Background
Birth is a peak experience
Decision-making in healthcare
Historical context of antenatal preparation
Technology and e-health changing midwifery practice
Methods
Developing the meta-synthesis question
“How do informal information sources influence women’s decision-making for birth?”
Search strategy
S1-S4 – first and ‘core’ structure of the search |
S1 TX pregnant women OR expectant mothers OR women preparing for birth |
S2 TX birth OR childbirth OR labour OR labor OR parturition |
S3 TX qualitative* OR focus group OR interview OR phenomenolog* OR grounded theory OR narrative analysis OR descriptive analysis OR thematic analysis OR ethnography |
S4 TX Information seeking behaviour OR choice OR decision making OR anxiety OR women’s experience OR women’s perception OR birth plan* OR women’s preparedness for birth |
S6- S9 added individually to the core search to generate results |
S6 TX Internet OR internet forum OR digital media OR social media OR blog OR podcast OR webcast OR mobile applications OR smart phone OR mobile phone technology |
S7 TX TV OR television OR reality television OR documentary film OR television documentary OR movie OR film OR cinema OR motion picture OR visual media OR radio OR entertainment |
S8 TX Newspaper OR newspaper articles OR magazine OR magazine articles OR self help books OR childbirth literature OR pregnancy literature OR childbirth magazine OR pregnancy magazine OR pregnancy books OR childbirth books OR news reports |
S9 TX Birth stories OR birth narratives OR birth Storytelling OR childbirth stories OR childbirth narratives OR childbirth storytelling OR oral tradition OR social networks OR peer support |
Results
Literature search
Exclusions
Included studies
Quality appraisal
++ | All or most checklist criteria is met, and where have not been met conclusions are unlikely to altar. |
+ | Some of the checklist criteria have been met, where they have not been met or not adequately described, conclusions are unlikely to altar. |
– | Few or no checklist criteria have been met and conclusions are likely or very likely to alter. |
AUTHORS | TITLE | AIMS | METHODS | POPULATION/PARTICIPANT | ANALYSIS | QUALITY ASSESSMENT TOOL | FINDINGS & CONCLUSIONS |
---|---|---|---|---|---|---|---|
Carolan M 2007 Australia | Health literacy and the information needs and dilemmas of first-time mothers over 35 years | To highlight information based dilemmas for women over 35. | 1:2:1 interviews 35 weeks, 10–14 days postnatal and 6–8 months postpartum 3 focus groups | 22 first time mothers > 35 years, antenatal/ postnatal 19 Women | Thematic content analysis |
+ +
Study design and methodologically appropriate. Useful insight into area of interest. Elements of analysis unreported. | Mothers were given large amounts of clinical information, despite common perceptions of empowerment these women often found the amount of information overwhelming. |
Dahlen H, Barclay L, Homer, C 2008 Australia | Preparing for the First Birth: Mother’s Experiences at Home and in Hospital in Australia, | To explore experiences of first-time mothers who had given birth in Australia. | In depth interviews postnatally. | 19 women 19–37 interviews lasting 20 mins – 3 h 17 primip, 2 multip Interviews From 6 to 26 weeks (mean 15 wks) Postnatal | Grounded theory One category from the overall analysis ‘preparing for birth’ was the content of this article. |
+ +
Study design and methodology appropriate. | Women cite that the period of preparation for birth has significant influence on and being an important part of their entire birth experience. Women who planned home births felt more prepared and better supported than those planning hospital births. |
Fenwick J, Staff L, Gamble J, Creedy D, Bayes S 2010 Australia | Why do women request a caesarean in a normal healthy first pregnancy? | To describe Australian women’s request for cesarean section in the absence of medical indicators in their first pregnancy. | An explorative descriptive approach interview guide based on previous work | 14 women 1:2:1 interviews 45–60 min postnatal had caesarean in the last 5 years | Thematic analysis |
+
Methodologically cogent Data not particularly rich. | Fear, safety, control and devaluing the female body and vaginal birth were contributing factors to women’s decision for caesarean birth. |
Fenwick J, Hauck Y, Downie J, Butt J 2005 Australia | The childbirth expectations of a self-selected cohort of Western Australian women | To explore/describe women’s expectations of labour and birth and to identify influencing factors | qualitative study using an explorative descriptive design and techniques associated with constant comparison. | 202 women pregnant or birthed within the last 12 months. 19–45 yrs. mainly middle class | Thematic analysis |
+
Data not particularly rich Analysis, remained at the descriptive level | Particularly influential on women’s expectations of childbirth were private and public discourses of birth exemplified by books magazines and stories from mothers and sisters. |
Flemming S, Vandermause R, Shaw M 2014 USA | First-time mothers preparing for birth in an electronic world: internet and mobile phone technology | Uncover the meaning of how mothers self prepare with electronic media | sequential mix of two qualitative designs: focus groups of professional for preliminary study 1:2:1 interviews for secondary | All low income 7 first time mothers 1:2:1 postnatal interviews 45 mins to 2 h field notes mostly unplanned birth (6/7) | primary hermeneutic (interpretive) design one-to-one in-depth interviews from a purposive sample (n = 7) of young first-time mothers (FTMs) hermeneutic (interpretive) phenomenological approach |
+ +
Rich description of data Methodologically appropriate and coherent. | FTMs were preparing for birth ‘what ifs’ with electronic media based on what is ‘known’ about birthing. Mothers became educated but also this increased levels of fear and anxiety. |
