Stories of childbirth make for engaging reading in newspapers, but to what effect on the future mothers who pick them up? Public scepticism over the values driving Britain's mass media has intensified since the Leveson Inquiry into press ethics and recent phone hacking trials. Yet a pregnant reader is still likely to have relatively high confidence in the information carried in direct quotations that form women's personal narratives of labour (Gibson and Zillmann, 1993; Sundar, 1998).
Interest in advisory material on pregnancy and birth is underscored by the retail success of self-help books such as What to Expect When You're Expecting (Murkoff and Mazel, 1999), a volume published in 30 languages, selling more than 17 million copies. Newspapers are another ready source of information. But the experiences headlined in sales-driven publications inevitably bring more drama—whether tragedy or miracle—than the majority of pregnancies (Williams and Fahy, 2004; Bick, 2010). This non-representative information is a powerful source of anxiety for women approaching the pivotal life experience of giving birth (Ryding et al, 2007). Reports about relatively rare clinical problems can plant seeds of fear that readers might not have previously even been aware of (Beck, 1992). The NHS online tool, Behind the Headlines, attempts to interrogate media reports using the best available evidence (NHS Choices, 2014). However, it is impossible for every article to be illuminated in this way. Thus, in order for midwives to be truly ‘with woman’, it would help to have an understanding of the material on offer.
More than half of the world's adults read a daily newspaper, with 2.5 billion choosing print and 600 million using digital (Marketing Charts, 2013). In Britain, 8.7 million women aged 15–34 (thus of childbearing age) read a daily newspaper (National Readership Survey (NRS), 2014). This study focuses on the UK press, given its influence both at home and abroad. Newspaper websites mean that British output carries weight in high-consumption countries like Australia and the US. Mail Online, an internet extension of the mid-market Daily Mail, stands as the world's most popular online newspaper (comScore, 2012).
Literature review
A review of research into how birth is presented in the media found almost no analysis that focused specifically on British newspapers. The majority of evidence available looks at television in the US and UK (Clement, 1997; Kitzinger and Kitzinger, 2001; Morris and McInerney, 2010; Pincus, 2010; Theroux, 2011; Garrod, 2012). Such authors contribute a dynamic insight into portrayals of birth (informative, sensational, comedic, tragic), with data sourced from reality shows, feature films, soap operas and hospital dramas. The UK and US both routinely export television material worldwide—an information flow that parallels the newspaper industry, which itself finds a global audience via its websites.
The body of evidence on print media is smaller, and very limited with regards to UK output. However, discourse analysis of articles about childbirth in a Melbourne daily title indicated risk as a key theme (McIntyre et al, 2011). Newspapers’ ability to affect public opinion (and thus government policy) is also documented (Young et al, 2008; Dahlen, 2010). A study into women's magazine culture found labour described as a ‘marathon’, requiring abdominal muscle training (Dworkin and Wachs, 2004).
Dahlen and Homer (2012) investigated internet news, and found that midwives received an inferior public image to obstetricians. Thus the status of normal vaginal birth may be reduced by association. For British mothers, internet research is a key source of information about childbirth (Coxon et al, 2013). Very few studies engage with specific newspaper articles, but one useful work does reference a story entitled ‘Are you too posh to push?’ as an example of how women's birthing preferences are explained (Moorhead, 1999; Kingdon et al, 2009).
Such is the ever-changing nature of today's media that this examination of British newspapers updates our evidence on how people are informed on issues including water birth, surgery and birth partner choice. The stories in this data set are not analysed as forensic evidence of events. Neither are the commercial pressures and reader preferences that can dictate what is published investigated. This article is a reflexive look at the overall impression of childbirth given to women in pregnancy (Kingdon, 2005).
The evidence could be of great practical use to midwives, who are well placed to tackle misconceptions by women, especially if they understand the material being read (Otley, 2011). It is asserted that pregnant women should be asked in early pregnancy (at the booking appointment) what they have seen and heard about birth (National Institute for Health and Care Excellence (NICE), 2008). This might begin such processes as ‘demystifying birth’ and ‘talking about pain’ as described in one useful profile of the ‘birth talk’, which should happen at around 36 weeks (NICE, 2008; Kemp and Sandall, 2010).
