Background: More and more women are turning to the internet in
pregnancy. Yet the value of this ever increasing quest for information is an area that appears to be under researched.
Objective: This qualitative study aimed to explore the perceived value of internet use in pregnancy, conducted from the viewpoint of three distinct groups: midwives, pregnant women and postnatal women.
Methods: Thirteen midwives, seven antenatal women and six postnatal women were recruited to three focus groups and seven in-depth interviews.
Results: Appropriate internet usage 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.
Conclusion: Greater collaboration between midwives and pregnant women is required to enable access to consistent, verified internet information which can be used appropriately and with confidence.
Claire Weston Community Midwife Hastings
East Sussex Healthcare NHS Trust
John L Anderson Senior Lecturer Postgraduate Medicine University of Brighton
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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.’ (AF5 18)
‘It’s just that some things...you know when to Google and not to Google’. (PF4 22) 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.’ (MI2 3)
‘I think it’s a useful tool but in the right hands and used in the right way I suppose.’ (MI3 1)
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
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more to say I don’t think you’re right.’
(AF1 10-12) 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.’ (AF3 11)
‘I think it can generate more topics of discussion with your midwife.’ (AF3 9) Midwives were in agreement:
‘It formulates a discussion because it’s all about their choice isn’t it?’ (MI3 2)
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:
l It can involve poor judgement:
‘The chat rooms...it put me off...one woman I saw on there had been bleeding for hours and she was going on there instead of phoning the doctor or midwife and I just, that’s, that’s quite dangerous…’ (AI1 8)
l It can be a result of overuse causing increased anxiety:
‘[be]cause you go further anyway cos it’ll come up like...could have this or this and you’re like, click, oh no, need to Google that.’ (PF4 15)
‘It can terrify them can’t it? You have to talk them down sometimes.’ (MF5 3)
‘Ladies’ partners often appear to be quite frustrated at the information the ladies look for and they almost treat it like they have an addiction, you know, “she’s been on those websites again and she’s got herself really worked up and she’s...got a list of questions to ask you and I wish that she more serious medical problems.
‘I think you would want the advice from a medical professional...rather than from lots of just crazy women.’ (AF3 3)
‘When it’s conflicting…if people are putting different things…it does get a bit confusing but, erm, then I’ll ask my midwife.’ (AI2 5) 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.’ (AF3 9)
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.’ (MF9 4)
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?”’ (MF6 6)
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
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wouldn’t go on them because I don’t think they’re helpful. They just wind her up. I come home from work and she’s in a state.”’
(MF8 5)
‘I don’t personally think it’s a good thing because it frightens them...’ (MF3 1)
‘I think it’s damaging...before the internet was about, I think, erm, you were less likely to, you know, worry and be scared about anything that’s happening cos you didn’t know, whereas now…when people put stuff on the internet it’s always negative…’
(MI1 2-3)
l For some it becomes an obsession:
‘If you want to keep looking…if you do too many searches...Paracetamol...I ended up going further down the searches so...there was the NHS, you know, Paracetamol’s fine, Paracetamol’s fine. It was almost like you can get in danger of this macabre-like thirst for finding out there must be something wrong...and of course coming across a danger study that had linked Paracetamol use with, erm, schizophrenia in later life, you know, I was like “yes I found it” [laughter].’ (AF5 17)
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!’ (MF8 14)
‘...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]’
(MF7 17)
‘...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]’ (MF6 17)
‘...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...’ (MI2 7)
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.’ (MI1 5)
Inappropriate test requests
‘They want more investigations just in case they’ve got the problem.’ (M1 2)
‘...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?”’
(AF5 9, 13)
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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...’ (MI2 4)
‘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?”’ (AF5 15)
‘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.’ (AF3 16) 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.’ (PF3 10)
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.’ (AF1 1)
‘Yeah I will say that’s the one I used as well.’
(AF3 1)
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.’
(MF6 11)
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.’ (AF1 12-13)
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 hand-held 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
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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. BJM
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