Freeze R 2008 USA | Born free: Unassisted childbirth in North America. | To explore reasons women, choose to have unassisted birth. Exploring why women make this choice; the knowledge sources they privilege; how they understand the concepts of safety, risk, and responsibility, and their complex and sometimes contradictory relationship with midwifery. | interviews and personal correspondence, surveys, and archives of internet discussion groups and forums. Internet was the primary means of gathering participants. Telephone interviews 30–90 min 4 professionals interviewed followed the discussions on many UC and birth-related Yahoo groups read over 100,000 posts | sixty-one survey responses 17 telephone interviews mostly middle class | Thematic Analysis? – not clearly stated but approach was documented as thematic |
+ +
Methodologically appropriate, very rich use of data | The process of freebirth is complex and an understanding of why women free birth is needed to identify why some women are driven away from certain models of care offered by professionals. The study highlights the abuses and limitations of current paradigms of care UC bridges the gap drawing from professional practices but acknowledging women’s need for autonomy in the birthing process. |
Lagan B, Sinclair M & Kernohan G 2011 UK | What Is the Impact of the Internet on Decision-Making in Pregnancy? A Global Study | To build on studies to explore women’s experiences and perceptions of using the internet for pregnancy related information and influences this has on decision making. | Interpretative qualitative Thirteen asynchronous online focus groups across five countries Pilot study tested first | 92 women who had accessed the Internet for pregnancy-related information over a 3-month period. | Framework analysis |
+ +
Methodologically appropriate Insightful regarding stories | The internet has a marked impact on women’s decision making across the entirety of their pregnancy, highlighting a great need for information. |
Miller A 2009 USA | ‘Midwife to myself’: Birth narratives among women choosing unassisted homebirth | Detailed women’s narratives created by women choosing to birth unassisted | 127 unassisted homebirth stories sourced from Yahoo and google 10 face to face in depth interviews to check findings coherence | 10 participants | Grounded theory Constant comparison |
+ +
Strong insights into internet and us of books Methodologically appropriate but some lack of detail in analysis | Women rely on both medical and midwifery models and wider understandings from unassisted childbirth circles to formulate agency around birth. They reference formal models of care whilst seeking to liberate themselves from it. |
Munro S, Kornelson J & Hutton E 2009 Canada | Decision-making in Patient-Initiated Elective Cesarean Delivery: The Influence of Birth Stories | Exploring birth stories and cultural knowledge that women use to inform decisions for elective cesarean without medical indication. | Explorative in depth interviews with 17 women One branch of the total research findings are represented. 7 sites 2003–2005 | 17 primiparous women interviewed by 2 researchers 30–90 min | Grounded theory Constant comparison |
+
Methodologically appropriate Some insights but limited in terms of data richness and analysis | Women drew heavily from social and cultural knowledge in forming their decisions to birth by caesarean. |
Regan M, McElroy KG, Moore K 2013 USA | Choice? Factors That Influence Women’s Decision Making for Childbirth | Filling the gap in knowledge investigating factors that influence women’s decisions about birth | Mixed method 13 focus groups over 12 months | 49 primiparous women 21–36 yrs. majority white | Consensual Qualitative Research method | ++ Methodologically appropriate Insightful and rich data about sources of information | Four major categories were found but only birth stories and attending a birth have lasing effect on influencing birth choices |
Rodger D Skuse A, Wilmore M, S. Humphreys S Dalton J Flabouris M & Clifton V.L 2013 Australia | Pregnant women’s use of information and communications technologies to access pregnancy-related health information in South Australia. | Examines how pregnant women living in South Australia use information and communication technologies (ICTs), principally Internet and mobile phones, to access pregnancy-related information. | 35 semistructured interviews conducted as part of the larger ‘Health-e Baby’ project, a qualitative study | 35 women aged between 19 and 40 yrs. | unstated | + methodologically limited –no discussion of analysis data richness limited some useful insights | Shows that ICTs have great potential for health promotion communication high levels of access not easy to predict personal choices pregnant women make for mode of communications they access, prefer & trust |
Seibold C 2003 Australia | Young single women’s experiences of pregnancy, adjustment, decision-making and ongoing identity construction. | To examine young pregnant women’s experiences of embodiment, identity construction decision making and how these are influenced. | Explorative descriptive study using feminist principles | 5 women 17–23 yrs. interviews both antenatal and postnatal telephone interview at six months post birth. Women also kept diaries | Techniques of grounded theory were used |
+ +
methodologically appropriate rich data | All women welcomed the physical changes of pregnancy. Acceptance of pregnancy was assisted by supportive families, friends and sympathetic healthcare professionals, as well as exposure to opinions via classes, information and educational opportunity. |
Song F, West J, Lundy L, Dahmen N 2012 USA | WOMEN, PREGNANCY, AND HEALTH INFORMATION ONLINE: The Making of Informed Patients and Ideal Mothers | To explore how white middle class women use the internet during experiences of conception, pregnancy and childbirth to ascertain how internet usage challenges, and medical paradigms shape women to make decisions | Part of a descriptive study on the information-seeking habits of women in five areas of early mother- hood: conception and fertility; pregnancy; labor and delivery; child’s feeding and nutrition; child’s health and safety products. | 32 mothers interviewed November 2008 and March 2009 24 to 36 years all but one Caucasian 1/3 multiparous women complex and un-complex health experiences | Grounded Theory Feminist approach | + Level of analysis unreported in places, methodologically appropriate | Internet enables socially privileged women to perform an informed patient role ad demonstrate their competencies as mothers. |
