Communication preferences during pregnancy care among patients with primary Spanish language: A scoping review

Abstract

Background:

Qualified language service providers (QLSPs)–professional interpreters or multilingual clinicians certified to provide care in another language–are critical to ensuring meaningful language access for patients. Designing patient-centered systems for language access could improve quality of pregnancy care.

Objective:

We synthesized and identified gaps in knowledge about communication preferences during pregnancy care among patients with Spanish primary language.

Methods:

We performed a scoping review of original research studies published between 2000–2022 that assessed communication preferences in Spanish-speaking populations during pregnancy care. Studies underwent title, abstract, and full-text review by three investigators. Data were extracted for synthesis and thematic analysis.

Results:

We retrieved 1539 studies. After title/abstract screening, 36 studies underwent full-text review, and 13 of them met inclusion criteria. Two additional studies were included after reference tracing. This yielded a total of 15 studies comprising qualitative (n=7), quantitative (n=4), and mixed-methods (n=4) studies. Three communication preference themes were identified: language access through QLSPs (n=7); interpersonal dynamics and perceptions of quality of care (n=9); and information provision and shared decision-making (n=8). While seven studies reported a strong patient preference to receive prenatal care from Spanish-speaking clinicians, none of the included studies assessed clinician Spanish language proficiency or QLSP categorization.

Conclusions:

Few studies have assessed communication preferences during pregnancy care among patients with primary Spanish language. Future studies to improve communication during pregnancy care for patients with primary Spanish language require intentional analysis of their communication preferences, including precision regarding language proficiency among clinicians.

Introduction

Hispanic/Latine people are the largest minoritized group in the United States, according to the 2019 American Community Survey from the U.S. Census Bureau (U.S. Census Bureau, 2022). That survey found that 61.6% of people who spoke a language other than English at home spoke Spanish. Latine patients whose primary language is Spanish may experience distrust, discrimination, and emotional distress due to language barriers with their clinicians, lack of qualified interpreter services, or insufficient time allocation during visits (Escobedo et al., 2023). Beyond language barriers, effective clinical communication can also be hindered by cultural barriers that may exist between patients and clinicians who do not share the same cultural, racial, or ethnic backgrounds.

Language concordance has been conceptualized as a clinician’s ability to deliver care to patients in their preferred language. In most cases, language-concordant care improves clinical outcomes (Diamond et al., 2019). However, consistent proficiency criteria are lacking across healthcare institutions to define which providers may appropriately engage in language-concordant encounters with patients who speak languages other than English (Lor et al., 2020). Diversifying a multilingual and multicultural clinician workforce and expanding access to interpreters may improve the quality of care that patients who face language barriers experience.

The Affordable Care Act, Section 1557 (U.S. Department of Health and Human Services, 2010) prohibits discrimination in healthcare delivery based on race, national origin, sex, age, or disability and requires that healthcare organizations ensure meaningful language access to individuals with limited English proficiency. Towards this end, qualified language service providers (QLSPs) have become increasingly common in healthcare settings. QLSPs include professional medical interpreters and qualified multilingual clinicians with professional language proficiency to provide care in another language based on standardized language assessments (Fox et al., 2020). Without appropriate interpreter services in language-discordant patient-clinicians dyads, patients may feel that they are receiving lower quality medical care (Brooks et al., 2016). Underutilization of interpreters may occur due to time constraints, access barriers, and impact on workflow (Fox et al., 2020). Moreover, language-discordant clinicians report increased difficulty with building therapeutic alliances with patients and less confidence in their ability to communicate effectively when linguistic barriers exist (Fox et al., 2020). Language-discordant clinicians may overestimate their own non-English language proficiency or the level of understanding of their non-English speaking patients (Taira et al., 2020). In response to clinical scenarios like these, healthcare institutions are increasingly assessing whether their multilingual staff may be categorized as QLSPs. Several institutions have found that many of their Spanish-speaking clinicians may have inadequate language skills required for the complex communication needs of clinical medicine (Fernandez et al., 2015). Thus, patients may experience different levels of quality and effectiveness in communication based on variable fluency levels of their clinicians.

In the United States, pregnant people with limited English proficiency are at increased risk of receiving suboptimal care and experiencing negative health outcomes during the antepartum, intrapartum, and postpartum periods (Togioka et al., 2022). Primary cesarean birth rates, for example, are significantly higher among nulliparous women who prefer languages other than English (Comfort et al., 2023). In the context of what is known about language barriers, effective communication, and relationship-building between clinicians and patients, there is limited understanding of communication preferences among patients with Spanish primary language during pregnancy care. Inclusion of patients’ perspectives regarding their communication preferences during pregnancy care is a critical foundation for improved outcomes. We aimed to synthesize and evaluate the literature on communication preferences among Spanish-speaking patients who face language barriers in pregnancy care.

