes various forms, with literature referring to mobile health
have expressed concerns about delay of care where they perceived
(mHealth), electronic health (eHealth), telehealth, mobile health
women were more focussed on their phone than on the midwife
applications and mobile technology as ways of informing about,
providing care, and where women were interrupting a conversation
or enabling access to, healthcare (Chib, 2010; Daly et al., 2018;
with their midwife to answer their phone (Dahl et al., 2017; Lewis
Fazal et al., 2020; Labrique et al., 2013; Lupton & Maslen, 2017;
et al., 2019).
Ministry of Health, 2020b; Speciale & Freytsis, 2013; van den
Heuvel et al., 2018; White et al., 2019; Willcox et al., 2019). Other concerns identified, which may have far graver
Email and text messaging between healthcare organisations and consequences, relate to the asynchronous nature of texting or
consumers of healthcare services enable efficient communication instant messaging, with uncertainty around whether messages had
in the form of appointment reminders, the dissemination of been received, and also the interpretation of messages (Häkkilä &
results and educational information on ways to change or improve Chatfield, 2005). Within Aotearoa NZ, communication practices
lifestyle behaviour (Dobson et al., 2017; Evans et al., 2012; where text messaging has been used between midwives and
Goldfarb et al., 2016; Leahy et al., 2017; Muller et al., 2016). With maternity consumers have led to complaints being made to the
advances in technology, mobiles and smartphones have become New Zealand Health and Disability Commissioner (HDC). These
more accessible to maternity consumers. Internet access has been complaints led to midwives coming under criticism from coroners
enhanced, applications have improved in effectiveness and social for using text messaging which was deemed to be inappropriate
media platforms have become more fit-for-purpose. This has for completing a clinical assessment, for inappropriate use of text
enabled information about pregnancy, labour and birth or postnatal messaging from a midwife to a woman, for failing to document
experiences to be more freely accessible than in previous times text messages within the clinical notes, and for situations where
(Alianmoghaddam et al., 2019; Fleming et al., 2014; Gleeson et al., the midwife had failed to appropriately advise women about the
2019; Lagan et al., 2010; Lupton, 2016; Lupton & Pederson, 2016; use of text messaging for urgent matters (HDC, 2013a, 2013b,
Tranter & McGraw, 2017; Tripp et al., 2014). 2014a, 2014b, 2016). While many of these complaints were
related to the use of text messaging, other concerns have been
In remote or rural areas where access to healthcare services may
identified with security, privacy of messages and confidentiality of
be limited, the flexibility and availability of programmes reliant
patient information held on devices that do not contain passwords
on mobile technologies such as mHealth or telehealth have
or encryption (Basevi et al., 2014; Goldfarb et al., 2016; Leahy
improved maternal and child health outcomes through texting,
et al., 2017; Muller et al., 2016; Nettrour et al., 2019). This was
voice messaging or video-calling health education and information
highlighted in a recent cyber-attack on a district health board
to pregnant women/people and families (Chib, 2010; Evans et al.,
(DHB) in Aotearoa NZ, which resulted in the entire IT system
2012; Fazal et al., 2020; Gelano et al., 2018; Labrique et al., 2013;
and phone lines crashing (Otago Daily Times, 2021). Hackers
LeFevre et al., 2017; Soltani et al., 2012; Speciale & Freytsis,
were thought to have gained access to the DHB network through
2013; Willcox et al., 2015; Willcox et al., 2019). Within Aotearoa
an employee unwittingly opening an email attachment (Cullen
NZ, the National Telehealth Service was established between
Law, 2021). The impact on patient services within the DHB were
the Ministry of Health (MOH) and Homecare Medical in 2015
still being felt a month after the attack (Wilson, 2021). So, while
to develop and integrate a national telehealth service which
the use of communication technology is widespread throughout
incorporated Ministry-funded health services and communication
the health system, evidence would suggest there is need for caution
platforms for consumers (MOH, 2020b). This service enabled
and, therefore, there is need for further exploration.
consumers to access virtually the healthcare service they needed
via a range of communication channels. Rationale for integrative review
Within the current global Covid-19 pandemic, use of digital The ubiquitous use of communication technology within all facets
technologies such as video-calling has in some instances replaced of life has highlighted both the benefits and concerns around
the physical face-to-face assessment normally undertaken by how such communication is used between maternity providers
midwives. In 2020, when Aotearoa NZ was engaged in a Covid-19 and consumers. There is little information, however, identifying
elimination strategy, midwives were encouraged to hold virtual how midwives and pregnant women/people use communication
appointments unless a face-to-face appointment was strictly technology when communicating with each another. An
necessary and, where this was the case, to limit contact to no integrative literature review involves reviewing, analysing and
more than 15 minutes (MOH, 2020a; New Zealand College of comparing studies on a specific topic that utilise a variety of
Midwives, 2020). research methodologies and is therefore useful when there is little
known on a particular research topic (Snyder, 2019). This differs
Concerns with communication technology from a conventional literature review which tends to summarise
within maternity care relevant literature, or a systematic review which specifically
While access to technology has been shown to be beneficial, some includes experimental research studies, which could otherwise be
mHealth technologies can be problematic, particularly if pregnant quite limiting.
 New Zealand College of Midwives Journal • Issue 58 • 2022 13

