Background
Social media is a highly prevalent form of communication, used by nearly two thirds of American adults [
1]. Parents use social media at even higher rates than the general population, to seek advice, share experiences, and receive social support on parenting-related issues [
2], For mothers, whose new role may limit free time [
3], social media can be an important and accessible means of communication and social support. In a study of Facebook use during the transition to new motherhood, most women logged into Facebook daily and many women reported increasing their Facebook use after having a baby [
4]. In addition to using social media to connect with their existing networks, mothers of infants join social media groups on a variety of parenting topics including breastfeeding [
5], prematurity [
6], and new motherhood [
7].
Through the growing use of smartphones, the “digital divide” of Internet access based on socioeconomic status has narrowed [
8]. Low-income new mothers frequently use Internet sources, including social media sites (i.e. Facebook, twitter), to find health and parenting information during the newborn period. In addition, social media may be a particularly useful source of information for low-income mothers as they have have more unmet health information needs in the newborn period compared to higher-income peers [
9].
Despite the high prevalence of social media use among parents of all income levels, little is known about the content and quality of parenting and health information shared in these networks and whether this information is in keeping with expert pediatric recommendations. Prior research on social media parenting groups has focused primarily on the social support [
6,
7,
10‐
12] that such groups can provide. To our knowledge, this is the first study assessing the accuracy of the health content shared in a social media parenting peer group. This study is focused on lower-income women; however, it is unknown if higher-income new mothers differ in their social media posts since the literature is limited on this topic. Regardless of the mother’s income status, knowing the accuracy of the information shared is important. As clinical practices integrate the use of technology, informational posts or moderated peer groups through social media platforms may offer opportunities to address misinformation.
Also motivating the present study, the accuracy of pediatric health information in internet sources other than social media has been found to be highly variable [
13‐
18]. For example, one study reviewed 1300 websites with information on infant sleep and found that 28% provided recommendations contrary to American Academy of Pediatrics (AAP) recommendations on safe sleep [
15]. In addition to guideline-inconsistent information on infant care from internet sources, family members of infants are reported to commonly give mothers advice contradicting recommendations about sleep, breastfeeding, immunizations, and pacifier use [
19].
This study examines the content of health and infant care information shared in a social media parenting group for low-income mothers. After the birth of a baby, mothers often face new pressures as they adapt to their role and acquire new skills. Social media groups offer a unique window into the lives of mothers and are a means of observing how pediatricians’ guidelines may or may not be discussed or practiced in the community. These observations may help pediatricians offer more practical and actionable guidance and support for mothers during this phase of transition.
The objectives of the present study are to: (1) identify the types of health questions asked by low-income mothers of infants in a social media parenting group; (2) describe whether peer answers are consistent with or contradict AAP guidelines; (3) identify the practices that mothers post about that are inconsistent with AAP guidelines.
Discussion
The Grow2Gether Facebook group intervention offered a unique means of observing the concerns, beliefs, and practices of low-income mothers of new infants. Though prior work has described low-income mothers’ self-reported internet and social media use [
28] and the social support received from such groups [
6,
7,
10‐
12], this is the first study that examines the content and accuracy of information shared in a social media parenting group of low-income mothers. Prior work has shown that mothers considered the Grow2Gether Facebook group a supportive environment and mothers actively engaged in the group, posting an average of 30 times per week [
20,
21]. Mothers were eager to both ask and answer infant health questions in this setting. Answers given to other participants’ questions generally neither endorsed nor contradicted AAP recommendations. Simultaneously, however, parents commonly posted photos and comments that demonstrated practices or beliefs inconsistent with AAP recommendations.
Two infant-care topics emerged as areas where mothers commonly posted practices inconsistent with expert recommendations. First, though there were relatively few questions about sleep, this was the topic with the most posts and photos demonstrating practices inconsistent with AAP recommendations. Specifically, mothers frequently posted photos of infants co-sleeping, sleeping prone, sleeping on unrecommended sleep surfaces (i.e. adult bed, sofa) or sleeping with unrecommended items (i.e. bumpers, pillows, loose bedding). Our findings are consistent with recent work that used nocturnal video recordings and documented high rates of unsafe infant sleep practices even when families knew their actions were being recorded [
29]. Similarly, in our study, participants knew a moderator was reviewing their posts, and the Grow2Gether intervention curriculum included a video that reviewed the AAP safe sleep recommendations. Posts depicting unsafe sleep practices were common even after this video was shared. These observations of unsafe sleep practices are concerning given that the racial and ethnic disparities in sudden unexplained infant deaths (SUIDS) may in part be due to differences in adherence to these safe sleep practices [
30‐
33].
