1. Introduction 2. Method
3. Historical Overview of Maternity Care in Ireland
3.1 Period of Antiquity
3.2 The Enlightenment
- 4. Current Debate
5. New Media Technology
5.1 Descriptions- The digital age and childbirth
5.2 Professional use of new media technology
5.3 Parental and NGO use of new media technology
5.4 New media technology as a tool for changing maternity services?
6. Summary and Conclusions 7. Appendix
7.1: Names of all participants
7. 2: Questionnaire
7.3: Table of results
Undertaking this research paper has been an interesting journey, one which has enabled me to delve into an area of great interest to me. Maternity services are undergoing a tremendous shift from both a societal and health professional level. In the last year I have had the privilege to research and document the highly politicised debate within Ireland and around the world. Whilst conducting the research I explored the forums, blogs and Facebook pages which are frequented by mothers and professionals and came to see how the internet is being used to access information, as a means of advocating for change and for communicating information to those new mothers who are isolated and in need of expert support and advice.
I would like to extend appreciation to my supervisor, Colin Sumner for the patience required to help me unravel and focus my thoughts, to Jason O’Donnell for his philosophical inquiry, to the Midwives, Doctors and parents who partook in the research and of course, to all the babies who are being born without a care or second thought about new media technology.
April 20th 2013.
- 1. Introduction
The report presented here is the results of my research on the changing face of childbirth and the use of social media. It has been carried out as the final project for my Sociology BA at the UCC where I have studied for the last three years. The objective of this research was to make an inventory of how social media is currently being used and to identify potential avenues for all users and service providers.
The survey, therefore has aimed to represent the different divisions and perspectives within maternity care. The results come from new mothers, Consultant Obstetricians, Independent Midwives, Hospital Midwives and health care coordinators. This study started in September 2012 and was completed on the 20th April 2013. The questionnaires were sent out by email to participants of the study on the 11th March 2013 and were all returned by the 10th April. By reviewing the Association for Improvement in Maternity Services (AIMS) 2009 survey I have provided an analysis of what women want and what they themselves as the service providers think. In addition, taking an historical perspective has been fundamental in gaining an understanding of the cultural perspectives which affect current debate. As presented, we see there has been little or no change in the entire period reviewed. Because of the nature of new media and its ever changing ‘face’ this paper also investigates some future possibilities in relation to the services. This is why a wide range of personal and professional backgrounds were chosen to participate in the research, of which will be discussed more fully in the next chapter on methodology. Through doing so I have attempted to present the dichotomy between women’s choice of where to give birth and who provides the care within the increasingly medicalised and litigious ‘risk’ society which I believe will eventually see Independent Midwifery and home births become a profession of the past that is forced to make way for complete obstetric practice.
This paper consists of seven chapters, each with their own sub headings which methodically take us through each step and background with clarity and logic. In chapter 2 the methods of the study are discussed. A detailed account of the history of maternity care and obstetrics is provided in chapter 3 as well as a full detailed analysis of the current debates both within Ireland and further afield in chapter 4. Discussions of new media technology and each respective use is examined in chapter 6 with findings from the research quoted throughout. The researcher summarises and concludes findings in chapter 7 with the appendix providing the questionnaire and results in table.
The purpose of this study is to describe the current debate in maternity services in Ireland and further afield with a specific focus on the use of social media as a means of communication. The study proceeded in several phases. I decided on questionnaire based research with the intention of a combination of closed (Positivist) and open (Interpretivist) questions which explores the different possibilities of two methods whilst also encouraging more information of an experiential nature to aid further research at a later date. I chose to conduct these questions by email so the participants could think about their answers and reply without any external influence which I may yield.
By means of desk research the historical perspective, current debate issues and literature review (referred to throughout) were completed first. Once I had this compiled I saw that there was very limited information on the use of new media technology specifically in relation to maternity care). I devised a questionnaire that could be sent out by email to 10 people from varying backgrounds (all of whom are connected with maternity care.) Each participant was asked to fill out the same questions at their leisure. I kept the questions short and concise in order to make it not too time consuming for those with high work load. I received 9 out of 10 questionnaires back within a month.