AIM Figure 1. Adapted PRISMA flow chart representing the

To explore the literature on how communication technology has literature review process
been used to enable midwives and pregnant women to connect
with one another.
METHOD
An integrative literature review of peer reviewed studies
published between 2010 and 2021 was undertaken to explore
how information and communication technology (ICT) was
used to enable midwives and pregnant women to connect with
each another. This approach allowed for the inclusion of both
qualitative and quantitative methodologies (Russell, 2005;
Whittemore & Knafl, 2005). Four databases commonly used
within healthcare research – CINAHL, Pubmed, Proquest and the
Australia NZ Reference Centre – were used to undertake searches
using the following terms (communication technology OR ICT)
AND (midwives OR midwife OR midwifery) AND (pregnant
women OR pregnancy OR expectant mothers). A description of
the review process has been captured using an adapted PRISMA
flow chart (Figure 1). While a PRISMA flow chart is generally
used when undertaking a systematic review, it is also helpful
in providing a visual representation of the integrative literature
review process.
Criteria for inclusion in the review
Included studies were those published between 2010 and
2021 which incorporated use of communication technology
used during the antenatal period by pregnant women and/or (Table 1) was then compiled to summarise the five studies. A final
midwives. The results were restricted to English language and peer column was added to the evidence table and included the main
reviewed publications. themes identified from the review. These themes were discussed
and agreed by the researchers.
Exclusion criteria
Excluded studies were those where the technology was used as an FINDINGS
intervention to screen or diagnose a condition, rather than as a Five research papers met the inclusion criteria and are presented in
communication device, or where the communication included Table 1. Included papers were summarised using an evidence table
health professionals other than midwives. with the following headings: Author, Methods/Design, Sample,
The initial search elicited 450 articles. The title and abstract of Aims, and Themes arising from results.
each article were reviewed for their relevance. This resulted in The studies summarised in Table 1 include two qualitative studies,
the removal of 431, leaving 19 relevant articles. Four duplicates two mixed methods designs and one quantitative design. The
were removed and, after reading in full the remaining 15 articles, studies were undertaken in Australia (2), Aotearoa NZ (1), the
five studies were retrieved and assessed for relevance using a United States of America (1) and the UK (1).
Critical Appraisals Skills Programme (CASP) checklist relevant The final column highlights common themes relevant to how
to the appropriate study (CASP UK, n.d.). CASP checklists were communication technology has been used between midwives
developed and piloted originally as an educational pedagogical and pregnant women. The four main themes identified were (1)
tool to be used when assessing a study’s validity and therefore an connecting, (2) access to healthcare, (3) privacy and confidentiality,
appropriate tool to use for assessing the robustness of qualitative, and (4) lack of skills and knowledge. The overarching theme
mixed methods and quantitative studies incorporated in this identified across all studies was connection between pregnant
integrative review (CASP UK, n.d.). All five studies satisfied the women and midwives. The ability to connect using technology
checklist requirements. enabled pregnant women to access healthcare services; thereby, it
has reduced barriers to healthcare (Gasteiger et al., 2019; McCarthy
Analysis
et al., 2017). The use of communication technology, however, was
Miles and Huberman (1994) describe a four-step process for not always viewed positively when it related to issues of privacy or
analysing data when undertaking an integrative review: data where there were concerns with having the skills to access and use
reduction, data display, data comparison and conclusion drawing/ the technology. Three out of the five studies reviewed identified
verification. An annotated bibliography was compiled to determine these issues as concerns (Dalton et al., 2014; Gasteiger et al., 2019;
which publications would be included in the review, and which Shroder et al., 2018).
would serve as background information (data reduction). Once
the annotated bibliography had been compiled (data display), the Connecting
studies were reviewed using the relevant CASP checklist to help Connection was the overarching theme across all five studies. Four
appraise and critique the relevance of each study to the review types of communication technology were described: texting, video
question. The five relevant studies were then compared looking calling, social media (or online discussion forums) and phone
for patterns, themes, or relationships (data comparison). This was calls or use of mobile phones (Dalton et al., 2014; Forti et al.,
done through use of different coloured highlighter pens to identify 2013; Gasteiger et al., 2019; McCarthy et al., 2017; Shroder et
the different themes between the various studies. An evidence table al., 2018).
14 New Zealand College of Midwives Journal • Issue 58• 2022