Method
This study examined first-person stories of childbirth published from December 2011 to November 2012. The Newspaper Licensing Agency database was used to search 23 leading British newspapers (and Irish editions) covering the political spectrum (Table 1).
| Tabloid | Midmarket | Broadsheet |
|---|---|---|
| Daily Mirror | Daily Express | The Daily Telegraph |
| Daily Star | Daily Mail | The Guardian |
| Daily Star Sunday | Mail on Sunday | The Independent/The Independent-i |
| People | Sunday Express | The Independent on Sunday |
| The Sun | Metro (freesheet) | Observer |
| Sunday Mirror | Evening Standard (London) | The Sunday Telegraph |
| Sunday Mail | The Sunday Times | |
| Daily Record | The Times |
Search terms
‘MY and BIRTH and MIDWIFE’ was found to produce the greatest frequency of first-person stories about normal birth. Accounts of intervention (forceps, ventouse or caesarean section) were also of some interest, but the priority of this study was to obtain the maximum number of tales about normal vaginal birth. The validity and style of stories was no factor in the selection of data: the study was interested in the end product of what women read, rather than how or why a journalist may present a story in a particular way. The study sought to maximise the number of stories about vaginal birth, hence the decision to exclude the search term OBSTETRICIAN.
Inclusion criteria
Articles that had been published in the 12 months between 1 December 2011 and 30 November 2012; direct quotations from mothers about their experience of giving birth were included in the study.
Data extraction
First-person narratives were deemed the most affecting source of information for pregnant readers, as evidence suggests direct quotations from those with first-hand experience of the situation can be most emotive and persuasive (Sundar, 1998; Kiousis, 2001). Therefore, direct quotations from mothers were extracted from texts, while other voices in the text (e.g. journalist, expert, partner) were excluded. The influence of alternative narrators such as these would merit further research, but was beyond the scope of this work.
Content analysis
A grounded theory method (Strauss and Corbin, 1994) was used to allow the text to ‘speak for itself’, and minimise observer bias. Bowling's (2009) coding steps were adapted to this context and carried out until all the data sets were processed (Table 2).
| Read a batch of 20 sets of data one-by-one |
| Give each new concept that emerges its own text colour, highlight, size or font to typologically interlink different units of data |
| Allow sentences to split into different coded parts where necessary, and allow blended coding where possible (combine a colour and a font to acknowledge simultaneous themes, e.g. pain and disappointment at once) |
| Change and refine codes as understanding broadens and improves |
| Repeat the process on subsequent batches of data until no new categories are generated |
| Log each story, including its headline, in a table |
| Count key themes for frequency |
| Select illustrations that epitomise key themes for subsequent discussion |
Adapted from: Bowling, 2009
Results
The database search yielded 521 items, with 198 stories inside the inclusion criteria.
Codes
The 61 codes that emerged are presented in Figure 1. The most common five themes were (in order of frequency): fear; ordeal; pain; effective staff and gratitude; malicious staff. Table 3 highlights selected extracts, to demonstrate how codes were applied to women's stories and to provide a sense of the material. Articles describing a poor birth experience often involved extreme clinical cases, staff negligence, or a celebrity. Television personality Amanda Holden's experience of haemorrhage was publicised on television adverts for the front page of the first edition of the Sun on Sunday. A positive outcome of her narrative was the neutral tone she used to describe placental complications, which may have served to educate rather than terrify. These excerpts indicate the space allowed for a plurality of views, particularly in mid-market newspapers. In topics of debate, newspapers often authorised a famous voice, such as BBC Radio 4 presenter Jenni Murray, to narrate. It is clear from the emotive language used in both tabloid and broadsheet coverage that such reports could be extremely frightening if taken at face value.