The subjects that were discussed were
- How they make use of social media/ new media technology at present.
- Thoughts on how to make better use of new media technology.
- What their thoughts were on accessing information on maternity care through new media communications.
- The future of digital technology within the maternity context.
The returned forms were then read through and specific points picked out which indicate the need for more use of the technology to be implemented but also more training and guidelines about how to provide the service.
The results of this study are presented within a table in appendix 3 with a summary in section 6.
One of the pitfalls of this study was that the questions focused solely on the use of new media technology. I could have asked much wider questions which related to the future of Midwifery and birth technologies. In retrospect I would have added a full review of the recent study conducted in Finland by the health service where they have successfully implemented new media technologies into their mainstream maternity system, after completing the current debates I was in danger of starting a much larger project than was possible. I acknowledge now that the prior knowledge of digital technology for communication (specifically within the maternity services) is extremely limited and training and education, if these technologies are to be used in the future developments is required. This is a problem which once identified can easily be overcome by including training within this area to new Midwifery and medical students coming through the system, who will most probably be digital natives and find it easier to navigate the ‘systems’ easily and quickly whilst teaching the older professionals as they go. Because of the time and word constraint the survey was limited to only 10 participants, all of whom are based in Cork. There is research from Australia, New Zealand as well as Finland which would benefit from further and more detailed analysis.
- 3. Historical Overview of Maternity Care
By providing an historical overview of the evolution of Midwifery we gain a deeper understanding of contemporary issues and where the seat of power, knowledge and control stem from. I feel this is a crucial aspect to writing about any area of intricate significance.
3.1. The Period of Antiquity
Although Foucault places the birth of modern medicine in the 18th century (1976, p xxi) Macadam Connell (1993) feels, in respect to midwifery it is important to go back to the period of Antiquity when childbirth had a natural place in the order of life and death. Probably influenced in this period by rituals and taboos, childbirth was not yet influenced by the separation of ‘mind’ and ‘body’ which made the body an object of study and domination. Early Christian teachings portrayed women as inferior, unclean and without a soul and all bodily functions including childbirth were seen as ‘bestial’ and ‘brutish.’(Thomas, K. 1983, 43) A combination of the philosophical revolution and church doctrine began the process of separation. The philosophical revolution of the 17th century began a separation of “humanity from nature, Mind from Matter, Rationality from Causality” (Macadam Connell, B. 1993, 12). This split is where modern science began and of crucial relevance to the practice of Midwifery. The Royal Charter of 1660 bestowed privilege to those who pursued this line of study and all other sciences which challenged the conservative attitudes of the period were purged from the universities, a place of education for the elite and predominantly male lecturers and students. The founding of the Royal Society for the Advancement of Science in 1662 succeeded in institutionalising the empiricist and mechanical science and ensured that science would develop along these lines. With science becoming objective knowledge, medicine became a distinct discipline and the property of medical practitioners. The significance of this period is that from the 17th century onwards the motive of progressive science was to “pursue ‘rational objectivity’ of a kind that could be arrived at only by a detached and reflective observer.” (Ibid, 13). The mind body separation of western culture encourages us to see a separation between the two, strengthened and characteristic of modern medicine which is portrayed as elitist, esoteric and most importantly, scientific. Important to note within this timeline are the religious beliefs of the time which were highly influential on emerging new ideas. These new scientific ideologies of objective study and human domination of nature were backed by religious interpretations, predominantly of the Bible. Generations of Christian teachings had advocated that once nature was known “it may be mastered, managed and used in the services of human life.” (Thomas, K. 1983, 27). The close significance of these attitudes to childbirth and women, according to Macadam Connell is that “women, babies and children were also seen to be near the animal state, and Biblical teachings could be used to support the idea of man’s dominance over his wife.” (Macadam Connell, B. 1993, p 14). These ideas ran closely parallel to contemporary Doctors who laid heavy emphasis on the animal aspects of childrearing, and “referred to pregnancy as ‘breeding’, until the 18th century the suckling of babies was considered a debasing activity by clergymen.” (Ibid, 15).