Table 1. Summary of studies reviewed

Author Methods/Design Sample Aim/s Theme/s arising from results*

Dalton et al. Mixed methods Midwives providing antenatal To investigate attitudes/ Lacking skills using and
(2014) information and education at experiences of using accessing technology
Semi-structured interviews a hospital in Australia information and
(n=8) communication technology Concern with privacy and
Two focus groups (n=4 & n=9) (ICT) confidentiality
Self-selected survey (n=19)
To identify potential factors Lack of connection when
that encourage/inhibit use in unable to see the person
antenatal care
Forti et al. Prospective cross-sectional Midwives from a group To explore which were Connecting
(2013) design practice in a tertiary hospital the frequently used
in Australia communication modalities
Survey (n=15) between midwives and their
clients
Gasteiger et al. Kaupapa Māori 7 women and 2 men from To explore perceptions, Reduced barriers, promoting
(2019) methodology ** Northland, Aotearoa NZ and use, of technologies by access to information
women and their partners
Semi-structured interviews who utilised Kaupapa Māori Saving time and travel costs
(n=9) perinatal health services,
which incorporate Māori Connecting; face-to-face
philosophies and practices valued

Lack of skills using technology

Privacy concerns

McCarthy et al. Qualitative longitudinal study 31 women and 4 midwives in 2 To explore the experiences of Online platform gave some
(2017) using thematic analysis National Health Service trusts pregnant women and their anonymity
in the UK midwife moderators using an
Focus groups (n=8; 4 online, 4 online Facebook group Enabled access to healthcare
face-to-face) information

Individual interviews (n=28) Connection; women trusted

the midwife, giving them
confidence
Shroder et al. Longitudinal mixed methods 82 pregnant women and 27 To explore communication Connecting, seeing the
(2018) caregivers, USA technology use by pregnant person
Surveys & interviews (n=109) women and their caregivers/
partners Convenience, saves time

Privacy and security concerns

* Full results available from corresponding author. ** Kaupapa Māori methodology focuses on research undertaken by Māori with Māori to improve Māori wellbeing.

