Portrayals of Childbirth : An Examination of Internet Based Media

More pregnant women turn to reality-based television programs and the Internet than to prenatal classes. Scant research examines the portrayal of childbirth in these new media. Although its impact is unknown, we do know that up to 20% of pregnant women fear giving birth; consequences include avoiding pregnancy, termination, depression, and increased maternal morbidity. Overall internet content tended to be contradictory but largely reflected two categories: natural and mainstream, with two different portrayals of childbirth. Natural sources focused on eliminating fear, discrediting hospital births, and promoting  ‘alternative’  options  such  as  homebirth  and  midwifery.  Mainstream sources reinforced fears, discredited home births, reported statistics from studies, and employed misinformation. Popular Internet sources tended to have the goal of educating whereas media uncovered in the purposive searches tended towards entertainment goals. Conflicting and misinformation from the Internet may entrench rather than assuage fears. Women may become confused and develop a heavily biased representation of birth. This could strongly impact a woman’s  approach  to  and  experience  of  birth.


Introduction
Women spend an ever-growing amount of time on the Internet.Media analysis shows that the Internet affects how people communicate and live (Kung, 2008).It has also found traditional media including film, television and print misrepresent childbirth realities (Karpf, 1988).Despite this inaccuracy, more women turn to birth shows than prenatal classes (VandeVusse, 2008).Many also go online for information.As a new trend, scant research exists that evaluates Internet portrayals of childbirth.To learn about women's childbirth choices, it is important to evaluate their information sources-including online text and video.
Twentieth-century medicalization of childbirth has resulted in a loss of community knowledge creating an information void-enter popular media.Many women develop 'experience' of birth through TV, magazines, or web browsing.Many children also learn about birth this way (Kitzinger, 2001).Media analysis shows pregnancy and childbirth are often portrayed as risky (Seale, 2002).A consequence may be a fear of birth.
Tokophobia-pathological fear of childbirth-is characterized by avoiding pregnancy, termination, depression, increased morbidity, and elective caesareans (Hofberg & Brockingston, 2000;Hofberg & Ward, 2003).Although it is reasonable to have some fears and anxieties during pregnancy, especially the third trimester, tokophobia is debilitating (Hofberg & Brockingston, 2000).This little understood phobia affects women young and old: Over 20% of pregnant women report fear and 6% describe a fear that is disabling.Altogether, 13% of non-gravid women report fear of childbirth sufficient to postpone or avoid pregnancy (Hofberg & Ward, 2003).
With many fearful and tokophobic women, it is not surprising that suicide is the leading cause of maternal death (Hogberg &Ward, 2003).This fear is in part due to secondhand "knowledge".Many women report fear originating from alarming publications, sex-education videos, or 'horror stories' (Melender, 2002).Some state they must leave the room if a childbirth scene is on television (Sadie, 2007).With a potential link between media and tokophobia, it is imperative to understand the media's portrayal of birth and its impact.
Media studies show television can alter viewer perception and behaviour (Clement, 1997).Change in behaviour after watching certain programs has also been observed.There is evidence that "people alter their estimates of real-world phenomenon in line with television statistics" (Clement, 1997).Women thus perceive great risk in pregnancy and delivery, possibly linking tokophobia with the media.Unfortunately, few studies on childbirth in the media exist, so the true impact of watching clamorous labours is undetermined.Internet studies are surprisingly rare (Seale, 2003) given that pregnant women acknowledge Internet-use as a significant source of information.This study will begin to fill the research gap regarding the portrayal of childbirth in online media.

Research Questions
1. What are the different portrayals of childbirth on the web?
2. How has Internet media influenced women's perceptions of birth?
3. Does the Internet contribute to a cultural fear of childbirth?

Methods
To discover different portrayals of childbirth on the Internet, and analyze their relation to fear, a broad qualitative approach was undertaken involving web searches for video and text-based information.Both popular and purposive searches were undertaken.Popular searches evaluated the most frequently occurring results of keyword searches.Purposive searches evaluated television programs-A Baby Story, Baby Week, Deliver Me-and magazines that are available online.This merging of other forms of media with the Internet is becoming increasingly popular and was therefore important to include in this study.

