How does social media influence expectations, decision making and experiences of childbirth?

In considering the safety of maternity services in England, the Health and Social Care Committee (HSCC) were told by clinicians that ‘the pressures of the wider community, social media, and antenatal classes…[are] contributing to “a big expectation of normality” amongst expectant parents' (House of Commons HSCC, 2021). Recent reports into the NHS maternity system (Kirkup, 2015; 2022; Ockenden, 2022) describe a ‘pursuit of normal childbirth at any cost’ (Kirkup, 2015). Some midwives, and parents are viewed as having a potentially dangerous ideological perception of normal, physiological birth (House of Commons HSCC, 2021; Walton, 2022).

Representations of birth have proliferated on newer online platforms (Cooper and Godfrey-Isaacs, 2020). With birth now missing as an everyday event in families and communities (Luce et al, 2016), there has been a change in how women establish community and gather knowledge about childbirth (Tizzard and Pezaro, 2019). The internet creates a cultural ideal for what it means to be a good mother and to have a normal birth (Luce et al, 2016). However, it is unclear if social media gives women accurate public health information (Marsh, 2022) and the potential role it plays in increasing fear of childbirth has been widely debated (Brown, 2018; Marsh, 2018).

Platforms such as Facebook and Instagram have been challenged by campaigners for their censorship of real images of women birthing their babies (Hill, 2014; Jones, 2018; Yarrow, 2018), while Tizzard and Pezaro (2019) highlighted how the nature of communicating virtually means social media could be an emotionally ‘dangerous place’ for women. Social media can enable restrictive connections as a result of ‘societal influences, mediation and the pressure to conform and perform’ (Tizzard and Pezaro, 2019).

There is an opportunity to better understand the ‘pressure’ (House of Commons HSCC, 2021) that women face as well as the role it plays in how they think and make decisions about childbirth (Luce et al, 2016; Kay et al, 2017). Many midwives are apprehensive of media and social media, anxious about how images are portrayed and the impact of their own engagement with these platforms on women (Luce et al, 2017a). The use of social media in the midwifery profession is not clear and there remains a lack of practical guidance (Marsh, 2022). This limits midwives' ability to fully acknowledge what affects women's values and their perspective of reality (Sanders, 2019), creating a barrier to individualised care and informed decision making (Nursing and Midwifery Council (NMC), 2018). The aim of the present review was to use the available literature to provide a contemporary, evidence-based insight into clinicians' beliefs that social media contributes to a ‘big expectation of normality’ among expectant parents.

Definitions

The term ‘normal birth’ has been challenged conceptually and politically (Downe and Byrom, 2019; House of Commons HSCC, 2021), but the International Confederation of Midwives' (2014) definition is that a normal birth is where a woman commences, continues and completes labour with the infant being born spontaneously at term in the vertex position, without any surgical, medical or pharmaceutical intervention. This definition is used for the purposes of this review.

Social media is defined as any online platform that allows users to exchange content (eg Facebook), as opposed to internet content that does not facilitate this (eg websites) (Aichner et al, 2021). Specific pregnancy mobile software applications (‘apps’) are not considered in this review, as they don't consistently feature user-generated content.

Methods

This literature review focused on qualitative research, to gather insight from rich data about women's experiences (Aveyard, 2019). Initial searches were undertaken in April 2022 in CINAHL Plus, MEDLINE, AMED, APA PsychInfo, APA PyschArt, MIDIRS and The British Nursing Database. The population, exposure, and outcome framework was used to guide the search strategy, rather than the population, intervention, comparison, outcome framework, as specific interventions were not being explored (Bettany-Saltikov and McSherry, 2012).

The key words selected were childbirth (population), social media (exposure) and expectation/decision making/experience (outcome) (Table 1). Synonyms were identified for each of these, and the refined search was limited to abstract and title (Aveyard, 2019).

A total of 347 papers from the seven database searches and additional search methods were screened against the inclusion/exclusion criteria set out in Table 2. Then 296 abstracts were rejected as they did not meet the inclusion/exclusion criteria. The full-text copy of 32 relevant articles were obtained, and after further review, five papers were identified for the final review. The literature search was re-run in March 2023. Five of the key subject specific databases were searched using the same criteria. Following a review of titles, no additional primary research-based articles were identified for consideration. The full review process is shown in Figure 1. A summary of the five selected papers can be seen in Table 3.