Providing this brief overview of the dominant religious and philosophical ideologies of the 17th century it is clear to see where the belief of women as inferior, weak and incapable had its roots sown. Within this period the practical assisting of women in labour was conducted by women midwives within the home, essentially women’s work. The Anglo-Saxon word, ‘midwife’ meaning together or ‘with’ (mid) and ‘woman’ (wife) reflecting the communal context of childbirth management. The midwife’s philosophy was usually to let nature take its course, although intervention was performed if necessary. (Ibid) Childbirth, within the 17th century therefore was a cultural and social event which placed the mother centre stage.
At the beginning of the 18th century it wasn’t deemed proper for men to attend women in labour. The church forbid men in attending (given that it was an animalistic and unclean process) yet with the developing professionalism of medicine came the breakdown of these ideals. Medicine was becoming a commodity, offered for money. With the rise of medicine came the demise of traditional healers which extended to midwives and herbalists with men seen as the best person to assist women in childbirth. The birth of the male midwife came about as early as 1663 when a physician named Boucher attended Louis XIV’s mistress in childbirth. As fashion has continued to dictate trends, the lay person followed suit and soon the male physician was the most favourable birth attendant within societal ideology. The ultimate vilification of midwives was “the exclusion of women from the universities and from the reconstructed companies of physicians and surgeons, the new medical knowledge which had been released first as a result of the Renaissance, and later more imperatively in the Enlightenment, was denied to women.” (Stacey, M. 1988, 52.) Formal training took precedence and midwives fell into disrepute. Along with the rise in male midwives came the use of the forceps, which as an instrument has become to symbolise the science of obstetrics more than anything else. (Rich, A. 1977, 142). For the first time, women in childbirth were encouraged to lie down where the instrument of the forceps allowed for easy viewing and intervention it was for the doctor. Invented (and made secret) by four generations of Chamberlans, it was eventually “revealed by a man midwife Edward Chapman in 1771.” (Macadam Connell, B. 1993. 18). A significant turning point in historical childbirth; no longer was the woman actively participating in her own birth, a practice which continues to this day. The lithotomy position (lying on the back) came to be the preferred position (for male midwives) whilst the midwives used birth stools, or an upright position which had the added benefit of gravity to assist delivery rather than direct external, mechanical intervention. In 1760 Elizabeth Nihill (Obstetrician) accused the surgeons of using forceps to force labour prematurely. Nihill describes “Her pride in the midwives multiplicity of skills, ‘small hands’ with their female dexterity, and ‘tenderness’ of heart towards women in her care.” (Rich, A. 1977, 146.)
As Macadam Connell points out it is as though the forceps were replacing the midwives hands as well as way of practising; she arrived early in labour and provided moral, psychological and emotional support (as well as physiological) whilst the obstetrician came for the moment of delivery. Three centuries on this is still the dominant mode of practice. The profession of obstetrics is created around pathology of childbirth, midwives around normality. The continued hospitalisation of women in childbirth meant that the doctor was symbolically reinforced as the expert and by moving a normal event into a setting of disease the woman and her body became the ‘spectacle under the clinical gaze.’ (Foucault, M. 1976, 118.) “The nub of Foucault’s argument is that the understanding of the body…was transformed by this new clinical ‘gaze’” (Stacey, M. 1988, 58). Clinical experience for the doctors was gained through the lying in hospitals which were established for the poor who could not afford private obstetricians to care for them. Here they gained experience on their objects of study and at the end of the 18th century the dissecting of corpses was also being conducted for means of extending knowledge; however with no sanitation the surgeons created an outbreak of puerperal sepsis (childbed fever) which became the major plague for all concerned with childbirth until the mid-19th century. It was demonstrated that the epidemic was connected in some way to the institution setting (as home care had far fewer deaths) and the suggestion was even made to close the Rotunda all together (Macadam Connell, B. 1993, 21). However, the opposite occurred and puerperal fever raged for the next 50years.