Methods

Search Strategy and Selection Criteria

A scoping review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines (Tricco et al., 2018; Peters et al., 2020) to chart the existing literature regarding preferences and experiences of patients with primary Spanish language during pregnancy care. A research librarian developed an initial search strategy using a combination of controlled vocabulary (MeSH terms, EMTREE, and CINAHL headings) and title/abstract keywords for patients of Hispanic or Latin American origin, the patient-physician relationship, and communication factors in PubMed in June 2022 (Table A.1). This produced an initial body of literature that the research team screened. The first search included assessment of patient communication preferences within all medical specialties; however, the research team decided to narrow the scope of this review to only women’s health and, ultimately, pregnancy care, in November 2022. To better ensure that all appropriate studies within pregnancy care were captured, the research librarian developed another search strategy in Medline (Ovid) using a combination of controlled vocabularies and title/abstract keywords for populations with limited English proficiency and language barriers, patient preference and satisfaction, and pregnancy and maternal health terminology. The search was translated into four databases—Embase (Elsevier), CINAHL (EBSCO), Web of Science Core (Clarivate), and Cochrane Central (Wiley)—to produce an additional body of literature to assess the communication experiences and preferences of primary Spanish-speaking patients during pregnancy care. Two investigators independently reviewed all titles and abstracts and a third researcher resolved any conflicts that arose. Two investigators then independently reviewed all included studies in full, and a third investigator assisted in resolving conflicts. Any remaining conflicts were discussed with the full study team until consensus was reached. Lastly, three investigators employed a reference tracing technique (“pearling”) of all included studies to identify additional studies to review that were not included in our search queries. This involved reviewing reference lists of our included studies and selecting relevant studies that met our inclusion criteria. The study protocol was not registered.

The inclusion criteria were: primary/original research studies, pregnancy care setting, location in the United States, published after 2000, and reported on communication experiences and/or preferences of patients whose preferred language is Spanish.

Data Abstraction and Synthesis:

Data were abstracted by two independent researchers using a REDCap survey (Harris et al., 2009) that included information pertaining to study characteristics, data collection methods, research design, validated measurement tools, clinician and patient Spanish language preference and/or fluency, and patient communication preferences. A third researcher reviewed all abstractions and cleaned the data.

Summary statistics (frequency and percentage) for study characteristics such as research design and use of validated measurement tools were reported. Main study findings related to patient communication preferences were grouped using iterative thematic analysis (Saldana, 2021). In brief, once patient communication preferences were identified for each study, the most prevalent communication themes were captured and subsequently refined into three main salient themes regarding patient communication preferences through which additional analysis of studies was completed.

Given that the objective of this review was to synthesize the literature surrounding primary-Spanish speaking patients’ communication preferences in pregnancy care, we did not assess the quality or risk of bias of the included studies.

Results

Our first search query in June 2022 identified 1082 studies, but these were not specific to pregnancy care. We ran a second search query in November 2022 that yielded 570 studies within women’s health (obstetrics, gynecology, breast care); 113 of these were duplicates, yielding 457 unique studies. In total, our two searches of the databases yielded 1539 de-duplicated studies. After title and abstract review, 36 studies were identified for full text review based on the inclusion criteria. After resolving discrepancies, a total of 13 studies were identified as meeting all inclusion criteria for the scoping review. Through reference tracing of these 13 studies, we identified two additional studies that met our inclusion criteria but were not retrieved in our search query results. A total of 15 studies were thus included in this scoping review (Figure 1).

Figure 1.

PRISMA flow diagram.

*Inclusion criteria: U.S. based original research papers, published after 2000, assessing communication preferences of primary-Spanish speaking (limited English proficiency) patients, within prenatal care.

The identified studies used qualitative (n=7), quantitative (n=4), and mixed methods (n=4). Table 1 summarizes characteristics of the 15 studies, including title/author/publication year, study purpose, and main findings related to patient communication preferences. Table 2 provides a synthesis of the study designs, data collection methods, numbers of study participants, communication preferences, assessment of language concordance in patient-clinician dyad, assessment of clinician language proficiency, use of validated instruments, and health outcomes based on language preference. Seven studies (46.7%) used validated tools for their data collection. Only one study (Granada et al., 2022) reported the percentage of participants who received language concordant vs discordant prenatal care. None of the studies objectively measured clinicians’ Spanish language proficiency. Two studies focused on different health outcomes between English- and Spanish-speaking patients (Hessol et al., 2012 in cesarean birth rates and Jimenez et al., 2012 in pain control).

Table 1.