Data Collection
Data collection was intended to mimic searches by childbearing women by using search terms suggested by Google and YouTube.Popular text and video were found using these common searches.
Purposive searches included known popular sources.Sampling also evaluated other media including magazines and online versions of television programs.
Inclusion criteria included English and intrapartum 1related content only.Exclusion criteria included blogs, advertised results, PDFs, 'about us' sections, animal birth content, links to external content, pregnancy and postpartum information, news articles, Google results other than 'web' (video, news, scholar etc., academic results, and websites created by midwives, doulas, hospitals or birth centers to recruit clients).Organization websites were included unless selling an item or service.Many sites were dedicated to a book, DVD, etc. and were excluded as their purpose was to sell items rather than inform the public.Those selling a wide variety of items were included in this study as these web pages often sold products from other companies and did not have a vested interest.
Appendix 1 includes URLs and each search's assigned code.

Data Analysis
While searches took place a formal qualitative analysis was conducted.Notable themes, quotations, and information were recorded on coding sheets and a frequency table.This record provided insight into online childbirth portrayal.
Each media source was compared against an analytic/ thematic template.Codes were determined based on the existing research and emerging issues such as the location and safety of breech delivery.Blank spaces were left on the coding sheets to allow the addition of further unanticipated/emerging themes during the data collection process.The first time a topic outside the coding template arose it was included in a blank space of the table.Because these themes were added during the data collection process as they appeared it is unlikely content was missed in earlier data collection.Most changes to the thematic template involved restructuring or reordering the codes.In these cases it was unnecessary to return to data to rerecord information.Both key and representative quotations from data sources were recorded in these templates.Collecting the quotations from ten articles provided sufficient evidence of the tone of the websites and examples of knowledge depth.
Frequencies of codes were also recorded throughout the data collection process.Each search category (magazines, Baby Week, Deliver Me, A Baby Story, popular video and popular text) was recorded separately.The same thematic template used for collecting quotations was used in tabular form.This table will be presented and discussed below (Appendix 2).

Common Themes
Themes throughout all media are most likely to be discovered by average consumers, likely having the greatest impact on childbearing women.Common themes were identified based on their presence in all search results.

Host country
Websites and videos were hosted from many countries.Magazines and popular text came from the US, New Zealand, UK, and India with the US and UK most prevalent.Not limited to Canadian content, little mention was made of birth in Canada;; thus, not all sites' information is applicable to Canadians.
UK and New Zealand media discussed TENS 2 machines atlength.The following account describes its use during labour: I used the TENS 2 machine for the majority of my delivery, and it was a fantastic device.I felt a sense of control during the labor because I was able to adjust the knobs as I desired, to experience more or less of the currents as I needed it.It also gave me something to focus upon and to do during the long hours of labor (Popular Text [PT]

10).
Despite this discussion, TENS machines are not a common option for Canadians.A woman wishing to use the device must supply her own.

Natural vs. Mainstream content
Two types of content emerged from all searches: what I will refer to as natural and mainstream.Both text and video sources could be divided into natural or mainstream categories.
Natural content highlighted women's ability to give birth without intervention or complications.These sources also emphasized eliminating fear, discredited use of pharmaceuticals and the generally medicalized hospital birth environment, promoted 'alternative' options including homebirth, midwifery, and in some cases, unassisted birth.For example: If the mother experiences a lot of pain during labor in a hospital, she will probably be given pain medications, even if she doesn't want them and is trying to have a natural delivery (PT8).
Mainstream websites focused on hospital birth and audience education in procedures and interventions.These tended to promote fears through topic selection, vocabulary, and commentary.They also discredited homebirths by citing out-dated information.Misrepresentation of literature was common in mainstream content.As consumers are unaware when authors cite out-dated or questionable studies, any reference implies validity.Referring to disproved literature is one method in which misinformation was employed.The following describes a procedure sometimes used in labour, however, justification for which is based on old inaccurate literature: An episiotomy can considerably shorten the time-consuming, painful and pushing stage of labour.It prevents injury to the muscles of the vagina and perineum and protects the foetal head from being compressed through a smaller opening… Moreover, it is certainly better to have a proper incision made rather than suffering a vaginal laceration (PT5).

Text and Video: Key Differences
Many themes pervaded popular and purposive searches, but differed in text and video sources.Commonalities between popular and purposive searches include in-text references to media portrayal, omissions from video, and viewer comments.Because text and video are seen regardless of search type they likely arise in pregnant women's internet searches, making them important to understand.