Critical appraisal of the qualitative research used the Critical Appraisal Skills Programme (2018) tool. The checklist of 10 questions supports systematic consideration of issues of validity, ethics and data analysis, and contextualises the research.

Aveyard (2019) sets out what is referred to as a ‘simplified and adapted thematic approach’ to reviewing literature. This framework, which includes guidance on identifying, fitting together and developing themes, was followed for this review. However, ultimately, this work presents a synopsis of information, rather than a thematic analysis (Braun and Clarke, 2006).

Results

This review considered five primary research papers (Das, 2017; 2019; Kay et al, 2017; Prescott and Mackie, 2017; McCarthy et al, 2020). Two papers by the same author, Ranjana Das (2017; 2019), were included as she has written extensively on this topic. These papers both used data from a larger body of material analysed in the project ‘Birth Stories’, but looked at different social media spaces (a Facebook group on hypnobirthing and Mumsnet).

All five papers used qualitative research, which helps understand experiences, feelings and attitudes (Ryan et al, 2007), making it well suited to this review. Two themes, incorporating frequently occurring subject areas, were identified from the reviewed studies: reshaping and polarisation of birth stories, and alteration of women's agency to make decisions about birth.

Quality appraisal of the studies

Kay et al (2017) aimed to explore how engaging with stories of birth, through personal contact and virtual technologies, affected two generations of women's expectations and experiences of childbirth. Purposive sampling and snowballing, by word of mouth, recruited 20 women, 10 pregnant women expecting their first baby in 2013 and 10 who had given birth in the 1970s–1980s. The small purposive sample lent itself to greater insight and depth of understanding (Aveyard, 2019). However, the transferability of the findings is limited as the sample was predominantly white, well-educated and middle class, which does not represent UK women's diversity.

Das (2017; 2019) framed both studies in literature that more generally explored mother's social media practices. Using social media analytics, a broadly ethnographic approach was taken, as Das (2017; 2019) observed women and sought to capture and understand how they behaved (Aveyard, 2019). Content was drawn from online posts and analysed via qualitative methodologies. Both studies formed part of Early Motherhood in Digital Societies (Das, 2020), which considered the use of technology in the perinatal period and implications for maternal wellbeing.

Das (2017) presented a thematic analysis of 1930 posts in 12 discussion threads on the parenting website Mumsnet. In considering what she termed ‘women's talk’, her work focused on the tensions in contrasting cultural discourses surrounding the birthing body, which arose in this virtual space. Das (2017) recognised that telling and listening to stories on social media could create a space that was synonymous with women's empowerment, facilitated debate and served therapeutic purposes. She explored the silencing in online discussions of difficult or negative accounts of birth and identified how mothers took on individual responsibility for these value laden narratives.

Das (2019) used a selection of posts made in 1 year on a public Facebook group about hypnobirthing and carried out a thematic analysis. She observed a strong emphasis on women together in their ‘united rejection of medical procedures and institutions’. Women rallied around in their support of a ‘good’ birth; however, this led to online spaces that included and excluded women, depending on their choices and experiences.

Das (2017; 2019) used purposive samples, an effective way of gathering relevant, information-rich data (Ryan et al, 2007). The use of discourse analysis helped understanding of the reality of women's experiences, rather than simply what was said when asked (Aveyard and Sharp, 2007). To improve generalisability, a specialist search engine focusing on social media sites could have been considered to gather insight from a wider demographic of women (Golder, 2019), rather than focusing on Mumsnet, which some believe to be particularly reflective of professional middle class maternity values (Pedersen, 2020).

The quality and trustworthiness of data from social media platforms can be problematic, as there is no assurance of post's authenticity, with a prevalence of programmed ‘bots’ interacting like real people (Golder, 2019). Das (2017; 2019) reported that most members of the groups were mothers living in the UK but acknowledged there was no certainty.

While it is recognised not everyone uses social media (Office for National Statistics, 2019), for the purpose of this review it was inferred that its effect will predominantly be on those who choose to engage with it. However, Das' (2017; 2019) research methodology excluded insight into women who were only viewing, not posting on, social media. Furthermore, there was no evidence of correlation between the number of posts expressing certain thoughts and feelings and the number of people experiencing them (Golder, 2019).

Retrieving data from social media raises ethical concerns, and Das (2017; 2019) did not include ethical approval for the studies, concluding that since the content was non-reactive data from publicly available posts, it could be analysed without informed consent. To limit traceability, Das anonymised names and pseudonym names before analysis.