Characteristics of Included Studies

Study Citation	Purpose	Main Findings Regarding Patient Communication Preferences in Pregnancy Care
Birthing Experiences of Spanish Speakers During the COVID-19 Pandemic in NYC. Granada et al, 2022.	To describe the birth experience during COVID-19 among monolingual Spanish and bilingual Spanish/English speakers.	COVID-19 specific challenges were more impactful on patient experience than patient-provider language discordance in this study.
Addressing Disparities in Prenatal Care via Telehealth During Covid-19: Prenatal Satisfaction Survey in East Harlem. Futterman et al, 2021.	To compare patient satisfaction with prenatal care conducted via telehealth to in-person visits at the height of the COVID-19 pandemic.	In patients who self-identified as Hispanic or who had Spanish primary language, there was no statistically significant difference in their satisfaction scores when they received prenatal care via telehealth during the COVID-19 pandemic.
Youth-centered Maternity Care: a Binational Qualitative Comparison of the Experiences and Perspectives of Latina Adolescents and Healthcare Providers. Decker et al, 2021.	To compare maternity care experiences of patients in Guanajuato, Mexico and Fresno, California.	Participants preferred clear communication and explanations, respectful instead of judgmental providers, and active engagement in decision-making.
Trust Development With the Spanish-Speaking Mexican American Patient: A Grounded Theory Study. Jones et al, 2018.	To explain how trust develops between the Spanish-speaking Mexican American patient and nurses, from the patient’s perspective.	Language barriers hindered trust in language-discordant care; however, nurses’ personalities are able to overcome this barrier to trust development. Participants developed trust with approachable nurses who did not speak Spanish.
Women’s Preferences for and Experiences with Prenatal Genetic Testing Decision Making: Sociodemographic Disparities in Preference-Concordant Decision Making. Molina et al, 2018.	To describe women’s preferred approach to decision making and if they experienced preference-concordant decision making.	Compared to White women, Spanish-speaking Latinas were significantly less likely to experience a preference-concordant decision process.
Anguish, Yearning, and Identity: Toward a Better Understanding of the Pregnant Hispanic Woman’s Prenatal Care Experience. Fitzgerald et al, 2016.	To seek a better understanding of needs and access issues among pregnant, low-income Hispanic women.	Health care providers’ attitudes and insensitivities regarding language discordance and language barriers caused patients confusion and misunderstanding of their care plans. This exacerbated the underlying fear already felt of pregnancy-related complications by Hispanic, Spanish-speaking women during pregnancy.
Language-Appropriate Appointment Reminders: Assessing the Communication Preferences of Women With Limited English Proficiency. Morse et al, 2016.	To assess the communication preferences for appointment reminders of women with limited English proficiency who attended an outpatient women’s health clinic.	The vast majority of women with limited English proficiency attending a women’s health clinic preferred to be contacted in their primary language, regardless of their ability to read, write, or speak English.
Expectations of Pregnant Women of Mexican Origin Regarding their Health Care Providers. Baxley et al, 2015.	To explore the expectations of Mexican pregnant women regarding trust and communication with their health care providers.	Participants felt that being bilingual was one of the most important aspects of communication in prenatal care. Participants most valued personal interactions and friendly behavior in building trust with clinicians. Participants wanted their care to feel more personalized and their health care providers to demonstrate they cared about them as people.
Maternal Acculturation and the Prenatal Care Experience. Fuentes-Afflick et al, 2014.	To evaluate the relationship between maternal acculturation and interpersonal processes of care* among women who received prenatal care.	In this study that included 675 pregnant women born in Latin America, women who were less acculturated reported better prenatal care experiences than more acculturated and US-born women.
What is Patient-Centered Care Really? Voices of Hispanic Prenatal Patients. Bergman et al, 2013.	To investigate Hispanic prenatal care patients’ understandings and expectations of patient-centered care.	Hispanic prenatal patients prefer having a friendly relationship with their providers. Patients appreciated the availability of Spanish-speaking individuals in clinical encounters. Participants described a preference for the medical team providing care in Spanish without the use of an interpreter.
Reported Experiences with Prenatal Care: Is There a Difference in Patient Satisfaction Based on Racial and Ethnic Background? Johnson et al, 2012.	To determine if racial and ethnic disparities exist in prenatal care by assessing patient satisfaction in private vs. clinic practices.	Hispanic and Black women were much more likely to respond that their primary language always or often influenced their quality of care when compared to White participants.
Interpersonal Processes of Care and Cesarean Delivery in Two Health Care Settings. Hessol et al, 2012.	To examine whether interpersonal processes of care* were associated with cesarean birth.	Women who reported receiving more questions about their problems and responsiveness from their providers had a lower risk of cesarean birth, whereas women who reported higher scores on empowerment/self-care had a higher risk of cesarean birth.
Patient-Reported Quality of Pain Treatment and Use of Interpreters in Spanish-Speaking Patients Hospitalized for Obstetric and Gynecological Care. Jimenez et al, 2012.	To determine whether interpreter use was associated with quality of acute pain treatment among Latina patients with limited English proficiency.	Interpreter use was associated with better patient reports of pain control, timely response to pain needs, and perceived helpfulness of healthcare providers to provide pain treatment.
Factors Affecting Latina Immigrants’ Perceptions of Maternal Health Care: Findings From a Qualitative Study. Gurman et al, 2008.	To identify barriers that Latinas faced when navigating maternal health care services and to explore perceptions of quality of care.	Many women experienced language barriers during their visits. In language-discordant care, perception of quality of care was mostly based on provider interpersonal attributes (respect, kindness, friendliness, warmth). Healthcare experiences of women in their home countries influenced their evaluation of their experience in the US health system.
Hispanic Women’s Perceptions of Patient-Centeredness During Prenatal Care: A Mixed-Method Study. Tandon et al, 2005.	To better understand Hispanic women’s perceptions of patient-centeredness in prenatal care compared to non-Hispanic mothers.	Fewer postpartum Hispanic women perceived aspects of their prenatal care to be patient-centered than non-Hispanic mothers. Moreover, the odds of experiencing language or communication problems with doctors or nurses during prenatal care appointments were greater for Hispanic mothers than for non-Hispanic mothers.