In three studies, texting was found to be easy to use and an Access to healthcare was enabled in two ways for pregnant women
efficient way for women to contact their midwife when changing living in a rural location in Aotearoa NZ (Gasteiger et al., 2019).
appointments, requesting health information or to ask questions Firstly, communication technology enabled access to online
(Forti et al., 2013; Gasteiger et al., 2019; Shroder et al., 2018). health information and connection with their midwife, thereby
Video calling was beneficial for pregnant women when accessing reducing costs for travel and wait times at a clinic for a face-to-
a health professional. The video aspect enabled people’s reactions face appointment. Secondly, communication technology (texting)
to be seen while also saving costs on travelling to a health provider enabled pregnant women to connect with their midwife in the
when accessing the call from home (Shroder et al., 2018). “virtual space” to ask questions or share information they might
Connecting women to a virtual midwife in an asynchronous not otherwise have done face-to-face or via a phone call. Pregnant
online platform environment was beneficial as women felt more women participating in an online Facebook group found this
comfortable asking questions which they might not otherwise ask platform provided anonymity and confidence to ask and share
a busy midwife face-to-face (McCarthy et al., 2017). The women information with a “virtual midwife” (McCarthy et al., 2017).
felt the Face-wives (midwife moderators) were more freely available The virtual midwife was able to respond to questions in a timely
to respond to questions and concerns in a timely manner. The manner which met a need in cases where women were unable to
Face-wives equally felt connected with the women and expressed access this information from their busy midwives in face-to-face
satisfaction with this online relationship. This connection was interactions. In contrast to using an online discussion forum,
developed through a relationship built on trust and confidence, Skype or Facetime enabled pregnant women to share physical
especially around information sharing (McCarthy et al., 2017). symptoms with their healthcare providers. This was reportedly
more convenient and avoided a physical face-to-face assessment
Access to healthcare (Shroder et al., 2018). The participants in this study commented
Three studies identified how use of communication technology on the preference for face-to-face online interaction to a phone call
increased access to healthcare information or contact with a as facial expressions and reactions could be seen which provided a
maternity provider (Gasteiger et al., 2019; McCarthy et al., 2017; more personal connection.
Shroder et al., 2018).
 New Zealand College of Midwives Journal • Issue 58 • 2022 15

