The internet, and in particular social media, now play a significant role in the day-to-day life of billions of people across the world. The ease of access to online material, an abundance of which relates to pregnancy, birth and early parenting, means that midwives, mothers and their families are no exception to the significant role of the internet, and use this vast resource to gain knowledge and understanding. While pregnant and new parents do gain a sense of empowerment by accessing the diverse range of information that the internet provides, there is also a very real risk that many of these sources lack scientific rigour or are biased. This becomes particularly problematic for midwives when obtaining true informed consent to maternity care and when supporting women and their families to make decisions that may impact the health and wellbeing of mother and baby.
The internet and social media platforms have become incorporated into many facets of contemporary midwifery practice, and this has arguably led to a range of both positive and negative impacts. Accessing the internet has been made easy because of the compact and mobile nature of smartphones and tablets, enabling midwives and students, at the touch of a button, to locate, share and evaluate research findings, access online learning materials and network with their peers (Downer et al, 2021).
While prompt and easy access to online information appeals to busy midwives and other healthcare providers, women and their families increasingly turn to the internet as a source of information on pregnancy, birth and early parenthood (Serçekuş et al, 2021). Tranter and McGraw (2017) highlighted how the internet is a frequently used as a source of information for pregnant and new parents, particularly when they are seeking prompt advice or answers to non-urgent questions. While access to an array of online information may be beneficial for women and their families, this can raise professional issues and considerations for midwives.
The evolving landscape of information sharing
Anyone that uses the internet will know that online content related to pregnancy, birth and early parenting permeates it in all forms. Increased ease of access to such a wealth of information serves as a way for parents to seek, explore, discuss and share knowledge with other parents during pregnancy, early parenthood and beyond (Serçekuş et al, 2021). The capacity for sharing and commenting on health-related topics online is seemingly endless, with the internet now being used to reach large numbers of people in target populations across the globe with ease.
In the context of maternity care, for several decades, the provision of online sources of information was primarily the domain of official organisations, such as governments, health services, charities and the media (Wu Song et al, 2012). More recently, however, the concept of social media has emerged. ‘Social media’ is a collective term used to describe a number of websites and interactive media platforms that allow all types of users to create and share content with their audience (Kohle, 2022), known as their ‘followers’. Some account follower numbers can span into the millions, enabling free communication, collaboration and the sharing of ideas and information in this vast pool of people. Social media platforms have proved immensely popular, and have rapidly become a prominent part of the online landscape, particularly among the younger generations (Lupton, 2021), but are also used by billions of people of all ages worldwide.
This significant shift in the way in which the internet is used has provided opportunities for individuals such as celebrities, social media ‘influencers’ and bloggers to create their own ‘brand’ on their chosen online platform (Goanta and Ranchordás, 2020). This allows them to create content, share experiences, promote products and, in some cases, share parenting information and advice in what is seen as a ‘relatable’ way.
This additional layer of information, adding to the already oversaturated pregnancy, birth and early parenthood space can leave women feeling overwhelmed and confused when trying to make decisions about their care (Vamos et al, 2019). When adding in search engines such as Google, which returns almost 6 million results when the word ‘pregnancy’ is searched, it is easy to understand how the consumers of maternity care in 2023 can become inundated with information that may be conflicting and difficult to understand. It could be debated that this is one of the reasons why women and their partners seek information and maternity care from a more diversely informed standpoint (Brown, 2019). For midwives, providing woman-centred care for those that are more diversely informed poses several challenges on both professional and personal levels.
Providing woman-centred care in the digital age
While there is no universally shared understanding or accepted definition of ‘woman-centred care’ (Brady et al, 2019), there are clear characteristics of woman-centred care that consistently feature in the literature. These include recognition of the woman as an individual with unique needs (Leap, 2009; Morgan, 2015) and the woman's right to choice, control and self-determination (Leap, 2009; Morgan, 2015; Hunter et al, 2017; Brady et al, 2019). It is no secret among mainstream maternity care providers that while they aspire to be woman-centred, in reality, there are many organisational barriers that prevent them from fully achieving this (Brady et al, 2019).
Mainstream maternity care systems, while they continue to evolve, remain rooted in paternalism and biomedical models of care (Brady et al, 2019). In these systems, there is an acute awareness of hierarchy in both power and decision making, where clinicians' ability to influence decision making pervades care, and women often find themselves subordinate to professional decision making (Hunter et al, 2017). The sharing and critique of health information that social media platforms have facilitated represents a potential shift in power towards the consumer (Erikainen et al, 2019).
Having greater access to information and knowledge may facilitate an increased capacity for self-determination, and therefore the confidence to choose and determine one's own care (Hunter et al, 2017), thus challenging the elements of clinician-centred care and the constraints of the institution. The resultant ability women have to determine their unique needs means they are better positioned to advocate for woman-centeredness in their care, regardless of any institutional barriers.
Unsurprisingly, seeking information during pregnancy is very common and deemed a necessity for most expectant parents (Serçekuş et al, 2021). Inadequate access to information during the perinatal period is associated with feelings of loss of control and disempowerment, and results in decreased participation in decision making (Vogels-Broeke et al, 2022). Accordingly, the possession of knowledge increases confidence when conversing with healthcare providers, and facilitates decision making and preparedness for parenthood (Vogels-Broeke et al, 2022). Social media, with its ability to facilitate a vast array of social and cultural exchanges between users across the globe, has significantly contributed to what Alianmoghaddam et al (2019) referred to as the ‘democratisation of medical knowledge’. This democratisation of knowledge more broadly removes doctors and midwives as the sole gatekeepers of health-related information. Arguably, this is a positive shift for women and their partners, whose role in their own care has transformed from one of passivity to that of active participants and decision makers (Alianmoghaddam et al, 2019).