^*Interpersonal processes of care describe various aspects of the clinician-patient relationship, including communication, patient-centered decision-making, and interpersonal style

Table 2:

Summary of Studies Included in Final Analysis (n=15)

	Total N (%)
Study Design
Qualitative	7 (47%)
Quantitative	4 (27%)
Mixed-methods	4 (27%)
Data Collection Method ⤉
Interviews	10 (67%)
Focus Groups	3 (20%)
Surveys	7 (47%)
Number of Study Participants
8–20	4 (27%)
21–100	3 (20%)
101–200	2 (13%)
201–500	3 (20%)
500–1332	3 (20%)
Communication Preferences
Interpersonal dynamics and perceptions of quality of care	9 (60%)
Language access through language-concordant clinicians or interpreters	7 (47%)
Clinical information provision and decision-making	8 (53%)
Assessed Language Concordance in Patient-Physician Dyad	1 (7%)*
Assessed Clinician Language Proficiency	0 (0%)
Used a Validated Instrument **	7 (47%)
Compared Health Outcomes based on Language Preference ***	2 (13%)

^⤉May total to over 100% as studies could include multiple methods for data collection.

^* Granada et al, 2022

^**Validated tools used include SAPS (Short Assessment of Patient Satisfaction) Survey, IPC (Interpersonal Processes of Care) Survey, PIPC (Prenatal Interpersonal Processes of Care) Survey, and CAHPS (Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey. One study adapted interview questions from Tandon et al study findings, another from Bergman et al study findings.

^***Hessol et al assessed differences in cesarean birth rates and Jimenez et al assessed differences in adequate pain control based on patient preferred language (Spanish).

Three major themes were identified regarding the target patient population’s communication preferences as they relate to language access, interpersonal dynamics and perceptions of quality of care, and clinical information provision and decision-making.

Preference for language access through language-concordant clinicians or interpreters

Seven studies demonstrated a salient patient preference for receiving prenatal care from language-concordant clinicians or interpreters (QLSPs) as opposed to non-Spanish-speaking, language-discordant clinicians. Three studies reported a patient preference for working with Spanish-speaking clinicians as opposed to with interpreters. For example, Baxley et al. (2015) found that patients prefer bilingual clinicians who can speak both English and Spanish. Bergman et al. (2013) report that primary Spanish-speaking patients prefer language-concordant care in Spanish and perceive this care as superior in quality. Gurman et al. (2008) showed that although most participants felt they could get by in language-discordant care with the limited English they knew how to speak or with the help of family members, language discordance greatly affected communication with clinicians. Specifically, language discordance hindered participants’ ability to communicate with hospital staff, to understand the information they were given, and to express their needs and preferences. Fitzgerald et al. (2016) found that Hispanic, Spanish-speaking participants’ fear, confusion, and anguish related to their pregnancy was heightened in the setting of language-discordant care. Jimenez et al. (2012) found that interpreters increased the perceived helpfulness of clinicians in language-discordant care, especially regarding adequate pain control. While Jones et al. (2018) also found that trust development was hindered in language-discordant care, they found that this obstacle could be overcome depending on a clinician’s interpersonal style.

Four studies explored patient experiences and preferences specifically when working with interpreters. Granada et al. (2022) found that 30% of their study’s monolingual Spanish-speaking participants reported that there were points in their care when they did not work with interpreters but felt that they needed one. Gurman et al. (2008) showed that patients did not find it helpful when language-discordant clinicians attempted to “make do” by providing care using short Spanish phrases that did not indicate Spanish language fluency. Participants in this study described better understanding of their medical care when an interpreter was involved in the clinical encounter. However, they also cited longer wait times for an interpreter as a barrier. Moreover, this study found that when interpreters are involved in clinical encounters, patients prefer that they are friendly, professional, and respectful of privacy. In a similar fashion, Fitzgerald et al. (2016) revealed patient preferences that clinicians are respectful and mindful of their desire to “maintain Hispanic cultural norms of modesty in appearance and behavior” in pregnancy care. In this setting, participants expressed concern with having male interpreters, preferring female interpreters.