Jo Murphy-Lawless states in her article, The Silencing of Women in Childbirth (1988) remarks that whilst looking at the conditions, the suppression of female midwives and the politics of obstetric control and power we overlook the most important person, that of the mother who is giving birth. “There is no record of women’s experience of services at this time in history and so conducting this historical overview it is mainly completed through case histories from male practitioners.” (Murphy-Lawless, J. 1988, 296) At this point in the historical overview of the maternity services Ireland it is clear that the documenting of women’s views, experience and beliefs at times in the history of childbirth are crucial for our understanding and for the future generations. As technology has advanced at such a pace in the last 100 years, we are at a crucial time in history and one where the woman’s voice is hardly heard.
In the 18th and 19th centuries antenatal care did not exist. As pregnancy was not seen to be of importance and did not constitute a phenomenon as childbirth did and therefore there was no necessity for care. Pregnancy itself was still seen as normal and although no ‘group’ yet claimed the care of pregnancy, there was no shortage of advice, something which continues in its extremes to this day. As of yet there had been no instrument or technology invented to listen to the foetus in the womb , no ‘clinical gaze’ had penetrated the womb and only traditional techniques of palpating the abdomen, observation and listening for the heartbeat by the ear were used.
With the 18th century seeing the growth of male midwifery and the beginnings of medicalization, the 19th century saw the increased professionalism of Obstetrics which exerted more and more power over women and their bodies. Foucault talks in The Birth of the Clinic of two modes of bio-power; disciplinary power and regulatory power. Disciplinary power he describes as knowledge of and over the individual body representing the body as a machine-rendering the individual more productive, useful and docile. This type of power takes its hold through the creating of desires, attaching people to identities and establishing norms which the individual will self-police. Regulatory power is linked to interventions governing society and so, it is useful to look at the development of Obstetrics and the dichotomy with Midwifery practice through Foucault’s lens. So then, what were the desires and identities that were created for childbearing women in the 1800s and how did these make women more productive, docile and useful? Were there regulatory policies put forward and did these succeed?
In Ireland the factory was taking a firm hold and the traditional rural setting was becoming more urbanised as capitalism took its grip on the economy. Up until this period most people were born, worked and died at home but with the industrial revolution and factory style work all three aspects began to occur outside of the home. By 1841 there were 39 infirmaries in Ireland, each with its own surgeon. The surgeon had high social standing and prestige. By 1851 a dispensary service was opened which provided for the poor and those who could not afford to pay. Those doctors, nurses and midwives who worked there had to have recognised certificates and though it was not yet legal it would become so by 1886. By the late 19th century medicine had become a modern profession with autonomy, self-regulation and dominance. Medical practice with rational science had reduced the body to that which is examined and the power relations between the elite practitioners and the low class poor who had become the object of study. Disciplinary power rendered these women useful, productive and docile while regulatory power gave the practitioners legal, ethical and medical domination over them. Macadam Connell draws the parallel here with Marx’s concepts of alienation, separation from the self through ‘surrender’, or Fromm’s view of alienation as a result of ‘instrumentalisation’. (Macadam Connell, B. 1993, 26) The body had become a mechanical machine which was open for exploration with little regard for the experience of the individual. The discovery of anaesthesia in 1842 was a turning point for the control of childbirth. With the use of pain relief women became more docile and easier to ‘manage’. The Doctors, aware of the increased control and ease for their work an unconscious body would have encouraged the practice along with which the incidence of forceps was greatly increased leading to an increase in the puerperal fever which lasted for 200 years. The spread of the fever was accredited at the time to the midwives but in 1885 with Pasteur’s discovery of bacterial infection it was understood that it was the lack of hygiene of the doctors not washing their hands in between patients which spread the awful disease which took so many lives. Along with the advent of analgesics and anaesthesia came the caesarean, which was originally only performed when a woman was dead or dying. Two further practices which are significant to alienation in childbirth of the 19th century are induction and the x-ray. The x-ray in particular gave further power to Foucault’s clinical ‘gaze’ and the medical profession claiming they know more about what is going on inside the womb than the mother herself. From 1899 the x-ray was used extensively without grounded research to do so, with grave consequences. By the end of the 19th century the ideology of medicalised childbirth was well on its way to being established in the minds of women although many were still birthing at home.