Weston C, Anderson J 2014 UK | Internet use in Pregnancy | Perceived Value of internet in pregnancy from the view points of midwives, pregnant women and postnatal women. | Thirteen midwives, seven antenatal women and six postnatal women three focus groups and seven in-depth interviews. | Appropriate internet use was valued by all groups | + Useful despite methodological weaknesses useful discussion of ‘apps’ although analysis appears on a surface level | Appropriate internet usage during pregnancy was positively valued by all groups. Greater collaboration between midwives and pregnant women is required to enable access to consistent, verified internet information which can be used appropriately and confidently. |
Design of Analysis and Selected Studies
Findings
Menu birth
Belief systems
‘Basically, I just wanted that opportunity to like choose the way my labour was going to progress but if I did need to make choices like about pain relief that I would be supported by the midwives and my doctor’ [44].
‘Early on, I made a list of all the factors and elements I did or did not want to be part of this experience. My main focus was on creating an absolutely uninterrupted, undisturbed process of birthing, controlled entirely by me. I wanted no input from anyone else while giving birth. I wanted no suggestions, no instructions, no checking, measuring, or labeling. I had total confidence that I would have a safe and normal birth.’ [40].
Perceptions of control
‘a controlled environment with all the bells and whistles and the experts there to do whatever needs to be done’ (Vera) [45]
‘drug free and not a caesarean as little intervention as possible’ [44]
‘I didn't read anything for 9 months except birthing books, I swear. I mean, I just studied it I knew it so well that the birthing classes suggested that I become a teacher. By the time I was in preparation for her birth, I had a lot of very, very positive expectations around the birth. I envisioned love around me and my own environment. To have all the things that I wanted, like music and the candles and the aromatherapy and my sister and husband and Amy [midwife].’ [43]
There are nuances between decisions made in the process of pregnancy and those relating to choices during birth. Women reported they had ‘little control in labour when things went wrong’ [47]. The concept of being ‘ready for anything’ because unpredictability is the only absolute, was echoed across papers [26, 44]. This acceptance of unpredictability and the desire to be ‘in charge’ [44] empowered women to experience control, avoiding feelings of disappointment or the sense that they had let themselves down if their menu birth was not achieved.‘I personally find the attitude of, ‘my (insert care provider here) will take care of everything no matter what so I don’t have to prepare,’ to be INCREDIBLY irresponsible.’ Adelaide [39].
Closest in relation to self-surrender appears to be the presence of God, and women readily relinquish power to a greater force directly related to women’s existing belief systems: ‘This baby was unplanned but there was no question that I would not have it, I had an abortion at 18 and that really upset me. This baby was God’s gift.’ (Megan) [47].‘I trusted them. I handed control of myself over to them. I was completely in their hands’. (Deanne) [45].
‘I just figured it was God’s will whatever happened.’ [40]
Included in the discussion of a greater force, are husbands. In several papers, husbands appear to hold positions of authority over the process as head of women’s families, in the stead of health care professionals. This is discussed within the wider religious context of unassisted birth and predominantly limited to those specific papers [39, 40]. ‘God had answered me. He wanted to show me a different way of doing things. A way that involved faith and not fear, and from that night on we decided that when we had children they would all be born His way. My husband said, “After all, God didn’t seem to be worried that His own Son was born in a stable with only Mary and Joseph present.” I couldn’t argue with that!’ Faye [39].‘They call it “do-it-yourself” home birth, right? Who’s really “doing it,” anyway? Does a doctor bring that baby out, or the Lord? But you know that already! It just seems such a revelation when you finally discover it for yourself.’ [40]
‘I had [my husband] check the position and the station of the baby’s head and to make sure I was complete, which I was, and to also do a quick Doppler scan of the baby’s heart beat.’ [40]. Institutional control is discussed across papers, with health care professionals situated as keepers of control and knowledge, able to harness the process of birth:
‘You’re not actually driving the car. You want the obstetrician to drive the car. That’s what you are paying him for’. (Megan) [45]
‘People were saying, ‘Oh my god, you can paralyze and this and that.’ I said, ‘Don’t worry about it. They know what they’re doing, they’re not paralyzing, you can get hit by a truck tomorrow, too.’ There’s so much misinformation about c-sections.’ [48]
Lagan et al. [28] suggest that a powerful sense of control is gained by women’s information seeking behaviours and this is found across most papers. Many women appear to approach the project of pregnancy and childbirth with the same method of organisation as a ‘work project’ by gathering information and then formulating a plan [26]. Inevitably there are overlaps between a sense of control and the loss of control experienced through the acquisition of information. This will be further explored in the subtheme Knowledge Hell. Information seeking then contributes to the way women seek to control those elements outside of themselves.‘When it’s conflicting...if people are putting different things...it does get a bit confusing but, erm, then I’ll ask my midwife.’ [41]
Information Heaven & Hell
‘You just don’t have any idea what you need to know, and no one can really tell you that, you just have to find it out as you go along…’ (Agatha) [26].