Interpersonal dynamics and perceptions of quality of care

Nine studies assessed patient perceptions of patient-centered care and how their clinicians’ interpersonal attributes affect these perceptions. Tandon et al. (2005) concluded that when patients perceive their care to be patient-centered, this increases understanding of their care, resulting in a desire to engage in consistent, longitudinal prenatal care. This study found that Hispanic participants, however, had lower odds of perceiving that their care was patient-centered, compared to non-Hispanic, English-speaking participants. Similarly, Johnson et al. (2012) report that a greater percentage of patients with Spanish language preference were dissatisfied with their care. Participants in the Fitzgerald et al. (2016) study reported that their clinicians’ attitudes and insensitivities regarding their Spanish language preference hindered them from seeking prenatal care. In an extreme example, one participant reported being ridiculed by a clinician because of her lower English proficiency level.

Six studies suggest that interpersonal dynamics between clinicians and patients are essential for high quality care and drive preferences regarding communication. Gurman et al. (2008) found that for Spanish-speaking, Hispanic women, quality care means receiving care by clinicians who embody interpersonal values of friendliness, warmth, and kindness, especially in language-discordant clinical encounters. Bergman et al. (2013) found that patients were actually frustrated that their clinicians were not as social, warm, or friendly as they expected them to be during their visits. Baxley et al. (2015) and Jones et al. (2018) observed that a clinician’s behavior and interpersonal style, such as being welcoming, influenced their ability to build trust with patients in language-discordant care. Interestingly, Hessol et al. (2012) found that a clinician’s interpersonal style, specifically their responsiveness and elicitation of patient concerns, was associated with significantly lower mean rates of cesarean births.

Preferences regarding communicating clinical information and decision-making

Eight studies reported patient preferences regarding communication of clinical information and decision-making. As noted by Tandon et al. (2005), patients understood medical information better when it was delivered in a patient-centered manner. Baxley et al. (2015) found that participants preferred to be told information as directly and accurately as possible, even if the medical information was negative. Similarly, Decker et al. (2021) found that patients prefer clear, direct communication. Fitzgerald et al. (2016) found that providing information to primary-Spanish speaking patients may help address the exacerbated fear around pregnancy and lack of English language proficiency. In the Decker et al. (2021) study, participants preferred to be included in their healthcare decision-making process and to be informed of their rights and options. Molina et al. (2019) showed that Latina women with Spanish-language preference were less likely to receive preference-concordant decision-making approaches when compared to White women. Morse et al. (2016) found that primary Spanish-speaking patients prefer to receive appointment reminders (phone calls, emails, texts) in Spanish as opposed to English. Lastly, Futterman et al. (2021) found that in the setting of the current COVID-19 pandemic, telehealth did not affect primary Spanish-speaking patients’ perception of quality of care.

Another dimension to consider regarding communication preferences is the degree of acculturation among Spanish-speaking patients. Gurman et al. (2008) found that when evaluating their US healthcare experience, immigrant primary-Spanish speaking patients were influenced by the healthcare experiences they received in their home countries; some participants had relatively positive experiences in the U.S. compared to the low standards of care they experienced in previous pregnancies in their home countries. Similarly, Fuentes-Afflick et al. (2014) found that immigrant patients may have lower expectations for the care they receive in the U.S., especially when it comes to decision-making. Specifically, this study found that women who are more recently arrived in the United States, and who may be less acculturated, might have lower expectations for shared decision-making processes and how involved they are in their treatment plans.

Discussion

After screening over 1500 studies, only 15 studies met inclusion criteria for this scoping review. There is a dearth of literature that captures patient-reported communication preferences among Spanish-speaking patients during pregnancy care. This reveals a need to intentionally identify patient perspectives on the factors they value in pregnancy care when linguistic and cultural barriers exist. Although most studies did not directly assess patient communication preferences in prenatal care as their main study goal, examination of patient feedback regarding their prenatal care allowed us to identify factors that patients considered important for higher quality care. Thematic analysis of the included studies identified three major domains of communication preferences that highlight clear communication facilitators and barriers when language discordance exists in pregnancy care.