Midwifes were encouraged to seek further education by the general council of medical registration to enable them to practise and was increasingly becoming part of nursing training and practice. Obstetrics was by now a well organised and accepted profession:
“The two hundred years of puerperal fever was coming to an end. The age of anaesthetized, technologized childbirth was simultaneously beginning.” (Rich, A. 1977, 155).
In 1841 Prince Albert accompanied Queen Victoria during the births of their children. Although causing some speculation in The Lancet (medical journal) when he did commoners followed where royalty treaded and birth, certainly within the middle class sample of parents in Jallard’s collection of letters, saw childbirth as a natural physiological process. (Bynham et al. 2006, 209). However, dying in childbirth was a significant reality and led to the pathologization of childbirth which was aided by the concerted campaign, led by Obstetricians to move delivery into the hospital. (Bynham et al. 2006, 210). With the rise of the professional ethics which was first enacted in the United States in conjunction with the American Medical Council of 1847, women had more choice in who attended them at the time of birth. However along with the code of ethics came the tight regulatory bodies of homeopathy, herbalism, midwifery and anything which offered free and natural advice for self-help and healing. (Ibid.) The Royal College of Physicians in London, Edinburgh, Dublin and Glasgow had control over the practice of birth.
National health became centre of debate in between the two world wars and welfare legislation had a widespread effect on women and children as never before. The Maternity and Infancy Act was passed in the States in 1921 and state child allowances were largely interwar innovations. The feminist movement in Ireland and around the world was an instrumental force in initiating change. Antenatal care became widespread and in 1942 79.5% of women received prenatal care in England. The long standing struggle between doctors and midwives persisted and became heightened by insurance schemes and the private market. Falling birth rates were a cause for concern, especially in France where in 1938 the birth rate fell below the death rate and pronatalism was encouraged with higher incentives for bearing children (maternity leave, family allowances etc.). The delivery of babies became an object of fierce competition as obstetricians advocated for birth to be in a hospital and the majority of people followed doctor’s recommendations. Midwifery became controlled by obstetrics and moved away from the community led midwife practice to hospital based care where midwives were and arguably still are more of a doctor’s assistant although midwives are trained in normal delivery and birth. American obstetrics created their discipline as a scientifically informed and technologically prepared speciality. Almost everywhere but most notably in America “obstetric modernism was associated by some obstetricians and many women with ‘Twilight Sleep’- the use of scopolamine to obliterate the consciousness of labour.” (Ibid, 335)
Despite European Community and WHO guidelines of greater integration in training and practice in midwifery (as in nursing) the haphazard midwifery provision remained until the end of the twentieth century and indeed continues today (outlined in the next section, current debates.) “In monopolistic systems, such as the NHS, midwives appeared to retain control over uncomplicated births, but financial and other incentives ensured that physicians would seek to gain greater access to the management of pregnancy and birth” (Ibid, 452.) Considered as gaining monopoly on birth, obstetrics and midwifery have had an age long battle over who is the most suited care provider of pregnant women. The structure of maternity care and the increased mode of centralisation means that midwife led care are becoming tied to insurance schemes and specialised skills for natural deliveries will die out. We are at a crucial turning point in the history of midwifery, obstetrics and women’s choice about how and with whom to give birth.
Since the pioneering of the active management of labour by Kieran O’Driscoll in the National Maternity Hospital, Dublin in the 1960’s we have seen the advent of episiotomies, spinal epidurals and a rise in caesarean rates which are at present at an all-time high. A student Midwife (Cork University Maternity Hospital) write to me saying;
“I am in my final month’s internship now and whilst inspired by the hard work and dedication of the midwives, I am upset with the increasing medicalization of birth with 50% induction, 70% epidural, 30% Caesarean section. What troubles me is the absence of the woman’s voice in all of this and it appears no one questions current practice. Recent home birth statistics are 168 births out of 75,000 births occurring at home.”