The project of pregnancy
‘my main priority (was that) the baby came out healthy no problems’.
‘expectations were really just to have a healthy baby at the end’. [44]
‘It didn't bother me. It’s just as long as he was healthy.’ (Nancy, hospital birth) [43]
‘My initial concern was telling my parents. I was no longer with my boyfriend and did not want him to be part of it [the pregnancy]. Once I knew Mum and Dad were OK with it I was relieved and settled. It was only later it started to dawn on me: This is going to change my life forever. I’m going to be a mother. How will I manage.’ (Karly) [47]
The result of placing the baby at the centre of birth becomes a discrepancy and experience/expectation mismatch. Women discuss their feelings with a lack of emotional connection – expressing ‘anticipation’ and ‘relief’ [45], and although women appeared to be positive about their choices they voiced experiencing an unforeseen ‘sense of ‘nothingness’ [45]. ‘You get up feeling no different go to the hospital a couple of hours later I’ve got a baby in my arms you feel like you’re at a shop getting milk or something’ (Katrina) [45]‘It was like suddenly she was here and I knew nothing. Before she was born I worried a lot about other things... ‘is she going to die’ I worried about the cord choking her... the business with the placenta, and how it can be left behind... everything I read seemed to point to some other danger, so although I read a lot, I kept myself very busy so that I wouldn’t worry too much... I didn’t let myself think... then when she was born I couldn’t sort of, couldn’t give my 100% attention to the baby, and I didn’t have any idea how to look after her.’ (Jennifer) [26].
‘It’s a little bit different from what you expect all your life. Once she was born and we saw her, the doctor said ‘there you go we’re finished’ and I thought is that all? Is that it? I had a lot of trouble with attachment. I can remember looking at her for several days afterwards and thinking ‘where did you come from?’ (Deanne) [45]
Patchwork of media
This is particularly relevant in relation to the internet searching where general search terms are at the whim of internet search engines:‘The Internet is fast and immediate. I didn’t have to wait until office hours or until someone returned my phone call. I didn’t have to go to a library or bookstore. I could look up information while at work or at home, anytime.’ (Laura, USA) [28].
Women amass copious amounts of information across the data which was met with various responses:‘When I was a kid, my parents were big ‘investors’ in encyclopaedias ... Google is the encyclopaedia of this century. The Internet contains so much information that can be accessed in seconds.’ (Infinity, Australia) [28]
‘. . .if you’ve got something on your phone that tells you what’s going on. . .you are more likely going to look at that than rummage through pamphlets trying to find something when you can type in physically what you want to know and it tells you.’ [46]
‘lot of reading….first pregnancy it was all sort of judged on what I’d read in books’ [44]
Compared with other sources, the internet is viewed by many participants as ‘the font of all knowledge’ [28], women reporting that it offers the wider range of views. Books and magazines are considered narrow in focus, quickly out of date, and costly offering no current accurate information.‘There are a number of books I’ve been doing my reading from during my pregnancy. Each of them are good in different ways. The more books I read the better I feel. Some books cover some things that others don’t. Some also conflict which I think shows every pregnancy is different.’ (Lorraine, diary entry) [47]
‘I was on the Internet all day. Like, any sign I was wondering if that was a sign that I could be pregnant, thinking every month I was pregnant. Or even how to get pregnant, like how long the sperm was in you. I was just constantly on the Internet looking at how to get pregnant and what I should be doing.’ [42]
Drawing on other women’s birth stories regardless of source seemed to serve the powerful function of attempting to engage with the sense of unknowing, women reporting that is was ‘Impossible to be fully prepared’ [26] and that by collecting a multitude of stories were able to dream into the uncertainty of birth, trying out differing scenarios to mitigate the discomfort of the unknown [27, 39, 43].‘I would get concerned with certain health issues, and look up things, I just wanted to know everything about it. I looked up a lot on folic acid because I was worried that I was having too little. I bought a lot of books and read them, but sometimes I looked for more information, like I would read something and ‘Oh that’s interesting, but didn’t give me enough’ and I’d tend to look up more on the Internet.’(Jane) [26]
‘child-birth is an unknown thing you never know what is going to happen’
‘Parenting magazines. I just read them…you read all the birthing stories’ [44]
‘we looked up on YouTube C-section videos ‘cause neither of us knew anything about it.’ [27]
‘[o]nce I got in the operating room ... I saw the images of a woman in my head being cut open, and I was just, oh, my gosh, that’s what they’re doing to me. I was just scared in general. I should have read about it instead, I guess. It was the blood.’ (Lucille) [27]
Knowledge heaven
This creates a safe and unfettered space where women can explore their options, taking control and shaping decisions about how informed they want to be, with women making decisions about birth drawing from both embodied personal knowledges as well as more medically accepted traditions to inform their decisions [48].‘That was very important for me, to be as knowledgeable as I could be about the process that my body was going through. I did read a lot... books, on the Internet, information from the hospital.’ (Harriet) [26]