Prescott and Mackie (2017) explored pregnant women's motivation for using what they referred to broadly as ‘the web’, and women's perception of the reliability of this information and support. Semi-structured interviews were carried out with 16 pregnant women from England and the transcripts were analysed using inductive thematic analysis, where data coding idoes not use pre-existing coding frameworks but is data driven (Braun and Clarke, 2006). These two approaches reflect a methodology that is responsive to participants' experiences. The study adopted a phenomenological approach, women's experiences were described and interpreted with analysis grounded in the data rather existing theory (Ryan et al, 2007).

McCarthy et al (2020) examined women's experiences of using a dedicated social media platform for information and advice on pregnancy and childbirth during the COVID-19 pandemic. Purposive sampling took place at NHS antenatal trusts, participants were self-selected and clearly comfortable with joining a special-interest, social media group. McCarthy et al (2020) explored the development of professionally moderated groups for pregnant women and the potential to achieve informational continuity or continuity of care as women and midwives exchanged information. Two secret (private/invitation only) Facebook groups were created and ran for 35 weeks. There were 31 pregnant women (‘facemums’) and these groups were mediated by four midwives (‘facewives’). The choice of Facebook as a platform was well justified, given it has the highest reported use by women aged 19–29 years old (McCarthy et al, 2020).

Reshaping and polarisation of birth stories

The theme of reshaping and polarisation of birth stories was identified in three of the papers: Das (2017; 2019) and Kay et al (2017). According to Kay et al (2017), nearly all women used online resources to help them access information on their choices to aid decision making. Information, social support and birth stories were sought through online communities and virtual media, with a ‘modern birth story’ being told through both traditional oral stories and technology. These women reported focusing on, and accepting, the negative ‘horror stories’ they had heard. However, for many, the alternative was birth stories ‘too perfect and wonderful to be believed’ (Kay et al, 2017). These positive stories were anomalies, in opposition to the perception of reality most stories created. The authors concluded that this generation of UK women expressed greater fear about giving birth than the generation before (Kay et al, 2017).

Although Kay et al (2017) reported positive birth stories were an anomaly, Das (2017; 2019) argued that there was silencing of ‘horror’ stories on social media. It was found that there was a limited, separate space on social media to talk freely about childbirth difficulties, with experiences of, for example, ‘birth trauma’ grouped together in a specific thread as though they were a uniform experience. Das (2017) outlined how women sharing fear on Mumsnet were dismissed by other posters, which was seen as contributing to the idea of failure shaped by personal opinions, and as such, traumatic experiences were seen as the mother's responsibility (Das, 2017).

The technical architecture of sites like Facebook controlled certain narratives. For example, the ‘trigger warning’ device was used in the hypnobirthing Facebook group in the Das (2019) study. Moderators edited posts where women spoke of difficulties, adding a warning that the post ‘may contain triggering material’. As a result, posts with these warnings slipped lower in the news feed because people were not commenting on it, and it was harder to see them among other posts attracting more comments. Messages that did not conform were effectively filtered out, increasing the profile of joyful birth to the detriment of a balanced perspective (Das, 2019).

Although it challenged mainstream media's portrayal of medicalised birth, social media's elevation of positive physiological birth stories could be problematic for women. Social media could create spaces of ‘camaraderie and solidarity’ (Das, 2019), with women uniting in campaign groups, such as The Positive Birth Movement (2018), rejecting a medicalised model and working to improve experiences of birth. Das (2017; 2019) explored this notion of a ‘good birth’ and how social media, in promoting curated idyllic births, established a protocol for birthing well. Expectations from social media were seen as ‘creating instead of removing pressures from the shoulders of women’ (Das, 2019).

Although both Das (2019) and Kay et al (2017) found that women were hopeful of choice in childbirth, this discourse was limited, with some social media platforms controlling and censoring portrayal of physiological birth (Das, 2019). The hypnobirthing discussion group found pain in labour was framed as something to be avoided, and women did not have a choice to use such language (Das, 2019). Boundaries existed around what choices would be ‘supported’, were ‘merely tolerated’ and what was ‘most unwelcome’ (Das, 2019).