(Begley-Merz, B. 2013)
This student Midwife is trained to be ‘with-women’ in natural birth settings, yet in the highly medicalised framework of birth there is no support for her to work in this way. To make the choice to work independently from government health care providers can mean becoming isolated from the medical community. As I write, the Independent Midwife association in the UK which has received the Gold Standard award from the UK Government for providing a high standard of service, (in line with what ‘true’ Midwifery is) are in discussion for the legal issue of not being able to attain public indemnity insurance cover. As the issue of childbirth has now reached the point where pregnant women and Midwives are deemed to be illegal when wanting a home birth, or providing care for a woman at home (UK) we see that birth truly has become a monopoly, controlled by obstetricians who determine the guidelines adhered to by the insurance companies. The legal issues which are arising over this are beyond what can be discussed in this paper but are none the less extremely important in the face of the changing childbirth. I will cover a few of the current international debates as well as those pertaining to Ireland in the next section. However, from this historical overview from the period of antiquity to the present day it is plain that we have seen the increase in Obstetric practice and management around labour and birth. With this in mind and feeling that we are indeed within the eye of the storm at what is the future of true women-centred Midwifery I am asking how social media is playing a role within services and also how it is playing a role in the changing tide.
- 4. Current Debate
4.1 Within Ireland
“There is a view in Ireland that the quality of maternity care does not matter, as long as you end up with a healthy baby. Well, of course that’s the most important thing but there are many other crucial issues relating to maternity care which are simply not being addressed; basically, women are not being listened to by those providing services.”
(Hunter, N. 2013.)
Maternity care in Ireland is becoming a solely centralised model of care. Between understaffing in hospitals, few Midwife Led Units (MLU) and Independent Midwifery in the minority due to insurance and HSE guidelines (Nurse and Midwife Bill 2010) birth is seen as pathology rather than a normal event in a woman’s life. AIMS Ireland (Association for the Improvements in Maternity Services) conducted a survey in 2009 entitled “What Matters to you? : A Maternity Care Experience Survey” which sought to discover what women’s experiences of the current system are and what they see is needed to create positive change and improve service. The survey collated data from 367 women who were self-selecting and anonymous, the prime motive being to find out what women’s experience of care was before, during and after birth and what improvements they would like to see being implemented. These women had all given birth within Ireland in the 4 years preceding the survey which was accessed by the women through the AIMs website and a number of parenting online forums.
Three issues were highlighted; Choice of where to give birth, understaffing and the lack of evidence based practice.
Many women in the survey commented that they did not receive information on their choices of where they could give birth from their GP’s on the initial visit and in some cases choosing a home birth was actively discouraged (AIMS). The main source for information were from their GP as well as family, friends, hospital consultations and internet forums, although one woman commented that the internet “while hugely helpful, is only ever anecdotal” (AIMS, 2009, 8). Women’s satisfaction with the availability of information was extremely varied, and largely depended on the type of information being sought. However, the majority of statements pertaining to information can be characterised by a sense that information relating to care models that deviate from the dominant medical model (hospital based, consultant-led, combined care with a GP) while available, is not provided to women as a matter of course. This is more commonly sought independently by women through media such as internet forums or the recommendations of friends. One woman commented that; “GP only gave info on combined care after I said I was going public, nothing said about DOMINO or homebirth or any other options.” (AIMS, 2009, 7). The providing of information regarding the woman’s choice of care was repeatedly highlighted throughout the study. Women who wanted to know about Midwifery Led Care (MLU) went online to find information with one woman saying that
“In the short period of time that I had to make a decision about care, I was only aware that I had to choose public/semi-p/private care but I wasn’t aware of combined care, DOMINO or midwifery schemes. If I had access to more information I would have chosen differently.”
