There was a time when pregnant women allowed the midwife, unquestioningly, to provide their care. The midwife was regarded as the respected authority in the field of normal childbirth and her decisions regarding pregnancy and birth were sacrosanct. Ever-increasing internet use on a plethora of accessible devices has meant that the professional word and authority of the midwife is being increasingly challenged by pregnant women with information gained from internet sources. The professional dominance of the past whereby health professionals felt that their esoteric knowledge meant that they alone would decide what was best for the layperson (Friedson, 1970), is no longer acceptable.
The modern day midwife-client relationship has changed, but has the balance now tipped too far the other way?
There are undoubtedly many benefits of the better-informed woman who can play a more active part in her pregnancy and birth plans. However, this omnipresence of information can challenge midwifery practice and breach Trust protocols. Misinformation from websites can also be dangerous and cause unnecessary anxiety.
So do midwives and clients value internet use for pregnancy and birth information differently?
Aim
The aim of this study was to explore the experiences of midwives, antenatal and postnatal women to try to discover their perceptions of the value of internet use in pregnancy.
Literature review
A literature review using Boolean searches were conducted on the following databases: Medline, CINAHL, EMBASE, BNI, PsycINFO and HMIC. The medical subject headings (MeSH) keywords ‘clinician/patient relationship’ and the terms (internet OR website*) and (midwife* OR pregnan*) were used. A publication year limiter was not added as it was felt that papers involving internet use would have been published in the last two decades. The publication type was limited to case reports or comparative study or evaluation studies or interview or meta-analysis or multicenter study or review or twin study or validation studies. The terms ‘management’, ‘perception*’, ‘influence*’ and ‘behaviour*’ were added to explore opinion and comment. Furthermore, the online Journal of Medical Internet Research and the RCM and MIDIRS websites were accessed. Grey literature on the subject was explored through COPAC and SIGLE. References at the end of papers provided a source for other relevant information. This process produced 300 results. The abstracts of these initial papers were scanned and full text was sought for 111 promising papers. Three papers had not been translated into English and were therefore excluded. The remaining papers were thoroughly scrutinised and 50 were thought pertinent for inclusion in the study and summarised for ease of reference.
There appear to be relatively few rigorous studies in the UK or globally relating to how women use internet information in pregnancy; those that exist are predominantly quantitative (Declercq et al, 2006; Llarson, 2009; Lagan et al, 2010; Lagan et al, 2011; Lima Pereira et al, 2012). There is some evidence that suggests women are increasingly using the internet for health information (Spink et al, 2004) but most research does not make specific reference to pregnant women or midwives.
The literature on the influence of the internet on relationships between patients and other health professionals is divided, some suggesting that it fosters a stronger relationship with increased interaction leading to greater satisfaction (Iverson et al, 2008; Giveon et al, 2009). Others perceive more conflict with diminished patient trust and confidence in health professionals (Potts and Wyatt, 2002; Murray et al, 2003a).
A lack of internet searching skills in the general public to retrieve health information is a recurrent theme in the literature (Hardiker and Grant, 2010). A study of 22000 medical and health queries to web search engines in the US and Europe (Spink et al, 2004) found that a significant number of people lacked the operational skills and were unaware of the specialised vocabulary needed to effectively retrieve relevant information.
Other studies show that although most people can navigate the web to find information on a topic (Murray et al, 2003a), they have difficulty in evaluating that information in terms of relevance and reliability. It has been demonstrated that most people have poor appraisal skills, with feelings of frustration, confusion and the sense of being overwhelmed consistent findings in the studies (Romano, 2007; Iverson et al, 2008; Lima Pereira et al, 2011; Buultjens et al, 2012). These issues pose a significant barrier to obtaining accurate advice.
Methods
Thirteen midwives, seven antenatal women and six postnatal women were recruited to the focus groups. There were three focus groups—one for midwives, one for antenatal women and one for postnatal women. This was followed by one-to-one interviews with people uninvolved in the focus groups—three midwives (one hospital midwife and two community midwives), two antenatal women and two postnatal women. The focus group questions were not piloted as approval for this study was not achieved until 23 April 2013 and the prospective antenatal population were due to deliver in May 2013. Interviews were partly structured allowing exploration of salient themes from the focus groups.
Sampling
Consecutive series sampling was employed for the two groups of women in order to enhance the external validity of the study (Burns, 1990). Primiparous women with babies born on 1 November 2012 were invited to take part in the study. Primigravid women with an expected date of delivery of 1 May 2013 were invited to take part in the study. Women were recruited from the Conquest Hospital, Hastings. Enrolment was continued for both groups on consecutive days until the required numbers of participants were recruited. The aim was to recruit 6-10 participants for each focus group, followed by two individual interviews, the ideal number according to the methodology literature (Robson, 1993; Dawson, 2002). Although all 10 women appeared happy to be involved, only five antenatal and four postnatal women attended.
Self-selecting convenience sampling was employed in the midwifery group.
Data collection
The focus groups were conducted at a DGH NHS maternity department. The one-to-one interviews took place in the local maternity department and the two postnatal women were interviewed in their homes.