While communication technology has been beneficial in enabling (the known face)” (p.132). Building relationships comes about
pregnant women/people to access and connect with a maternity through “sensory engagements” where health professionals and
care provider, there have also been concerns identified around health consumers draw on senses when communicating with one
its use. Two main concerns were identified from the studies in another (Lupton & Maslen, 2017). The importance of the “known
this review and will be reported under the themes: privacy and face” has been highlighted in other areas of healthcare where
confidentiality; and skills and knowledge. telehealth assessments have been undertaken. Gordon et al. (2020)
noted that patients felt uncomfortable during a video telehealth
Privacy and confidentiality assessment if they had not developed a prior relationship with
Privacy and confidentiality were of concern for several of the their healthcare provider. Similarly, “seeing the person” online was
participants in three of the studies (Dalton et al., 2014; Gasteiger enough for midwives to feel they could assess a woman in early
et al., 2019; Shroder et al., 2018). Midwives were concerned labour (Faucher & Powell Kennedy, 2020; Spiby et al., 2019). It
about antenatal information provided in an online environment is arguable that sensory engagements are what create the difference
being taken out of context or potentially being misused due to not between a physical face-to-face interaction versus a virtual one,
“seeing” who the information was being shared with (Dalton et al., particularly when people are unknown to one another.
2014). Use of communication technology raised several concerns The lack of sensory engagement or non-verbal communication
for midwives around their own privacy when their images were is a possible explanation for why midwives were concerned with
posted on social media (Dalton et al., 2014). using an online platform without visual connection (Dalton et al.,
Gasteiger et al., (2019) reported women were concerned about 2014). For the midwives in this study, “not seeing the person”
advertising appearing on their Facebook site about pregnancy- meant they could not respond to facial expressions or see how
related matters when they had used search engines to access health the person responded to information provided. Conversely, the
information related to pregnancy. This information was then lack of face-to-face enabled pregnant women to ask their midwife
visible to anyone accessing the woman’s Facebook site and was questions they might not otherwise feel comfortable to ask kanohi
something the women had not realised would happen. ki te kanohi (face-to-face; Gasteiger et al., 2019; McCarthy et al.,
2017). This has similarly been found in other areas of healthcare
Skills and knowledge or online forums and such connections would therefore appear
Lack of skills and knowledge in using communication technology to provide a protective space for sensitive questions to be asked
was identified by women and midwives in two of the studies (Gleeson et al., 2019; Wallwiener et al., 2009).
reviewed (Dalton et al., 2014; Gasteiger et al., 2019). The concerns While a lack of physical face-to-face connection has benefits
raised were around accessing the electronic patient portal system with people being able to connect using technology, it can also
(Gasteiger et al., 2019) and concern with “where” the information highlight issues with users of communication technology feeling
was going in an online forum (Dalton et al., 2014). Dalton et as though they always need to “be connected”. There are concerns
al., (2014) found midwives were concerned about their own that this need for always being connected has had implications
ability and skills with using the technology to communicate with with respect to people’s ability to form relationships during face-
women via social media or other online discussion forums where to-face interactions (Allred & Atkin, 2020; Gergen, 2002; Rotondi
physical face-to-face interactions were not available. They felt et al., 2017; Srivastava, 2005; Thompson & Cupples, 2008).
uncomfortable responding to questions in an online platform as Gergen (2002) discusses some of the challenges that mobile phone
they were unsure who was accessing this information and whether users have with relational communications when individuals
this information could be taken out of context. are connecting with “absent others” while being present in the
room with others. This challenge has been identified by midwives
DISCUSSION AND IMPLICATIONS FOR
FURTHER RESEARCH who were concerned they were competing with the phone when
providing care to women following birth (Lewis et al., 2019). This
The aim of this integrative review was to explore how
in turn may have implications for the way midwives and pregnant
communication technology has been used between midwives and
women/people establish and navigate relationships face-to-face,
pregnant women/people. The outstanding theme from the five
where there is potential for distraction when communication
studies reviewed related to the way communication technology
devices are used to communicate with others outside of the room.
enabled a connection to occur between the health professional and
maternity consumer. In summary, both midwives and pregnant women in this
integrative review identified having a lack of knowledge and skills
Being connected did not necessarily mean face-to-face. A feeling
when using communication technology to communicate with
of connection was important, in supporting the pregnant woman/
one another. This would appear to fit with a report undertaken
person in their access to maternity services. Colorafi (2016) discusses
in 2017 in Aotearoa NZ which found that 50% of Aotearoa NZ
connection as “the energy that exists between people when they feel
workers had concerns about their digital capabilities (Zwimpfer
seen, heard, and valued; when they can give and receive without
et al., 2017). Using communication technology is here to stay;
judgment; and when they derive sustenance and strength from the
therefore, part of navigating these connections will need to involve
relationship” (p.2). While the midwives and pregnant women in the
midwives and pregnant women/people having discussions around
studies reviewed were not always “known” to each other, or could
how communication technology might be used effectively and
see each other, there appeared to be an “emotional connection”
competently throughout the perinatal journey.
which was enabled through use of communication technology.
This emotional connection has been discussed in relation to the CONCLUSION
proximity of care or “intimacy at a distance” that is enabled through The literature revealed that communication technology provided
use of technologies such as email, texting, webcam and video-links a platform for pregnant women/people to access maternity care in
(Lupton & Maslen, 2017; Milligan & Wiles, 2010). a manner that meets individual needs. Despite advances made to
Kenney (2011) suggests that “mutually respectful relationships” accessibility of communication technology over the last 30 years,
within the midwifery partnership are “nurtured by te kanohi kitea there appears to be a gap in the published literature relaying how
16 New Zealand College of Midwives Journal • Issue 58• 2022

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Accepted for Publication June 2022

Wakelin, K., McAra-Couper, J., Fleming, T., & Erlam, G. (2022).
Exploring the ways communication technology is used by midwives and
pregnant women/people: An integrative review. New Zealand College of
Midwives Journal, 58, 11-18.
https://doi.org/10.12784/nzcomjnl58.2022.2.11-18