| Topic/HEADLINE | Publication | Quotations | Codes |
|---|---|---|---|
| Stillbirth/MIDWIFE SIMPLY LAUGHED AT MY TORMENT OVER STILLBORN BABY | Evening Standard | Sarcastic…belittling…insensitive…rude… | Malicious staff |
| ‘Do you think that won't hurt? Believe me it will’ | |||
| I am angry and disgusted…I've been let down massively by the hospital…I want a full inquiry…No woman should have to go through what I did | Combative mood Inadequate care Rights | ||
| Stillbirth/A PAIN LEFT UNSPOKEN | The Guardian | The midwife couldn't find the heartbeat. Our world fell apart | Fear Devastated |
| Just a quiet, lifeless body put on my chest | Ordeal Incredibly moving | ||
| Celebrity/MY CHRIS DIDN'T KNOW IF I WAS ALIVE OR DEAD - AMANDA HOLDEN WORLD EXCLUSIVE | Sun on Sunday | As much blood as they were putting into me was going out. I lost about 13-15 litres | Alarm Out of control |
| I had something called placenta previa — a low-lying placenta that prevents you from giving birth naturally. I also had placenta accreta, which meant my placenta was stuck to the C-section scar from two previous births | Neutral tone Educational | ||
| Then they very calmly came over and said there's a lot of bleeding so we're putting you under. No one was panicking. I felt calm | Effective staff | ||
| Negligent Care/MOTHER LEFT IN AGONY BY BOTCHED BIRTH OP | Daily Mail | I was still in loads of pain. But she was my first baby so I thought it must be normal | Pain First baby |
| At the scan they told me there was a big piece of placenta still in there and it wasn't going to be passed naturally. Because it was going on so long my body was infected and they said I was too ill to operate on at that time | Fear Infection Inadequate care | ||
| Male partner/YOU SAY | The Times | I am 80 years old, and when I gave birth to my children, men were not allowed in the ward, but now it is the norm. If men are ‘disgusted’ about childbirth, they should never marry or have sex | Male support Humour |
| Intervention/NATURAL BIRTH LOSING OUT TO THE EPIDURAL | Daily Mail | A lot of it is fear of pain and a lack of understanding. Births on TV shows always looks traumatic and a lot of women imagine an epidural will be a magic solution | Neutral tone |
| With an epidural, you are drugged up and it can stop you from feeling the physical experience of giving birth | Anti-intervention | ||
| With my second son, I had a natural birth and found it a much better experience | My plan Anti-intervention Pride | ||
| Unusual birth/I DELIVERED MY OWN BABY | The Guardian | I rang 999…one question that drummed home the reality: ‘Can you feel any part of the baby?’…I could feel the head | Surprise |
| What if the baby's not breathing when it's born? What if I tear horrendously and bleed to death?…very frightened about the amount of pain I was in | Fear Pain Revolting No choice | ||
| My waters broke and I felt a huge urge to push…The operator was still on the line, calmly instructing… | Neutral tone | ||
| Unusual birth/I DELIVERED MY OWN BABY | The Guardian | My body knew…the best position for me to deliver in | Effective care Mother's instinct You can |
| Euphoria washed over me…hugely empowering and uplifting | Incredibly moving | ||
| Opinion piece/AS PLANS TO CUT DOWN ON EPIDURALS CAUSE A FURORE, JENNI MURRAY SAYS ‘GET REAL GIRLS! PAIN IS PART OF CHILDBIRTH’ | Daily Mail | I had an experienced midwife and a sympathetic, young obstetrician | Trust |
| I kept moving throughout and at 4pm went into a quiet, dark delivery room with my midwife and partner | My plan | ||
| Need to focus on birth Male support | |||
| At the crest of each contraction, I took a whiff of gas and air, which eases the grasping feeling…there's the positive pain felt by a marathon runner whose every muscle cries ‘Stop!’ but they go on because the end will be a triumph. Like childbirth | Positive pain |
Discussion
Newspaper sales rely on high impact, unusual stories—a calm account of everyday birth will rarely make it into print. The media plays a vital role in bringing to light clinical error, sub-standard care and inadequate maternity provision. Revelations about inequitable rural services in one Australian newspaper underscore the fact that publication of such stories should continue (McIntyre et al, 2011). However, newspapers often prioritise the ‘exclusive, exciting or controversial’, and this study demonstrates how narratives about childbirth offer ‘evidence’ of horror stories to pregnant readers at a time when they are often highly receptive (Wells et al, 2001). Women deserve recognition for their ability to discern the differences between a newspaper case and their own situation, especially with obviously sensationalist stories (Tulloch and Lupton, 2003). However, the ability of the media to influence people's health-seeking behaviour is measurable, evidenced and forms the basis of this discussion (Beck, 1982; Grilli et al, 2000; Tulloch and Lupton, 2003; Coxon et al, 2013).
Surveys of newspaper readers have indicated that perception of risk is informed by the non-representative quantity of extreme situations described in such titles (Williams and Dickinson, 1993; Young et al, 2008). In Beck's (1992) concept of modern life existing in a paranoid ‘risk society’, newspapers allow people to discover adverse outcomes that potentially could—but probably won't—happen to them. The predominance of fear, pain and ordeal is the first stage of readers experiencing the ‘0.1% doctrine’ (Suskind, 2006; Dahlen, 2010). This term sums up the magnified perception of risk a woman might feel, for example, of having a stillborn baby after reading the accounts of the unlucky few who experience it. Another potential consequence of frightening reports is the ‘vicious circle principle’, that women who are instilled with fear of childbirth during pregnancy also experience fear when the time comes, which may have an effect on the final outcome (Zar, 2002; Dick-Read, 2004; Kjærgaard et al, 2008).