Focus groups and interviews were digitally recorded and transcribed verbatim to written text. A general thematic approach was combined with a framework approach to analyse the data (Pope and Mays, 1996).
Ethical issues
Ethical consideration was given to the conduct of the research and regulatory approval was granted by the BSMS Division of Medical Education Dissertation Panel, the Research and Development Department in the local NHS Trust and the National Research Ethics Service.
Results
Key to quotations: A=antenatal woman, P=postnatal woman, M=midwife, F=focus group, I=interview; e.g. AF5 18=antenatal focus group client 5 on page 18 of the transcription.
Appropriate internet use
The overriding positive theme in all groups was that the internet can be beneficial, with the caveat ‘if you use your common sense’. This was a common thread running throughout the data:
‘Yeah so you kind of have to do a certain amount of self-regulation I think.’
‘It's just that some things…you know when to Google and not to Google’.
and was supported by midwives.
‘A lot of women come in and say “I had” for example “terrible heartburn. I didn't know if that was normal so I looked it up and it says it's perfectly normal” so they've actually thought about it and it's, it's actually a positive outcome.’
‘I think it's a useful tool but in the right hands and used in the right way I suppose.’
Preferring midwifery advice
The data were also encouraging: women held midwives in high regard and still appeared to prefer midwifery advice to internet information. They independently stated that their usual practice was to use the internet for minor queries and product advice but would seek their midwife's advice for more serious medical problems.
‘I think you would want the advice from a medical professional…rather than from lots of just crazy women.’
‘When it's conflicting…if people are putting different things…it does get a bit confusing but, erm, then I'll ask my midwife.’
Influences on relationships
Empowerment
Empowerment was not mentioned at all by the postnatal group but was a moderate theme in the antenatal group.
‘You know, years ago when people didn't have such free access to information you just did as you were told and that was, you know, that was the way things were gonna happen and that was it, whereas I think now it does allow people to make more informed choices or at least ask the questions around other choices and other ways to do things.’
This was also a significant theme in the midwifery discussions, indicating that midwives acknowledge some of the benefits of women's increased empowerment through internet information.
‘As we know from research if women are better informed then, erm, you know, they feel more in control…it's all about them making informed consent.’
However, data indicated that this empowerment can also be used to challenge care. This was a strong theme in the midwifery group.
‘They come to you and say “why haven't you done this with me?”’
Women also displayed an insight into this issue.
‘I know what to expect a bit more from my, erm, appointments because of the internet…so if they don't do something you can, er…it must be a nightmare for midwives…I think [name of midwife] forgot to measure me like on my first one or something I was like “aren't you supposed to measure me? Measure my bump?”…I think if you had a shoddy midwife and you were well informed…it would sort of empower you to say, to challenge a bit more to say I don't think you're right.’
Discussion trigger
Internet information was also felt beneficial as a discussion trigger:
‘…and I think as long as it just enables a discussion between you and your midwife…I don't think it's a bad thing, people having opinions and looking at things.’
‘I think it can generate more topics of discussion with your midwife.’
Midwives were in agreement:
‘It formulates a discussion because it's all about their choice isn't it?’
Inappropriate use
There are many instances where common sense was not apparent. Thus some pitfalls of seeking information on the internet are not the fault of the information providers, per se, but the inappropriate way in which it can be used.
The following representative quotations reflect current midwifery concerns about women's inappropriate use of the internet, evidencing that:
Inappropriate use of social media
Midwives also voiced concerns about the current influence of inappropriate social media use on care. This study demonstrated that the use of apps in labour is influencing care:
‘…at a home birth…the mobile phone…the Facebook app was on the whole time and we'd delivered the baby…trying to plan to deliver the placenta…and mum just sort of got really really irate and frustrated and she's saying “it's out there already. She's beep, beep, you know announced it on Facebook”…someone's already announced the birth of the baby before the placenta's even come out! [Laughter] And it wasn't her!’
‘…this woman with an app…to tell her whether she was in labour…well she gave me everything that was going on and I said to her “I think you really need to erm stay at home…I really don't think you're actually in established labour yet” but, “well my app on my iPhone tells me that I am!”[Laughter] I said “well, come in”…and I took great delight in sending her home half an hour after she arrived [Laughter]’
‘…and the lady was using, must have been a similar app…and the iPhone kept telling her she was in labour and she wouldn't believe it…her husband was saying “you're gonna start pushing in a minute” and she was going “don't be so silly” and then she went to the toilet and started pushing on the toilet, so the app actually did tell her right…but obviously she didn't believe it cos it was all too quick so…it worked for her husband very well! [Laughter]’
‘…this constant, erm, texting and twittering of or tweeting as I think it's called…I find it irritating…because I think what, what is a very personal journey in my world is not how they perceive it to be…they're of a different generation where media and life is instantaneous…I feel they maybe should be concentrating a little bit on more of the experience…’
Influences on care
There was a striking difference in the amount of discussion regarding the internet's influence on midwifery care. It provided little significant data in the women's groups. However, it generated a large discussion from the midwifery participants.