Alteration of women's agency to make decisions about birth

Altering women's agency to make decisions about birth was a theme that was observed in three of the papers (Kay et al, 2017; Prescott and Mackie, 2017; McCarthy et al, 2020). Women reported that independently seeking information on the web helped them feel informed, in control and empowered about birth and pregnancy (Prescott and Mackie, 2017). Accessing online forums, reading the stories and experiences of other pregnant women, helped normalise childbirth by reducing worry and negative thoughts. Connections made through online forums were seen as a valuable way of developing networks and increasing a sense of support. Prescott and Mackie (2017) recognised women's ability to ‘skillfully surf’, stopping when they felt reassured or when the information was no longer helping them. This seemingly effective use of the web to support decision making contrasted with the more generalised argument by Kay et al (2017), who presented women as more passive and overloaded with information from the internet.

Women were aware they should be skeptical about trusting information from social media, recognising that this content was often based on personal experiences and raises questions of reliability (Kay et al, 2017; Prescott and Mackie, 2017). Kay et al (2017) were critical of the value of knowledge gained through social media referring to ‘idle talk surrounding birth’. Claims were simply accepted and then continued to be disseminated, as opposed to meaningful knowledge and understanding being developed. Women conformed to what was seen as the norms of childbirth as shared in stories on social media, ‘disburdening themselves of the need to make difficult choices and decisions’ (Kay et al, 2017).

McCarthy et al (2020) found these groups to be a positive space for sharing and, importantly, validating information. The ‘facewives’ played a key role in providing timely, reliable, individualised information. For many members, the group became the main source of information during their pregnancy.

Discussion

As childbirth stories create knowledge, a cultural expectation of birth is constructed (Livo and Rietz, 1996). This exchange of narratives has shifted to online spaces, with social media networks offering a structure for these stories and the ‘lived or future experiences of others’ (Sanders, 2019). Women use the internet as a mechanism for seeking out information and to get social networking support to have more control over pregnancy and birth (Young, 2010).

A reported 79% of women are reading blogs, watching YouTube and joining social media forums to fill knowledge gaps about childbirth (Luce et al, 2016). During the COVID-19 pandemic, social media became key to the healthcare system's functioning (Wong et al, 2021). Marsh (2022) considered how ongoing pressures on midwifery staffing and reduced access to many antenatal classes because of the pandemic meant social media was key for women as they gathered knowledge and developed expectations about childbirth. Additionally, Prescott and Mackie's (2020) findings corresponded with a systematic review by Backstrom et al (2022), which reported that the use of online discussion forums, or health intervention programmes, by expectant parents led to greater empowerment and self-efficacy.

The ‘special stories’ told online typically presented themselves as either from a natural or a medicalised perspective (Sanders, 2019). This reflected the way maternal choice and decision making in childbirth is increasingly framed as a dichotomy (Luce et al, 2016; Das, 2020). Despite clinicians' concerns that social media contributes ‘to a big expectation of normality’ (House of Commons HSCC, 2021), much of the literature argues that the predominant portrayal of birth in mainstream media is negative (Luce et al, 2016; Downe and Byrom, 2019). Birth is normalised predominantly as medically managed and we are seeing a ‘hyper-medicalisation of childbirth’ through traditional and social media (Das, 2018). Censorship has been found online, as Cooper and Godfrey-Isaacs (2020) identified many joyful images of childbirth, which were censored and labelled as pornographic on social media. Birth is seen as unacceptable if it is outside the dominant medical narrative, for example, it is ecstatic or owned by women. Humans' decisions follow their expectations, with behaviour reflecting, and subsequently reinforcing, the dominant narrative (Brown, 2017). Therefore, it follows that women's experience of childbirth is altered because their expectations are aligned to medical intervention in birth.

Decisions during pregnancy and childbirth are affected as women submit themselves to the potential scenario they are exposed to (Kay et al, 2019; Cooper and Godfrey-Isaacs, 2020). By surrounding themselves with others who choose to do the same, decisions are simply validated and false information perpetuated (Morse and Brown, 2022). Incorrect health information may be shared, with decisions potentially being made simply on other's shared opinions (Brown, 2019).

However, with its capacity for user-generated content, social media has potential to challenge, as well as reinforce, the portrayal of medicalised birth (Kay et al, 2019; Cooper and Godfrey-Isaacs, 2020). The influence of social media is increasing (Vogels-Broeke et al, 2022) and it can be a mechanism for raising women's social capital and improving health (Moore and Kawachi, 2017). As a midwife empowering woman to share decisions about their care using evidence (NMC, 2018), it is important to better understand how such platforms, and their role, can support and threaten this.