A Sunday Times article reported a neonatal death at a freestanding midwife-led unit (Templeton, 2012) where the baby of a 35-year-old woman, who had experienced complications towards the end of pregnancy, died 6 hours after she was born. An inquest ruled the birth should have been in an obstetric unit. Such an incident is an issue of utmost gravity, and merits reporting on grounds of public interest. Yet the story could arguably have had a negative effect on how the newspaper's readership went on to view midwife-led care in general. This article does little to encourage a pregnant woman to birth in a free-standing midwifery unit. The impact may be similar on the reader's friends and family—important sounding-boards for expectant mothers (Lupton, 1999; Tulloch and Lupton, 2003; Yee and Simon, 2010, Coxon et al, 2013).
Despite the ratio of healthy infants to mortalities at the unit in question, the story entitled ‘My baby's dead, isn't she nurse?’ is also likely to affect the risk-perception of health professionals working in a litigious age (Douglas and Wildavsky, 1983). Furthermore, a service commissioner is unlikely to be drawn towards this model of care when reading a grieving mother say: ‘I hope women are better informed about the dangers, the real, massive risks of delivering in a midwife-led unit. I think stand-alone midwife-led units should provide antenatal care and postnatal care but they should not be used for deliveries’. A health minister may also navigate a normative, biomedical path away from such a birth environment, given that ‘the political sphere can only ignore published opinion at the risk of losing votes’ (Beck, 1992). Of course such professionals consult a range of materials when planning, but an emotive story is disproportionately powerful for decision-makers, as ‘risk-as-feelings’ often dominate over cognitive assessments (Loewenstein et al, 2001).
This story's message that an absence of obstetricians is dangerous is countered comprehensively by the landmark Birthplace study (Brocklehurst et al, 2011). Yet the added visibility given to this worst-case scenario by the act of publication for 2.5 million readers will never be balanced by stories about happy, healthy births in freestanding midwifery-led units (NRS, 2013). The discrepancy between robust evidence and society's assumptions about what harms us has far-reaching implications on policy in other health-related fields. As with childbirth, research-based facts are muddied by cultural prejudice that dictates a hierarchy of safety, even if the data indicates otherwise (Nutt et al, 2007; Nutt, 2012). Ultimately, ‘when perceived pregnancy risk is out of proportion to real risk, and when risk management procedures are applied to all pregnant women with benefit for a few, unintended and harmful consequences may result’ (Jordan and Murphy, 2009: 198). For labouring women, there is a well-documented cascade of intervention that flows when they enter more medicalised settings, prompting questions about cost—both to mothers’ physical and mental wellbeing and the economy (Tracy and Tracy, 2003; Saxell, 2006).
Focusing on the potential impact of newspaper stories on pregnant women, a wealth of evidence links fear of childbirth to adverse outcomes. Potential consequences of such anxiety may include an increased risk of poor maternal mental health (Rouhe et al, 2011), emergency caesarean (Ryding et al, 1998) or prolonged labour (Johnson and Slade, 2003; Adams et al, 2012). Postnatally, women who had severe fear of childbirth or an anxiety disorder when pregnant may be at increased risk of post-traumatic stress disorder (Sutter-Dallay et al, 2004; Söderquist et al, 2009). Of course some anxiety about birth is normal, and can motivate expectant mothers towards healthy behaviours (Jordan and Murphy, 2009). But when this kind of preoccupation becomes a pervasive fear, it can blight rather than nurture (Dick-Read, 2004). A culture of ‘fatalism’ can prompt women, their partners and professionals to seek medicalised birth settings, thus restricting any real choice of birth place (Houghton et al, 2008). Extreme worry about childbirth can also prompt women to evade the experience altogether; either by avoiding pregnancy (Hofberg and Ward, 2004), seeking abortion (Larsson et al, 2002) or electing to have a caesarean section (Fenwick et al, 2009; Haines et al, 2011).
The extent to which the media are responsible for women's fears is a point for future investigation, but Robson and colleagues (2008) suggest that Australian website and magazine interest in women's right to choose surgery could be a motivational factor towards caesarean. Antenatal anxiety was a notable feature of revised UK NHS caesarean section guidelines, in 2011, which made elective surgery an option for women whose fears were not sufficiently calmed by counselling (Garrod, 2011; Otley, 2011; NICE, 2011). The suboptimal stories of childbirth found in this study's data sit alongside a caesarean rate in England of 25.5% (NHS, 2013). This figure has risen from 9% in 1980, and nearly half of operations are elective, prompting financial and public health questions (Tracy and Tracy, 2003, McFarlin, 2004; National Audit Office, 2013).