‘If she accesses the internet to do her birth plan…they've got these views that are just not realistic…their expectations are too high.’
Inappropriate test requests
‘They want more investigations just in case they've got the problem.’
‘…got really worried about Toxoplasmosis because I house sat for my friend whose cat has just gone to the loo everywhere…and I got some on my finger and I was like “oh my god that's it, my baby's gonna have no ears” or whatever [Laughter]…I think like by looking around on the internet it might [have] kind of scared me a little bit…the midwife thought I might be bonkers (laughter) taking my blood going “she's 38 weeks. What on earth is she doing?”’
Website use
Discussion Forums
A negative view of discussion forums was portrayed in all groups.
‘When women are looking at chat sites a lot of the time it's only people's personal experiences not necessarily, er, fact…they actually might not pertain exactly to what they have or it might be misconstrued the information and therefore that could potentially be damaging…’
‘It's seen as…the mums' opinion army…and you start thinking “my goodness I haven't got a Bugaboo, why haven't I got a Bugaboo?”’
‘It's so competitive as well…this baby is not even here yet and already people are kind of comparing “oh what's yours doing?” “Oh my bump, I play classical music to my bump” [laughter]…on things like Mumsnet, it's quite smug I think about how wonderful their children are and I think…it's just a bit patronising really.’
Popular websites
NHS
The NHS website was used with confidence by all the participants.
‘It's the NHS. You can look up things like…C sections…you know it's gonna be right and it's all been researched and it's accurate.’
Baby Centre
The use of the Baby Centre website was far more popular with the antenatal and postnatal clients, all holding it in high regard.
‘I've just gone on every week to look at how my baby is growing and, erm, I like looking at the description of what size of fruit it is that week…that was on the baby centre as well actually which seems to be the, err, top one.’
‘Yeah I will say that's the one I used as well.’
However, when asked about this website, of the 13 midwives, 10 had not heard of it, two had heard of it but not used it and only one had explored it, but only as a pregnant woman.
‘I've never been on it and never heard of it.’
This lack of awareness of website use by midwives was highlighted independently in the women's discussions, causing a sense of frustration that midwives do not fully engage in the women's choices of information source.
‘It would be good to know if the midwives are perhaps, erm, looking up on their own at the most top common concerns that their patients have and seeing what is available online so that they've got an idea of the kind of stuff that we're viewing…even if it's rubbish.’
Discussion
The data demonstrated that all groups had considerable knowledge regarding the evaluation of internet information in terms of quality standards. This is not consistent with other literature (Murray et al, 2003a; Lagan et al, 2010; McKenna and McClelland, 2011) perhaps because growing familiarity and increased knowledge is enabling more pregnant women to navigate the web with confidence.
There was commonality in the findings that all groups valued pregnancy internet use when used appropriately and with common sense. However, there were significantly stronger themes in the midwifery data in several negative areas of internet usage, including their perception of feeling challenged by women with internet information, which is consistent with other studies (Murray et al, 2003b; Giveon et al, 2009) and their perception of inappropriate use of the internet.
This perception could be influenced by an apparent lack of awareness and confidence between the groups of the sources of information that are being accessed. The data indicated that by far the most popular website among women was Baby Centre, a website that most of the midwives had never heard of. Conversely, while the Trust handheld maternity notes contain a lot of research-based information and advice pertaining to pregnancy and labour, the midwives did not feel that women were reading them. This suggests that, although the women rated the NHS Choices website highly for answering health-related problems, and appeared to value and trust midwifery advice, there is still a chasm between the type of websites that midwives prefer to recommend and those that clients prefer to access. This corresponds with previous studies that have shown that while people acknowledge that commercial sites are less reliable than government sites, they are still by far the most widely used method of retrieving information (Provost et al, 2003; Lagan et al, 2010).
Strengths and limitations
The literature search revealed no comparable studies which would give weight to or provide an argument for these research findings. However, this confirmed the originality of this study.
The social demographics of internet use were not explored, either in the literature review or the study itself as this was beyond the scope of this research. Additionally, all participants were Caucasian, predominantly British.
Previous related research regarding internet use in pregnancy is predominantly quantitative in nature. The findings of this qualitative study, focusing on perceived value, have enabled a greater exploration of different viewpoints that will contribute to this evidence-base.
Implications for practice
The contemporary issue of social media use in labour emerging from the data highlighted midwives' concerns regarding inappropriate use. Yet there were no Trust protocols or management guidance in this area. This needs to be rectified. There is also currently no staff guidance by midwifery educators on the evaluation of internet information.
Conclusion
Appropriate use of information from the internet during pregnancy was positively valued by all groups. However, midwives were more negative in their perceptions of inappropriate use. The data indicated that this could be influenced by their lack of awareness of current pregnancy website use.
Until there is a common consensus between the midwifery profession and the antenatal population regarding the best websites to use and those to avoid, a consistency of reliable, current information will not be achieved. This can only be brought about by greater collaboration between clients and midwives with an engagement in more extensive dialogue in the future. Thus the value of appropriate pregnancy internet information could be universally appreciated and used with confidence.