Regarding language access, our review shows that patients prefer receiving care from QLSP clinicians and interpreters as opposed to language-discordant, non-Spanish speaking clinicians. Because of the lack of professional assessment of clinician proficiency in Spanish in any of the studies, it is unclear how many of the bilingual clinicians met criteria as QLSPs. Moreover, this review found that, in most cases, interpreters help improve clinician-patient communication and comprehension, quality of care, and trust formation while decreasing fear and confusion, when language discordance exists. Some studies highlighted the specific preferences that patients have when working with interpreters, specifically that they be professional and respectful of privacy, and Fitzgerald et al. (2016) found a patient preference for female interpreters in the pregnancy care setting. This review highlighted a few barriers to interpreter access, including longer wait times and unequal visit time distribution. Included studies showed that suboptimal communication without a QLSP in language-discordant care affects comprehension, knowledge, and therapeutic alliance between clinicians and patients. Simply trying to “make do” in the setting of language discordance by not working with an interpreter and relying instead on non-verbal communication or shortcut sentences in Spanish is not effective or appreciated by included study participants, and it leads to lower perceived quality of care.

Another clear patient preference and communication facilitator is preference for clinicians with strong interpersonal skills who are warm and friendly, especially in language-discordant scenarios. Clinicians who are approachable can overcome barriers to trust development with their patients by showing them that they truly care for and are invested in them. Clinicians with a kind manner may be especially appreciated by primary-Spanish speaking patients who may have fears of being judged for their language preference on top of pre-existing concerns about potential pregnancy complications. Although only two studies in this scoping review reported different health outcomes based on patient Spanish language preference (pain control in Jimenez et al. (2012) and cesarean birth rates in Hessol et al. (2012)), both cited non-medical and interpersonal factors as potential drivers of these differences. This scoping review begins to shed light on some of these interpersonal, non-medical communication facilitators and barriers; however, this area remains largely underexplored.

In terms of clinical information provision and decision-making, our review highlights how important it is for patients with Spanish language preference to receive complete, accurate, and clear clinical information, preferably in Spanish. This desire for clinical information seems to be exacerbated by language barriers in the setting of pre-existing fears about potential pregnancy-related complications. Patients with primary Spanish language also have variable expectations about their roles in clinical decision-making. Fuentes-Afflick et al. (2014) reported that patients who are less acculturated do not expect to play as active roles in decision-making, while Decker et al. (2021) found that patients prefer to be included in decision-making. Regardless of the expectations or preferences concerning decision-making, based on Molina et al. (2019), it appears that patients with Spanish-language preference may be less likely to receive preference-concordant decision-making approaches, especially when compared to non-Hispanic White women.

As the U.S. population continues to diversify and healthcare institutions aim to become more inclusive of patients of all backgrounds, languages, and cultures, our scoping review provides insight into what primary Spanish-speaking patients prefer in communication during pregnancy care, especially when language barriers exist. However, this review has some limitations. We ran two extensive search queries with over 1500 results in total, and there were no studies that were present in both of our searches. While this may highlight the paucity of research in this subject, it may also reveal potential limitations in our search queries. Secondly, although there were a few more recent studies included in our review, 40% of the studies included (n=6) were published before 2013. Given the more widespread prevalence of QLSPs, especially certified interpreters, communication preferences may have shifted in the past decade. Third, for studies that primarily sought to assess patient perceptions of quality of care, our team had to extrapolate patient communication preferences, often using perceptions of patient-centeredness as a proxy for patient preferences. While our main research goal was to assess the communication preferences of patients with primary Spanish language, most of the studies in our review had different primary research goals, exposures, and outcomes, resulting in inconsistent comparison groups (race, ethnicity, language) throughout the different studies included in our review. Altogether these limitations reinforce the need for more research that directly and carefully assesses patient communication preferences when language barriers exist.

Implications for Practice, Policy, and Research

Language-concordant care from Spanish-speaking clinicians is a key preference of primary-Spanish speaking pregnant patients in the United States. This is an urgent call for health care workforce diversification and compensation to recruit and retain multilingual clinicians. Leveraging and financially compensating multilingual staff for their additional language skills is an innovative investment for healthcare institutions to expand adequate language access for patients with limited English proficiency. One example is the Kaiser Permanente Qualified Bilingual Staff (QBS) program (Meyers et al., 2009; Tang et al., 2011). This program is one worth emulating because it increases the likelihood that medical staff have the appropriate level of language fluency to provide care to patients in languages other than English.

Patient-centered outcomes research should require more intentional inclusion of language proficiency and preferences in the patient-clinician dyad. Future studies should directly assess patient communication preferences using qualitative and quantitative methods. Our review also highlighted the importance of clinicians having a warm and welcoming disposition, regardless of their language proficiency levels. Further research is needed to directly compare patient preferences regarding levels of language proficiency with clinician interpersonal style and non-verbal communication. To this end, clinician secondary language proficiency should be systematically assessed. While this scoping review of the literature over a 20-year period seems to suggest that patients highly value a clinician’s empathic non-verbal cues, these attributes may not be enough to overcome inaccurate shortcut sentences in Spanish, despite an intention for direct communication. An unexplored line of inquiry is determining the minimum level of proficiency that will allow for sound communication and that might be acceptable to patients when combined with positive interpersonal communication dynamics (i.e., might patients prefer a clinician with a warm manner and imperfect but adequate language skills to using an interpretation service?).