This means that those birth practices which were considered fringe and unconventional, such as unassisted childbirth, become familiar and more mainstream and a viable choice through increasing levels of media exposure [39], offering broader choices to a wider population.‘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.’ [41]
‘When I found out I was pregnant, I knew that this time I wanted a homebirth. I had just moved to Mississippi, so I didn’t know where to find a midwife. . . . There just wasn’t anybody. Then one day I was online looking at pregnancy stuff and found Laura Shanley’s website on unassisted birth. I couldn’t believe it! I mean, these stories, they were so—they were just like nothing I’d ever seen. I knew then that was what I was going to do.’ (interviewee) [40]
Knowledge hell
Some women commented on the difficulty when sifting through layers of information to uncover relevant facts which can enable effective and informed due to varying amounts of misinformation.‘You’re just inundated with lots and lots of information, I’m sick of reading, everything you read mentions other things you never even thought of....’ (Annie) [26]
Women also reported concerns regarding a lack of background knowledge or framework with which to position this newfound information, often causing high levels of anxiety and confusion, prompting a type of literal fight or flight response needing to encounter more resources or retreat from information all together:‘a lot of pregnancy books are geared towards one ideal or another, and it’s hard to get information that’s just factual.’ (Participant 25). [41]
Therefore, while informal information allows women to be empowered, engaging proactively in decision-making [28] it also propagates fluctuating fears and a certain level of distrust.‘...now I wish I had adopted an ostrich type principle, where you don’t worry so much about it, where you don’t want to be so informed.’ (Jane) [26]
Risk & safety
Mothers spoke of their specific views of the information they collect and how this information gathering led to ‘perceptions of risk and vulnerability’ [26, 45], exploring perceptions of risk and safety and how risk becomes rationalised and incorporated along the decision-making process. The papers which discuss caesarean birth in the absence of medical indication [45, 48], suggest women generally reported either filtering out or ‘switching off’ to risks, that somehow because the surgery was controlled and planned for, women didn’t consider known risks to be applicable to themselves. This is rationalised by women as an issue of choice, and in their consumerism of this mode of birth they reach a sense of informed decision-making and choice, at the same time as often lessening the prospect and potential severity of surgical birth.‘I was a bit overwhelmed with all the things that could go wrong’. (Karly) [47]
Papers discussing unassisted childbirth [39, 40] considered women’s choice to birth unaided as a means of disengaging from the current paradigm of risk averse maternity culture to determine their own spectrum of acceptable risk and safety. Rather than discussing risk in terms of the uncontrollable elements of birth that might go wrong, they spoke of losing their sense of agency and authority over their own experience, as well as the influence of staff actions, drugs and technologies which accompany institutional forms of care on offer.‘Risks? So what? There is risk in everything you do and to me, having a caesarean section presented me with less risk than the vaginal. I felt I was bypassing the risk and so did my doctor’. (Jane) [45]
Women acknowledged that there was a constant state of searching out anything which could potentially propose risk but that this needed moderating:‘in preventing the stress, interventions and routines that come with having a ‘professional’ at the birth who looks for things to go wrong, I know that I will be providing the best atmosphere for things to go right.’ Ernestine [39]
Safety can be found in choice, with some women reporting an emphasis on avoiding certain eventualities of birth such as Fenwick et al.’s [45] paper citing women’s desire to not ‘get all ripped up’ (Deanne) transferring issues of safety to their unborn babies: ‘Your child’s head doesn’t need to be squished like that, and it would not have happened had she had a vaginal bypass’ (Amelia)’.‘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].’ [38]
‘They [hospital staff] were there if I needed help, so I felt pretty secure there [hospital].’ (Nancy, hospital birth) [43]
‘You'd have a better chance of it being natural, a natural type of birth at home, than you would in hospital.’ (Leanne, home birth) [43]
Type and presence of care providers is discussed, noting the strong influence of birth stories which asserted negative outcomes, as well as the risks of adhering to advice from unregulated sources such as the internet.‘I watched a movie on Netflix about hospitals and like giving birth in hospitals ... they told me like once you have an epidural, you can’t move.’ [27]
‘I didn’t go through the midwives only because it was my first baby and I was wary. So I thought I would go through a doctor.’ (Bess, hospital birth) [43]
‘when my brother was born he had a broken nose and a broken collar bone and I was in fetal distress when I was born’. (Sophie) [45]
Although recognized by women, risk was not often overtly spoken about in terms of decision-making, rather some women reported a reversed type of arrival at decisions, where information which didn’t fit into their rational of choice was disregarded.‘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…’ [38]
‘Quite frankly I still don’t know how many risks there are with caesarean section. I wouldn’t have wanted to know about the risks I had made my decision’. (Dee) [45]
Fear
The pervasive nature of images, accounts and information emphasising the ‘horror story’ narrative running through cultural discourses surrounding birth, and the damaging nature of decontextualized snap shots which then become dramatic representations within certain mediums, have lasting effects on women. The result of the previously discussed overload of information is that women report feeling frightened and anxious [27, 28, 44].‘birth is scary and frightening’ [44]