In-Text Reference to Media Portrayals
Many of the analyzed textual websites referred to media warping the process of birth: You might think that you'll be most comfortable lying on the bed, perhaps because you've seen lots of women in labour on the TV doing so; however, keeping as upright as you can will help your labour to progress and will help you and your baby to cope better during labour (PT2).
You will hear (particularity on the internet) about how awful inductions are from some women, but others report it being not much different to when they went into labour on Such generalised media analysis is a common theme.Authors may refer to media depictions of birth to make their article sound more authentic, and to discredit opposing claims.Controversial topics such as the safety of epidurals appear especially vulnerable to this type of authentication.For example: While the Internet has immeasurably increased the quantity and accessibility of medical information, it has also fostered the spread of misinformation about pain management and childbirth… Pain management has no effect on labor, except in rare and exceptional cases… Contrary to claims frequently cited on the Internet, there's no credible evidence to show that epidurals or other forms of pain management slow speed of labor, lead to Cesarean sections or are associated with a higher incidence of depressed infants (PT1).
This quotation sounds convincing, but is not evidencebased.The literature states the opposite: epidurals slow labour, lead to caesareans, and cause the infant to be "sleepy" (Mauberry, 2002).

Video Omissions
Several codes were recorded amongst text-based content (magazines and popular text) that were absent or rare in video content.No topics observed in videos were absent from text.This is likely because texts are intended to inform whereas videos more often seek to entertain.Table 1 shows themes present only in text.A major consequence of video omissions is promoting fear and distorting when labour ends

Emphasising the unlikely
Episiotomy is discussed 20 times in texts but never seen in videos: Vaginal birth injury with visible tears or episiotomies are common (PT9).This is likely because displaying an episiotomy on video would require showing an incision of women's genitaliaavoided for privacy or viewer-rating reasons.There is, however, an option of discussing the procedure on film as it takes place or afterwards.This was not included in video, possibly due to the procedure's rarity.Episiotomy, once routine, is seldom-used and only in emergencies.It is therefore expected that they are absent from video or text discussions.Their widespread discussion, without demonstration, may lead women to fear what is highly unlikely to happen.It is also worth noting that episiotomies are rarely performed in today's birthing practices, yet are discussed as often as common procedures such as induction or caesarean section.This may be due to fear that women have of episiotomies.No website, however, commented on their rarity.

The end is not the end: Stages of labour
The stages of labour were often discussed in text in conjunction with information regarding childbirth education.Textbook examples of the three stages of dilation and the stages of labour ensue.Not observing a woman in distinct phases of labour makes for a skewed image of labour and delivery.Videos often only show women in transition and stage two -pushing.This suggests labouring women are in intense pain throughout the process.Nuances in the timing and intensity of contractions go unlearned.This information does not create 'drama' and thus is excluded from videos.
The placenta is discussed 8 times in text and not at all in video.Text discussed its importance to the foetus, and its expulsion in the third stage of labour.This stage is omitted from videos, and labour is instead shown to end at the second stage.The third stage is an important part of birth.
Many complications, such a haemorrhage, can occur in this stage.Fear would not explain this omission as expelling the placenta is not painful.The sight of blood could explain the placenta's absence.

Viewer comments
Comments on videos often referred to pain during labour, expressing surprise if the mother was not "screaming":

OMG!!!!! I'm never having kids! (PV6) I'm amazed at how calm the mother is. I would imagine she would be screaming her head off at this point (PV7).
Oh no giving birth it's so painful.I don't even want to remember it's painful but real beautiful when u see that baby (PV5).
This suggests that many viewers are unfamiliar with the birthing process and fear the pain.Misinformation was common in comments: If I got pregnant I would like to give birth at home too.I was born at home.Risky but so natural (PV7).
Here homebirth is considered less safe than hospital birth-a common myth.Some comment threads include attempts to correct misinformation.This was often done in a judgmental way, and was just as likely to be misinformed: Many viewers were misinformed and demonstrated fear of childbirth.This suggests that popular Internet video does not provide deep understanding of childbirth.Women who feared childbirth appeared either surprised by the calmness of a labouring woman or had fears confirmed by misinformed viewer comments.

Popular and Purposive Searches
Overall, popular searches presented a more balanced portrait of childbirth likely due to education goals.Conversely, the goal of drama and lack of concern over fears and accuracy distanced the purposive samples from the popular.Conflicting information was more common in popular searches though it did occur in the magazines.The natural / mainstream duality was observed across both purposive and popular searches with natural content being more common in popular media.
Topic frequencies can be found in Appendix 2 but will not be discussed at length as their importance to viewer searches relies heavily on which type of search a woman conducts.Thus, general conclusions cannot be formed.

Discussion
The Internet is a popular information destination for pregnant women.For this reason evaluating its accuracy and portrayal of childbirth is important.The findings and implications of this media analysis are discussed below.

Childbirth Portrayals
This study examined ways in which childbirth is portrayed in online media.Many portrayals of online media were found.Content could be divided into popular/purposive, text/video and mainstream/natural.Similarities were found across all media, but the differences have unique implications for childbearing women.These differences likely result from competition for an audience.