Gaining valid informed consent
While it is clear that having access to a broad range of information does have benefits, it is important to recognise that not all pregnancy, birth and early parenting information shared on online platforms is accurate or reliable (Tian and Robinson, 2021). For example, the webpage or platform content may have been created by individuals with no formal relevant qualifications and is therefore based upon their own subjective experiences, or, in some cases, may even be paid advertising content. This poses the very real risk that the information shared conflicts with scientific evidence or is biased (Shine et al, 2022). In turn, this can lead to negative impacts being felt by the consumer of the information, presenting them with a range of legal and ethical dilemmas, and posing challenges for midwives, particularly when seeking informed consent to care.
Midwifery practice is governed by professional codes of conduct, ethics and standards. The overarching principles in these documents are clear about the responsibility that midwives have to ensure that women have adequate access to information prior to providing consent to care and treatment (International Confederation of Midwives, 2014). Simply directing women to the internet for sources of information is not appropriate, particularly when ensuring that the resources accessed are unbiased and evidence based. This is particularly important when the information being sought will be used to assist with informed decision making.
Women and their families are faced with a multitude of decisions to be made during their journey to parenthood. Critical to the process of informed decision making, women must consider all available information regarding their options to make decisions that are right for them, made freely and without coercion or influence (Goldberg, 2009).
Challenges sharing information
Midwives are naturally positioned to partner with and support women throughout the decision-making processes they encounter during the childbearing continuum. A key part of this role is to provide unbiased, comprehensive and evidence-based information on which they can make their decisions (Perriman et al, 2018). This process can be relatively straightforward when the decisions to be made fall within a midwife's professional scope of practice. However, when approached by women seeking information about obscure, novel or potentially harmful therapies, midwives must be equipped with the contemporary evidence to underpin their discussions.
Confirmation bias (Nickerson, 1998) is a frequently seen phenomenon among women seeking health information during pregnancy. Even when comprehensive and unbiased information is shared, if this is not consistent with the woman's preferred narrative, this can result in the rejection of information that aligns with best practice (Chou et al, 2020). When women choose to engage with social media to inform decisions about their care, midwives are confronted with both professional and personal challenges given their key role in the informed decision-making process. And as midwives increasingly care for more diversely informed women, whether they are well-informed or misinformed, engagement with contemporary evidence-based information is more important than ever if they are to effectively facilitate informed decision making and meet their professional obligations.
Being vulnerable to influence
Whether engaging individually or collectively in matters of pregnancy and birth, social media has generated greater awareness of the choices available to pregnant and new parents. The near-unrestricted sharing of information and experiences means that more women are diversely informed of their care options, some of which may be at odds with organisational policies and the biomedical philosophy found in mainstream maternity care.
The influence that social media use can have on this crucial life phase cannot be underestimated. This influence may be positive or negative and have diverse impacts on different groups of women. For example, it has been suggested that people in the most vulnerable groups of society are far more likely to believe what they see online (Scherer et al, 2021). Those that feel disadvantaged, powerless and voiceless are more likely to seek out information validating their beliefs and practices, regardless of whether this aligns with conventional recommendations (Goertzel, 1994). Arguably pregnancy, birth and early parenthood are all times when many people feel some degree of vulnerability and experience a sense of loss of control (Martin and Robb, 2013). With this in mind, the desire to seek out non-conventional information is not at all unusual during this time. However, this becomes concerning when this type of information is used to inform decision making that may have adverse impacts on maternal and newborn health.
Interestingly, the evidence suggests that opinions formed through engagement with social media content are frequently perceived to be based on the users' independent assessment and evaluation of the information shared (Vogels-Broeke et al, 2022). On this basis, the information is then either accepted or rejected, free of the influence of others. However, it is unlikely that this can truly be the case. This was well illustrated by a study by Witteman et al (2016), who distributed a mock news article about home birth to participants. This article was accompanied by either negative or positive social media comments. Regardless of the participant's pre-existing knowledge or opinion about home birth, exposure to the article and its respective comments led the participants to adjust their own opinions of the topic in favour of the types of comments they read. This demonstrates the inherent potential for social media content to influence a person's beliefs.
The supportive nature of social media
The sense of personal empowerment facilitated by social media can extend beyond the realm of mere knowledge and can lead to social and emotional benefits for pregnant and new parents. Gaining social and emotional support, seeking advice and discussing common experiences with peers in social media communities is common practice among expectant and new mothers (Baker and Yang, 2018; Gleeson et al, 2019). This offers a platform to seek support from those experiencing the same or similar stressors and to discuss perspectives that may be different to the traditional narratives shared in the offline community.
It has been suggested that the support provided by those that have had similar experiences is considered more effective than that provided by family and friends (Thoits, 2011). Peer support is thought to improve mothers' self-confidence, self-efficacy and parenting confidence (McLeish and Redshaw, 2017). Additionally, peer support has been observed to be particularly significant in validating mentally and emotionally stressful birth outcomes that have involved obstetric violence, trauma (O'Connell, 2019) and perinatal loss (Whitehead, 2015).
Conclusions
The use of online platforms and social media to access information about pregnancy, birth and early parenthood is common among midwives and the women and families they care for. While having easy access to information and support can be beneficial, there are also risks associated with reliance on potentially inaccurate sources to inform decision making. This creates a ‘grey area’ for midwives when gaining informed consent to care and becomes particularly problematic when the decision to accept or decline care is based on non-evidence-based or biased information. This highlights the importance of remaining abreast of the evolving narratives related to pregnancy, birth and early parenting that are shared in online forums. Midwives should also maintain familiarity with contemporary evidence and how it applies to online narratives if they are to safely facilitate informed decision making, protect the safety of mothers and babies and meet their own professional obligations.