To better assess the preferences of the diverse population of US patients who do not speak English as their primary language, research infrastructure requires multilingual and multicultural research teams that can strategically recruit and include linguistically and culturally diverse populations in future research efforts. This is especially important when we consider the diversity of Spanish-speaking communities within the Latine diaspora in the United States and their differences in cultural values, practices, and expectations that may differentially affect their pregnancy care experiences and preferences.

Conclusion

There is a paucity of literature assessing communication preferences during pregnancy care among patients with primary Spanish language. Future studies should include intentional analysis of the communication preferences of patients with Spanish primary language, as well as precision regarding language proficiency among clinicians.

Abbreviations:

QLSP

Qualified Language Service Providers

LEP

Limited English Proficiency

Appendix

Table A.1:

Search Terms

Query #	Database	Search Terms	Results
Query 1 (July 2022)	Pubmed only	(((communication[Title/Abstract] OR language*[Title/Abstract]) OR ((“Communication”[Mesh]) OR “Language”[Mesh])) AND ((Latinx[Title/Abstract] OR Latino*[Title/Abstract] OR Latina*[Title/Abstract] OR Hispanic[Title/Abstract] OR Spanish[Title/Abstract]) OR (“Hispanic or Latino”[Mesh]))) AND ((“patient satisfaction”[Title/Abstract] OR “patient relations*”[Title/Abstract]) OR (((“Professional-Patient Relations”[Mesh:NoExp]) OR “Physician-Patient Relations”[Mesh]) OR “Patient Satisfaction”[Mesh]))	1082
Query 2 (November 2022)	MEDLINE (ovid)	1. (((limited OR language learning OR language learner OR second language OR translat*) adj3 English*) OR (LEP OR language barrier* OR ESL OR ELL OR limited-english* OR low-english* OR language abilit* OR (language adj2 prefer*))).ti,ab,kf,kw. OR (exp Limited English Proficiency/ OR Multilingualism/ OR exp Communication barriers/) 2. ((patient* OR client OR professional OR physician* OR provider* OR doctor* OR nurse*) adj3 (satisf* OR relate OR relationship* OR rapport OR interaction OR prefer*)).ti,ab,kf,kw. OR (Professional-Patient Relations/ OR exp Physician-Patient Relations/ OR exp Patient Satisfaction/ OR exp Patient Preference/) 3. (pregnan* OR prenatal OR neonat* OR ‘post natal’ OR post-natal OR postnatal OR postpartum OR peripartum OR ‘maternal health*’ OR preconception OR ‘maternal-child health*’ OR ‘new mother*’ OR gestation* OR childbirth* OR obstetric* OR OB-GYN OR gynecol* OR midwif* OR Midwiv* OR Nurse-midwif* OR Nurse-midwiv*).ti,ab,kf,kw,jn. OR (exp Pregnancy/ OR exp Maternal Health Services/ OR exp Postpartum Period/ OR exp Pregnancy Trimesters/ OR exp Pregnant Women/ OR exp Gynecology/ OR exp Obstetrics/ OR exp Midwifery/ OR exp Nurse Midwives/) 4. AND/1-3	174
	EMBASE (Elsevier)	1. (‘limited english proficiency’/exp OR ‘multilingualism’/exp OR ‘migrant’/exp OR ‘communication barrier’/exp) OR ((limited OR ‘language learning’ OR ‘language learner’ OR ‘second language’ OR translat*) NEAR/3 English*) OR (LEP OR ‘language barrier*’ OR ESL OR ELL OR limited-english* OR low-english* OR ‘language abilit*’ OR (language NEAR/2 prefer*)):ti,ab AND [embase]/lim 1. ‘patient attitude’/exp OR ((patient* OR client OR professional OR physician* OR provider* OR doctor* OR nurse*) NEAR/3 (satisf* OR relate OR relationship* OR rapport OR interaction OR prefer*)):ti,ab AND [embase]/lim 3. (‘pregnancy’/exp OR ‘pregnant woman’/exp OR ‘maternal care’/exp OR ‘obstetrics’/exp OR ‘midwife’/exp OR ‘gynecology’/exp OR ‘obstetrician’/exp OR ‘gynecologist’/exp OR ‘childbirth’/exp) OR (pregnan* OR prenatal OR neonat* OR ‘post natal’ OR post-natal OR postnatal OR postpartum OR peripartum OR ‘maternal health*’ OR preconception OR ‘maternal-child health*’ OR ‘new mother*’ OR gestation* OR childbirth* OR obstetric* OR OB-GYN OR gynecol* OR midwif* OR Midwiv* OR Nurse-midwif* OR Nurse-midwiv*):ti,ab,jt AND [embase]/lim 4. 1 AND 2 AND 3	221