Media's Influence
With an infinite amount of content online, webhosts must compete for audiences.Competition is divided between natural birth and mainstream, video and text, as well as magazines and other texts.Each medium approaches childbirth differently.Beyond the mentioned divisions, sites part further between popular education-driven sites and purposive entertainment media.Competition for consumers has resulted in an invisible battle between hosts.
Information from one website to another often conflicts such as the safety of pain medications.Authors resort to strategies such as citing academic journals, credible or not, and referring to media misrepresentation to gain an edge over competitors.The effect of this background battle on consumers is little known.Comments related to videos suggest women are misinformed and scared about childbirth as was seen regarding the safety of homebirth.More research is needed to determine the effects of the internet on women's perceptions of childbirth.

Cultural fear of childbirth
Media analysis shows that childbirth is portrayed as risky for mother and foetus (Seale, 2002).This theme is reflected in Internet content in a more complex manner.As on television, women frequently discussed fears of labour, pain being the most common.Purposive content furthered this fearful portrayal by adding physicians' fearful commentary or dramatic narration.As this content originated as television and magazine media, it is possible that these representations have a more fearful overtone.
Popular searches acknowledged the culture of fear around childbirth and attempted to alleviate it by informing readers.This portrayal of fear is quite different from that commonly seen on TV and in the purposive searches.Despite the presence of articles directly targeting fear, others directly contributed to fears.Discussions of interventions, infant deaths, and pain management all had an air of danger.
The natural birth oriented webpages are most likely to be successful in empowering its readers to not fear childbirth.They focused on a woman's natural ability to give birth, as opposed to the mainstream question of whether a woman will be able to endure the pain.
It is thus possible that the Internet contributes to society's fear of childbirth.With such a wide spectrum of portrayal, the fear a woman experiences regarding birth is likely to depend on which type of internet media she subscribes to.
To fully understand to relationship between Internet media and tokophobia, more research is required.

Methodological limitations
The Internet, an interactive medium, changes daily.Content analyzed during this study will change over time.Each month, magazines post new articles, new websites and new searches will become popular and viewer comments will change.Although unproblematic in the short term, this will render the results obsolete in the long-run.
Text and video provided different amounts of information making it impossible to quantify data.Frequencies gave only a qualitative sense of themes that are addressed or ignored.
Implications from this study could only be drawn based on existing research and viewer comments.To fully understand the implications of childbirth media on women, further studies are required.

Future Research
The scale of this study presented some limitations.A larger study should be conducted to examine more specific search terms that women would frequently use such as common interventions and diagnoses.A study of what women tend to focus on in searches and self-education would also be useful.
As mentioned above, further studies are needed to determine the impact of study findings on childbearing women.Fear and misinformation should be given particular focus.
Online childbirth education classes are becoming popular amongst childbearing women but were not included in this analysis.A study should be conducted comparing these classes to classes offered by hospitals and childbirth education organizations.
Further forms of media such as news stories further influence the Internet's portrayal of childbirth.Again, due to the small scale of this study, these sources were excluded.
As much of the content analyzed was from international websites, a study of exclusively Canadian sources ought to be done.Since Google has an option to search only Canadian content, some women may limit their searches in this way.Misinformation due to foreign sources of selfeducation media would be eliminated from such a study.

Conclusion
This study shows there is wide variation in online childbirth portrayal.From unassisted birth to cascading interventions, each portrayal of childbirth has its own set of implications.Misinformation and conflicting information were found to be quite common.Viewer comments suggest that audience members are confused about childbirthperhaps from this tangled web of misinformation.Further studies should investigate this relationship.The competition to attract women to particular websites may cause of the vast amount of conflicting information.Website authors discredit other media and cite literature to make their website stand out.These messages tell women that each website is authentic, whereas all others should not be trusted.As communicators are granted the ability to shape their information environment, individuals, organizations and public bodies each want a piece of the Internet (Ward, 1993).Search results show that each portrayal of birth takes a different angle in attracting and maintaining an audience.Each source portrays birth in a particular way and these particularities have an important effect on women's attitudes and childbirth choices.

Notes
[1] During labour and delivery.
[2] A transcutaneous electrical nerve stimulation (TENS) machine sends small electrical pulses to electrodes placed on the skin.During labour, the electrodes are placed on a woman's back to relieve pain.
[3] Hypnobirth is a method of childbirth education that focuses on birth guided by natural instinct and selfhypnosis techniques (HypnoBirth, 2009).

Table 1
Frequency of topics in Text vs. Video: Content (Popular and Purposive)