Strengths, limitations and future study
This study was well designed and rigorously executed, following RCT standards. The intervention, i.e., teach-back embedded in education programmes targeting women with LMHL, and education protocols for the two groups were systematically and contextually developed, following the national guidebook of improving MHL and commonly agreed communication guidelines. Nurses who provided education sessions to the women were invited to participate in the workshop for developing the intervention and protocols, so that nurses could develop a deep understanding on the intervention and an agreement on the implementation of the trial could be achieved among nurses. The nurses were intensively trained, and their performances were evaluated by experts before the trial. In this study, the factors that might affect the results of the trial were well considered. For the baseline analysis, this study collected information about whether women had previous experience with pregnancy and childbirth-related education sessions, which was missing in the majority of relevant studies [This study has some limitations. First, due to the nature of the trial, a nurse who provided education sessions to the women was not blinded to the structure and contents of the education sessions to which she was assigned. Second, the practice of grouping women for the first two education sessions may result in within-group interactions or other intra-cluster effects, which could bias the results, although we took some efforts to reduce the bias. Third, caution should be placed on the generalizability of this study, which was conducted in a tertiary hospital located in a moderately developed region. Further studies should explore the effects of the presented intervention in various contexts. Fourth, the cost of using this teach-back embedded education programme (e.g., staff training, workloads for nurses, resource additions, and organizational changes) has not been investigated, so large-scale implementation of this method in clinical routine is still uncertain. Cost-effectiveness analysis and user experiences should be included in future research. Fifth, this study did not provide solid evidence of the retention and the long-term effects of using the teach-back method on maternal and child health, which requires further exploration. The teach-back supported education programme should be further developed based on scientific research-based results.