	Web of Science Core Collection (Clarivate)	((TS=((pregnan* OR prenatal OR neonat* OR “post natal” OR post-natal OR postnatal OR postpartum OR peripartum OR “maternal health*” OR preconception OR “maternal-child health*” OR “new mother” OR gestation* OR childbirth* OR obstetric* OR OB-GYN OR gynecol* OR midwif* OR Midwiv* OR Nurse-midwif* OR Nurse-midwiv*))) OR (SO=((pregnan* OR prenatal OR neonat* OR “post natal” OR post-natal OR postnatal OR postpartum OR peripartum OR “maternal health*” OR preconception OR “maternal-child health*” OR “new mother” OR gestation* OR childbirth* OR obstetric* OR OB-GYN OR gynecol* OR midwif* OR Midwiv* OR Nurse-midwif* OR Nurse-midwiv*)))) AND (TS=(((limited OR “language learning” OR “language learner” OR “second language” OR translat*) NEAR/3 English*) OR (LEP OR “language barrier*” OR ESL OR ELL OR limited-english* OR low-english* OR “language abilit*” OR (language NEAR/2 prefer*))) AND TS=((patient* OR client OR professional OR physician* OR provider* OR doctor* OR nurse*) NEAR/3 (satisf* OR relate OR relationship* OR rapport OR interaction OR prefer*)))	66
	CINAHL complete (EBSCO)	(MH (“Patient Satisfaction+”) OR TI ((patient* OR client OR professional OR physician* OR provider* OR doctor* OR nurse*) N3 (satisf* OR relate OR relationship* OR rapport OR interaction OR prefer*)) OR AB ((patient* OR client OR professional OR physician* OR provider* OR doctor* OR nurse*) N3 (satisf* OR relate OR relationship* OR rapport OR interaction OR prefer*))) AND (MH (“Pregnancy+” OR “Postnatal Period+” OR “Expectant Parents+” OR “Childbirth+” OR “Maternal-Child Care+” OR “Obstetrics” OR “Gynecology” OR “Midwives+”) OR TI (pregnan* OR prenatal OR neonat* OR “post natal” OR post-natal OR postnatal OR postpartum OR peripartum OR “maternal health*” OR preconception OR “maternal-child health*” OR “new mother*” OR gestation* OR childbirth* OR obstetric* OR OB-GYN OR gynecol* OR midwif* OR Midwiv* OR Nurse-midwif* OR Nurse-midwiv*) OR AB (pregnan* OR prenatal OR neonat* OR “post natal” OR post-natal OR postnatal OR postpartum OR peripartum OR “maternal health*” OR preconception OR “maternal-child health*” OR “new mother*” OR gestation* OR childbirth* OR obstetric* OR OB-GYN OR gynecol* OR midwif* OR Midwiv* OR Nurse-midwif* OR Nurse-midwiv*) OR SO (pregnan* OR prenatal OR neonat* OR “post natal” OR post-natal OR postnatal OR postpartum OR peripartum OR “maternal health*” OR preconception OR “maternal-child health*” OR “new mother*” OR gestation* OR childbirth* OR obstetric* OR OB-GYN OR gynecol* OR midwif* OR Midwiv* OR Nurse-midwif* OR Nurse-midwiv*)) AND (MH(“Limited English Proficiency” OR “English as a Second Language” OR “Communication Barriers+”) OR TI (((limited OR “language learning” OR “language learner” OR “second language” OR translat*) N3 English*) OR LEP OR “language barrier*” OR ESL OR ELL OR limited-english* OR low-english* OR “language abilit*” OR (language N2 prefer*)) OR AB (((limited OR “language learning” OR “language learner” OR “second language” OR translat*) N3 English*) OR LEP OR “language barrier*” OR ESL OR ELL OR limited-english* OR low-english* OR “language abilit*” OR (language N2 prefer*)))	109
	Cochrane Library Registry of Trials (Wiley Online)	((pregnan* OR prenatal OR neonat* OR (post NEXT natal) OR post-natal OR postnatal OR postpartum OR peripartum OR (maternal NEXT health*) OR preconception OR (maternal-child NEXT health*) OR (new mother*) OR gestation* OR childbirth* OR obstetric* OR OB-GYN OR gynecol* OR midwif* OR Midwiv* OR Nurse-midwif* OR Nurse-midwiv*)):ti,ab,kw AND (((limited OR (language NEXT learn*) OR “second language” OR translat*) NEAR/3 English*) OR (LEP OR (language NEXT barrier*) OR ESL OR ELL OR limited-english* OR low-english* OR (language NEXT abilit*) OR (language NEAR/2 prefer*))):ti,ab,kw AND (((patient* OR client OR professional OR physician* OR provider* OR doctor* OR nurse*) NEAR/3 (satisf* OR relate OR relationship* OR rapport OR interaction OR prefer*))):ti,ab,kw	10
	Total		1662
	Total (de-duplicated)	1082 (search query 1) +457 (search query 2) =	1539