Women want their relationships with their midwives to be more consistent, trustworthy and a better source of accurate information (Prescott and Mackie, 2017; McCarthy et al, 2020; NHS, 2020). Although the midwifery continuity of carer model is an approach currently suspended, until and unless safe staffing is shown to be present (Ockenden, 2022), there is high-quality evidence for the positive impact that continuity of carer has on a range of outcomes for women and babies (Sandall et al 2016; Royal College of Midwives, 2018). The provision of evidence-based information helps shared decision making with women (NMC, 2018), and informational continuity. The timely availability of relevant information is one aspect of continuity (Sandall et al, 2016).

During the COVID-19 pandemic, the midwife mediated ‘facemums’ social media group gave a new source of continuity, which improved informational continuity and emotional support (McCarthy et al, 2020). Women used this platform to check the accuracy of information and consolidate understanding, their findings were verified with midwives and this process was recognised as preferable to them carrying out more haphazard searches online (McCarthy et al, 2020).

It is not just social media, but the wider community and antenatal classes, that create ‘pressure’ and an ‘expectation of normality’ (House of Commons HSCC, 2021). How digital sources are used to support health is affected by socioeconomic and cultural factors (Backstrom et al, 2022) and a woman's ability to comprehend what is presented to her (Varnos et al, 2019). The influence of social media on women's ability to make informed decisions about childbirth depends on the online space they navigate and their ability to critically consider content. Addressing this would support the government's levelling up agenda (Dixon and Everest, 2019), focusing on the wider determinants of health required to close the ‘health gap’ (Institute of Health Equity, 2020), and potentially improve the inequalities in childbirth experiences and outcomes (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK, 2021).

There is an opportunity for midwives to support women to have greater agency in decision making, navigating the online world so that, irrespective of whether birth is medicalised or natural, these virtual networks and shared stories support, not compromise, the safety and wellbeing of birthing women and their babies.

Limitations

This review is a summary of data identified in published qualitative primary research. While the merits, principles and different versions of thematic analysis are acknowledged (Braun and Clarke, 2006), this review did not adopt formal thematic analysis methodology and as such presents a synthesis of existing literature. The decision to undertake a qualitative meta-synthesis was made because of the benefits of such rich data in helping understand experience; however, it is recognised that further insights may have been drawn by considering quantitative primary research.

Computerised search tools cannot identify all relevant literature (Aveyard, 2019) and further approaches were used, including snowballing sampling (Greenhalgh and Peacock, 2005) and an author search.

Considering only published material may introduce an element of bias and limit the review (Aveyard, 2019). Other material, so called grey literature and information, includes a range of documents not controlled by commercial publishing organisations (Adams et al, 2016). While hard to search for and retrieve for evidence synthesis (Adams et al, 2016), information held in these sources may have been valuable, given the rapid pace at which social media evolves and the timeframes for academic journals, meaning the most recent insights may not yet be available.

To keep findings transferable, and generalisable, studies were excluded that looked at specific subsets of women, for example based on their age. It is recognised however that in addressing inequalities (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK, 2021) these insights are key, but the limited scope of this review would not allow meaningful conclusions to be drawn.

Conclusions

Social media creates spaces which polarise and control binary (medicalised or physiological) narratives of birth. The dominant narrative on social media is of medicalised birth, and women are readily conforming to these norms of childbirth through their subsequent decision-making and birth experiences. The narrative around physiological birth is also curated and controlled, and social media can indeed arguably be contributing to an expectation of normality.

Key points

• Social media is now an integral part in how women learn about childbirth; however, newer online platforms offer challenges as well as opportunities.
• Online spaces have been created that polarise and control binary (medicalised or physiological) narratives of birth.
• The influence that social media has on women depends on the online spaces that they navigate and their ability to critically consider content.
• There is an opportunity to better support midwives in using social media professionally to help women's informed decision making.

CPD reflective questions

• How confident are you working with women in a way which is respectful of individual choice, and helps women use the opportunities, and mitigate the risks of social media?
• Which social media resources would you signpost women to so they can be better informed and empowered to share decisions about their treatment and care?
• What resources are available to help you develop your knowledge, and work with social media effectively? Which of your colleagues have expertise in or a role working with social media?