Similarly, mothers did not ask any questions about the appropriate use of screen time or media for their infants. Posts or photos depicting infants using screens were quite common in the Facebook groups despite the AAP recommendation in place at the time of this study, which discouraged screen time for children younger than age 2 years [
34]. Of note, this recommendation was recently revised to discourage screen time for children younger than 18 months of age [
35]. The frequent posts of infants engaging in screen time are consistent with a prior study that found nearly universal exposure to screens among young children ages 6 months to 4 years [
36]. This is important because exposure to screens and media during infancy is associated with sleep disturbances [
37] and lower congnitive and language development [
38,
39].
Though mothers report high levels of trust in their pediatricians on infant care topics [
40], our study demonstrates that, even in the context of an infant care intervention, families often do not put expert recommendations into practice, particularly with regard to safe sleep and media use. Importantly, however, parents were open about sharing infant care practices that were inconsistent with AAP guidelines, even in the context of a clinical research study being implemented by a Children’s Hospital. This study did not assess why mothers in our study did not follow AAP-recommended practices. Parent behaviors and beliefs regarding expert recommendations may reflect a lack of awareness or disagreement with the guideline. Additionally, if mothers do not have social support at home or work, there may be practical difficulties with implementing guideline-based parenting practices. In addition, the majority of the women in our study are of racial/ethnic minorities; implicit bias of physicians towards minority adults and children has been well documented [
41‐
45]. Healthcare providers have been found to be less likely to discuss important perinatal health issues, like breastfeeding, with African-American mothers [
46] and maternity care practices supporting these behaviors may be lacking in regions with higher numbers of African Americans [
47]. Inconsistent healthcare provider reinforcement of AAP endorsed behaviors may have contributed to recommendation-inconsistent practices. Lastly, pediatricians are not the only source of advice on infant care practices, and families may receive conflicting advice from other sources [
19].
Further research on the barriers to implementing AAP recommendations regarding safe sleep and screen time may allow pediatricians and others to deliver messages that are more readily and consistently implemented by families. For example, in a study about messaging on safe sleep recommendations, families who received messages framed in terms of both suffocation prevention and SIDS prevention were less likely to use soft bedding as opposed to those who received messages about SIDS prevention alone [
48]. Moreover, social media platforms utilized in clinical settings may offer pediatric clinicians an opportunity to identify and discuss problematic infant care behaviors and practices with parents. The use of social media by diverse groups of parents is well-documented [
1]. Future research on social media interventions should ensure the adoption of healthy behaviors for women of racial and ethnic minorities as well as those from other groups. In addition, efforts are needed to ensure that supportive groups are available to new mothers, regardless of background.
This study has several limitations. First, the Grow2Gether curriculum, which included content on safe sleep, screen time, and feeding, may have influenced mothers’ beliefs and practices to be more consistent with AAP recommendations, and it is not known what their practices would have been without this intervention. Second, although we know mothers actively engaged and posted in the group, we do not have the means of assessing specifically whether mothers viewed the video curriculum. Third, the presence of the group moderator may have resulted in social desirability bias, and participants may have been hesitant to post photos demonstrating practices or questions contradicting the group curriculum. Still, many guideline-inconsistent posts and practices were recorded despite the Grow2Gether curriculum and presence of a moderator. Fourth, though our sample size was large enough to achieve thematic saturation, the sample was drawn from an infant care intervention for parents from one urban area, so results may not be generalizable to other settings. Fifth, the data examined only the information participants chose to share on social media; we do not know the content of the advice given or practices followed outside of social media. However, prior research suggests that social media posts can be predictive of behavior. [
49] Sixth, since there was a small sample size of first time mothers (
n = 8, out of 43 total), thematic saturation was not reach for this group and we were unable to draw conclusions about how first time versus multiparous mothers used the Facebook group. Seventh, we do not know what other Facebook or social media parenting groups participants may have been members of and the information shared in those channels. Last, since the focus of the present study was on interpreting posts in keeping with professional guidelines, we did not review the codes and themes with participant mothers. Development of future work with social media would benefit from validation by study participants.