Midwives are well-placed to alleviate women's fears, as they intervene at a time when most are more receptive (Skinner, 2008; Jordan and Murphy, 2009; Lyberg et al, 2012). Biro (2011) argues for a ‘public health consciousness’ in maternity care, so that this 40-week window of opportunity might be maximised. In order to effect change, the midwife must fully understand and probe the sociocultural and mental preoccupations of each woman. Anecdotally, most midwives working in countries with a heavy media presence have a sense of prevailing newspaper discourses on pregnancy and birth. But a more comprehensive, organised understanding is required if they are to meet mother's hopes, address their fears and thereby incrementally rewrite the story of natural vaginal birth.
It is worthwhile to consider simple measures within broader health services that might help promote more positive attitudes towards natural birth (Irvine, 1999). Evidence from related fields includes interventions that strengthen individuals’ critical thinking, e.g. media messages about smoking (Pinkleton et al, 2012). A similar approach led to increased childbirth satisfaction for women who had experienced fear antenatally (Rouhe et al, 2013).
In this study, the process of cataloguing the ‘evidence’ in Britain's national press is underway. Yet in an age of electronic media, it is just the start. Recently, British television has scored huge ratings with reality series One Born Every Minute (Channel 4, 2013), period drama Call the Midwife (BBC, 2012), and documentary Home Delivery (ITV 2013; Garrod, 2012; Page, 2013). The internet and social media are also troves of information, both good and bad, that cannot be ignored. Much information is helpful, dismantling taboos surrounding bodily experiences that have stalled us in normalising birth. This is particularly pertinent at a time when health policy makers and clinical practitioners are searching for solutions to disproportionately low home birth rates, sub-optimal breastfeeding records and high caesarean section rates (Renfrew et al, 2005; Peristat, 2008). An understanding of birth narratives of all kinds, therefore, seems a valuable tool for health practitioners and policy makers alike. Much remains to be documented.
Evidence on how birth is presented across the wider media would benefit from more detailed analysis. This might offer midwives a keener understanding of the material women may read, listen to, or watch. The ‘media literacy’ of expectant mothers should also be probed. We should investigate what women actually absorb from media sources, and how seriously they take them. It would also be valuable to gauge any differences in impact between ‘new media’ and more traditional forms. Encouragingly, recent studies into the influence of social networking sites explored whether new ‘healthcare platforms’ might help change behaviours linked to sexual health and breastfeeding (Bull et al, 2012; Wolynn, 2012; Shelton and Skalski, 2013).
Limitations
The key obstacle to generalisability in this qualitative work is the subjectivity of the one single researcher who undertook it. The reliability of these findings would have been enhanced by two or more researchers independently coding and liaising, but resources were limited. Reflexivity was nevertheless an overriding priority during the process, and was supported by Bowling's coding system (Kingdon, 2005).
Different search terms (e.g. ‘consultant’) would have produced other articles – but, as mentioned above, the combination ‘MY and BIRTH and MIDWIFE’ offered the greatest number of first-person stories of spontaneous vaginal birth.
The lack of information about how quotes were elicited might be viewed as a weakness, but the primary concern here is the information presented to women, not its provenance.
Inclusion of women's magazines would have added an important further dimension, but the sheer volume of material on offer was beyond the capacity of this study.
Conclusion
The evidence here of ‘alarming’ newspaper stories supports a call for probing the messages a woman may have absorbed, making such questions an integral part of the antenatal booking appointment. It may be sensible to ask: ‘What have you seen or heard about birth in the media?’ This activity could become universal by demarcating a formal space for it in women's notes. Admittedly, the time constraints that restrict midwives’ capacity for extra tasks mean such measures would require additional funding in an already resource-poor NHS. Training for midwives to structure any subsequent discussion would also be important, perhaps involving visual tools such as the Paling Palette, which shows the estimated numbers of people likely to face an adverse outcome alongside those who probably will not (Paling, 2006). Such steps are worth consideration. By empowering women to strive for a birth experience driven by informed priorities, the midwife can work effectively in today's media age rather than against it.
Midwives and other health professionals should seek every opportunity to address the media to explain the rationale for supporting natural birth. A crucial step towards this would be comprehensive media training to boost the confidence of well-informed individuals who might otherwise decline requests for interview.