Some anxiety discussed, is based on women’s prior experience with fear arising out of a wish to avoid repeating what went before, or a distrust of hospitals and institutional care models [39].‘I was absolutely petrified of the whole ordeal of the birth itself through the vaginal canal and also a lot of it had to do with the loss I felt, the loss of dignity to the mother at the time of birth.’ (Annette) [45]
According to Flemming et al. [27] nearly all participants experienced visual media as invoking ‘extreme fear’ or ‘pure terror’ responding to an array of birthing videos or internet shows.‘Because I saw the pain! . . . I was like, I’m about to go through this, and I can’t do it. If I hadn’t seen her go into birth, I probably would be like, I can do it. It’s nothing. But I saw it, and I can’t.’ (Participant 26) [41]
Even those women who chose not to access visual information made the choice out of a motivation of self-preservation, knowing that the information would be in some way destructive, one woman describing her avoidance of televisual representations so as to ‘Pretty much not to be horrified before I go the hospital, you know?’ (Tiani) [27]. This is reflected in other papers across the study, regardless of delivery mode, with a dramatised version of childbirth heightening the cultural sense of pathology, which confirms and compounds women’s preconceived understanding that labour is a fearful event.‘[i]t didn’t really help prepare me. It ... made me, – anxious to get it over with because I wasn’t really prepared for the actual birthing part. I thought it was going to be terrible. With TV shows, birth is filmed like they do when they show a rape. The lights dim down, the music changes and show becomes more dramatic. Your heart starts racing.’ (Dana) [27]
Spheres of support
Close ‘in real life’ support
‘My mum had five children my mum told us about being born she had four home births and one hospital birth, so she told me what it was like and what she has gone through so I think that was a big influence.’ [44]
The recounting of maternal narratives from mother’s pregnancies and birth experiences are intended as encouragement and comfort for many women, aiding some women’s capacity to visualise birth in relation to expectations and perceptions regarding mode of delivery [45].‘to think, six months ago I was barely discussing anything with my mother. I knew she was a wise woman, but I didn’t want her involved in my business. Now I want her very much involved.’ (Karly) [47]
Women disclosed the importance of guidance from other close personal relationships when navigating questions of information resources and birthing venues.‘When I was born I almost killed my mother. It was a twenty-four hour labour and she had two hundred and seventy internal stitches’ (Sharon) [45]
‘I mean, there’s a ton, there’s so much information out there when you’re pregnant and there’s so many different books to read. I’ve had several friends who have recommended many of these books to me that have had natural childbirth or been with midwives, so maybe that’s why I’m getting these particular kinds of books.’ (Participant 32) [41]
The power of these maternal and sororal stories and birth narratives cannot be understated with many studies calling for further exploration of the implications of these private dialogues.‘My friend. it wasn’t that she wanted to scare me, but I was asking her to explain to me exactly how she delivered and she’s my best friend and she told me exactly.’ [48]
Outside influences
Virtual shared experiences
The interactions of online forums and social networks allows women to be publically enfranchised whilst retaining a sense of personal anonymity. The sense of freedom this allows is widely reported [27, 28, 40, 42, 46, 48]. While many women do utilise ratified websites such as healthcare and governmental information sources, this is outweighed by the use of commercial and social media [46]. The urge to connect with other women in order to glean insight into birth, especially for those seeking alternative or niche birth choices such as unassisted childbirth, was voiced with expectant mothers finding safety and acceptance on the worldwide web which may not be present in everyday spheres of support [28].‘I wanted to make sure what I was experiencing, was not unique to me, that other women had experienced the same thing.’ (Noelle, Canada) [28]
‘My ‘real-life’ friends didn’t have any experience of pregnancy, so the Internet forums I visited provided me with ‘friends’ who had been through it before, or were going through the same experiences as myself.’ (Nicky, UK) [28]
This level of connectivity gives women entrance into a space of consideration unencumbered by potential disapproval or critique, allowing for a different sense of privacy in which to explore options [28]. The alternative side to this freedom is that women can encounter extremes of the birth spectrum, with stories offering alarming as well as reassuring narratives.‘The Internet. mostly the Internet and the people. Talking to different people. it was experiences because I wanted to hear it firsthand from others. And each has their own opinion or own vision about it so. then you make your own conclusions and you make your own choices on all of this.’ [46]
Online distance also enabled other aspects of pregnancy choice to be expressed, and although predominantly supportive, women reported that this wasn’t always the case, and just as in face to face communities there were instances of interactions becoming passive aggressive in nature.‘You’re the one I’m going to believe, help me out here ... they give you like worst case scenarios and best case scenarios; how common is this really?’ [27]
However, these annoyances were outweighed by the positive responses women felt they received from their peers and the facilitation that these encounters rendered. The range of national contexts and private versus publically funded practice did not seem to have a marked difference in responses from women.‘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.’ [40]
Perceived professional lack
A general perception of professional lack is suggested throughout women’s information seeking journeys. This lack of professional guidance and support is experienced in a wide array of forms. Although reportedly this is partly due to the time constrains imposed by current heath care providers and their systems, this constitutes part of a more complex malaise. The lack of an individualised and meaningful relationship with a known care provider leaves women with an unstable foundation and this subsequent sequalae brings about a lack of trust in not only the health care professional but in the information they provide [28, 38].‘Health professionals often don’t have the time or inclination to explain things in the detail you would like.’ (Leah, Australia) [28]
Routine schedules of care imply a predetermined and professionally orchestrated agenda rather than a woman-centred approach for professional contacts. Women sought to fill this information void by self-generated research.‘. . . it does surprise me, I actually have to say, that the process of the OB/G visits haven’t been as personal as I thought that they would be. I thought my birth plan was something that you sit down with your OB/G and discuss but I’m figuring out this is something that I [have to do] on my own.’ (Participant 47) [41]
Allied to this, there is a reported discrepancy between information received from midwives and that of physicians, suggesting that more options were discussed by midwives than their clinical counterparts [41]. This variation was not only based on type of professional but also on the demographic of participants. It could be argued that this is a positive approach to individualizing care, and that information should be women-centred and respond to each woman’s needs. It is noteworthy that women at either extreme of the childbearing age spectrum are considered to have different informational needs by professionals, appearing to receive an increased level of information or to be curated for differently [26, 48]. The experiences of women across the study report a distrust in professional’s ability to facilitate and enable their birth choices.‘Appointments these days seem very few and far between (every 6 weeks, right up to 36 weeks), and I often have concerns and queries in the meantime which can be found out about, and often resolved, using the Internet. Even with such a fab mid wife, though, appointments are often very short, and although for her pregnancy is a completely everyday matter, for us expectant mothers it is a huge and important part of our lives for 40 weeks.’ (Kerry, UK) [28]
As well as feeling unsupported, women also commented on how midwives were disconnected from women’s own concerns. Women suggested that the internet was valuable for generating conversations with midwives, but that midwives should also be accessing internet sources to better comprehend women’s specific concerns.‘None of them could say whether I could have a water birth. They weren't very supportive of the idea.’ Tracey [43]
Women report hesitation in trusting professional veracity, questioning the advice they receive from doctors and midwives. Historically there is a perception of reliance on healthcare providers, and the emergence of alternative avenues of support and information has eroded the primacy of this position.‘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.’ [38]
This apparent lack of connection with professionals, further fuels women’s need for information and connection outside the professional sphere of support.‘If I had not had the Internet and just had to rely on the information the doctor gave you, I really don’t feel confident that that is all there is to the story. I never feel confident that they are going to tell you every single thing that you need to know. So I thought it was my job—if I was going to do this—to learn about it.’ (Joanna) [42]
Trust
Additionally, acquiring information from informal sources emboldens women’s sense of confidence, not only in questioning the type of information they receive from professionals, but also their faith in professionals’ willingness to share all information with them [28, 42].‘... My health professional had only one opinion and appointments are short. I found the Internet had different perspectives to offer and more current information.’ (Jeannie, USA) [28]
Whilst women expressed feelings of distrust toward professionally provided information, they acknowledged that they were still partially dependent on professional ‘expertise’. Women stated they would access midwives’ advice on issues which they perceived as being ‘serious’ or clinically based [26, 38, 42].‘I felt really empowered having such an amazing resource available from my own home ... it put me in control to a degree, and I feel really lucky that I was pregnant in this decade and not in the “old days” where all info came from a medical professional, who often gave only their OPINION and not balanced info ... I found that if I researched a topic, and THEN approached my doctor, I got a more “honest” answer (more detail). Having the ability to research at home helped me to make informed choices during my pregnancy...’ (Rhianna, Australia) [28]
Empowerment in knowledge
Increasing confidence discussing their care arose from being better informed about issues of import to women, rather than professionals being the keepers of knowledge [42]; making it possible for women to challenge the authority of their providers [38].‘Oh, I think people just rolled their eyes and said, “There she goes again,” because I always want to do things myself and be independent. I can’t stand the idea of giving someone else the power to decide what happens to me!’ [40]
Not only are women empowered through informal information to alter the historical professional dominance, some women also appear to place equitable value on informal sources as those gleaned from professional sources.‘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.’ [38]
Although they continue to place value in their care provider, women consider that their value is equal to their own capability to resource themselves. This is also connected to previous themes of embodied knowledge, that if information found does not align with women’s perception of birth, then they feel stronger to discard it and continue to seek that which is more confluent to their beliefs [43].‘We’ve come to a certain point where we know a lot more than we would have 20 years ago, and we want to know, the risks and all that, so I find that a really difficult question because I don’t know if I could approach it any other way if my doctor didn’t give me enough information I would’ve got it somewhere else.’ (Jane) [26]
Trust in the body
‘It truly was a life altering experience for me, and the most incredible thing ever. My faith in myself as a mother, as a woman, as a human being, went up 200% after that. I just really and truly believe that my body was made to have babies and my faith in it is so strong now. Its almost impossible to put to words.’Lee [39]
‘I had a powerful experience when I was early on [in my pregnancy]. It was home birth of my friend’s . . . I think for me, deciding to go with home birth had somewhat to do with being there at a home birth. . . .That seems worthwhile: I want to be a part of that. I want that. And so early on, we made that decision.’ (Participant 40) [41]
‘My body, and nobody else, knew the best way to deliver my baby!’ [40]
This realization was apparent from those women choosing unassisted childbirth. By gaining control via informal sources, women’s beliefs are confirmed, and as Freeze suggests ‘women are becoming anti attendant and their thought processes are that if they trust the process 100% then nothing bad will happen’ [39].my sister and my mum and my aunty and everybody else you know had babies ‘in lifts and all sorts of things so I expected it to be easy’ [43]
‘I started out with the plan to have a nice homebirth with a midwife. But after reading all the books, I just thought, hell, I can do this. I’ll just be a midwife to myself!’ (Interviewee) [39]
Other women placed trust in the fact that they would be able to birth but acknowledged that it would be an experience to endure.‘I was simply listening to what my body was telling me and following that without question.’ [40]
‘I was expecting a very painful and long childbirth and I was expecting quite a lot of medical intervention’ [44]
Some women absent themselves from the process because of a lack of trust in their ability. By avoiding undergoing the process of labour women’s choice to elect caesarean birth negates the possibility of perceived failure.‘Awful! I really expected it to be extremely painful because Mum said her labor was 23 hours for her first, which was me, and I was really scared. But it wasn't as bad as I thought it was going to be.’ [43]
‘She had a second child and had it planned right, so like I called her up and said, ‘When’s the baby due?,’ and she was like, ‘Oh you know, like July 1st at 3:15.’ And I’m like ‘What?,’ and she’s, ‘Oh we’re planning it this time. If I couldn’t do it the first time I’m not doing it the second time.’ And starting from then, I sort of went, ‘Oh, what a civilized way of doing it.’ [48]
Evaluation & Common Sense
‘Yeah so you kind of have to do a certain amount of self-regulation I think.’ [38]
This trawling for common sense is based in process and purpose, however what is often discovered are feelings of communality rather than a commonality of understanding. This communality serves an emotional deficit but does not constitute a rigorous base from which to create decisions. There is a persistent lack of women applying standards of quality to information they interact with. Thus, it is only women’s own ability to critique the incoming barrage of material in relation to their own position that is used to prioritise information for inclusion or exclusion.‘They put the scariest ones or the worst ones on television. And it didn’t really help prepare me. It just kinda made me, you know, more – I don’t know – anxious to get it over with because I wasn’t really prepared for the actual birthing part. I thought it was going to be terrible.’ [27]
‘It’s just that some things...you know when to Google and not to Google’. [38]
Arguably the process of determining credibility increases women’s vigilance to their own experience of pregnancy. The papers demonstrate that beneficial knowledge can be gained from an increased confidence in negotiating informal information, especially that sourced online [28, 38, 42]. This is also based on how women choose to situate the found ‘evidence’ within their embodied knowledge base [48]. Women still struggled with a lack of comprehension and advanced information seeking resulting in concerns not previously considered [26]. The filter of common sense relates to the impact of found information, yet not always applied to knowledge which was considered fear-inducing.‘[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.’ [38]
‘I would stop searching when I thought that I had enough information to make an informed decision/opinion.’ (Susan, Australia) [28]
Song et al. [42], also suggests that the process of women becoming informed allows them to ‘prove’ themselves as informed patients, representing culturally favourable ideals of positive mothers as a result, all contributing to women’s decision-making capacity.‘Stopping searching for me was often more to do with being satisfied that I had learned all I could on the topic (a bit like knowing when you’re full at the dinner table).’ (Tania, New Zealand) [28]