(AIMS. 2009, 9)
Finding information on home births was even harder for women, with nothing provided by their GPs women felt their health professional “acted like I was having bub on Mars” (AIMS. 2009, 1). Once making the decision to employ an Independent Midwife to provide their care the next hurdle was to source information on grants to fund it. Clear information is required by women in the early stages of their pregnancy when they take the important step of informed choice regarding who is to be their primary carer. Location was a determining factor as to what choice there was; in rural communities, outside of urban centres women had far less choice available to them which often meant travelling an hour plus to reach a hospital whilst in labour with obvious risks associated. A striking number of women commented on the urgent need for the provision of one single resource containing information on details of the care options available in their area:
“No one resource available to let you know what your various options might be….It would be great if there was a pack available that could be given out by GP’s as they are usually the first person you go to confirm your pregnancy before you make your choice.”
(AIMS. 2009, 23)
The issue of choice is a clear debate in contemporary Irish maternity care. Within Cork County there are only a few choices available and this information, as stated by the women themselves is not readily available. The options are 1. A hospital birth at the CUMH in Cork City or 2. An Independent Midwife (home birth) who works within strict HSE guidelines and criteria which confines birth to a set time (Murphy-Lawless, J. 2011). There is no DOMINO (Midwife Led Unit providing home and community care) scheme available in Cork at present which is localised to a small catchment area in Dublin. The issue of choice and information of those choices was the most prominent issue raised from the survey.
Understaffing was also commented on throughout the study where women felt rushed and upset by the lack of communication before procedures were carried out. One woman stated that the hospital staff “Never asks for consent for serious interventions such as episiotomies [sic].” (AIMS. 2009, 163) and due to time constraints and understaffing the women (and babies) are in and out of hospital as quick as possible. The lack of communication was more of an issue for the women than the procedures needing to be performed and reached to areas postnatally as well as antenatally and during delivery. Women stated that their postnatal care was poor and that “The Irish maternity system is simply not geared up to support normal birth for the most part.” (AIMS. 2009, 153).
Evidence based best practice which advocates Midwife led care, is clearly not adhered to due to understaffing and funding issues which put mothers and babies at risk. One mother claimed that the “current environment is not conducive to healthy birth” (Facebook discussion, AIMS ‘Wall’ 7th March 2013) and other identified areas for concern were the “lack of evidence based information being provided to mothers, overcrowding in maternity hospitals, understaffing in maternity hospitals, lack of autonomy for independent midwives…” (Ibid). Evidence based care and research shows that MLU and home births have very positive outcomes for all, reducing caesarean rates, interventions, midwife satisfaction, mother and baby satisfaction (Home Birth Ireland) so the issue seems to be in the structure of the system not being able to accommodate for the rising numbers of women birthing in Ireland with understaffing and economics being a large part of the problem. This paper is posing the suggestion that the employment of new media would be a cost effective means of reducing this strain on services, staff, mothers and hospital finance.
Care after the birth is the area which fared the worst in the AIMS survey, shown as the area in most need of improvement. In all, 45% of women felt their care was “average” or ”poor”, and nearly half of respondents report receiving inadequate information. Lack of adequate breastfeeding support was reported by several participants with almost one-third of women, 33%, rating the support for breastfeeding as ‘poor’. One woman stated that “the general consensus among my friends is that postnatal wards are intolerable, even inhumane places to be. No support, very bad food, no opportunity to sleep, poor infection control due to overcrowding etc…. Most women want to leave hospital as quickly as possible.” (Facebook discussion on AIMS, March 7th 2013).
Maternity services in the greater Dublin area are currently being reviewed by consultants for the HSE. Jene Kelly, chair for the Association for Improvement in Maternity Services (AIMS) says however that “it is disappointing that the options which have emerged to date from the review appear to focus on providing units similar to the traditional model of maternity care in this country and do not focus enough on alternatives such as midwife-led units.” (Hunter, N. 2013)
In 2010 the Nurses and Midwives act was brought in to govern independent midwifery and homebirths in Ireland. Part of this meant that Self Employed Community Midwives (SECM’s) would obtain insurance through the State’s Indemnity Scheme but in the process, lose autonomy to decide which women they may attend, and the State/HSE created a list of criteria of women who are not eligible for homebirth (Nurse and Midwife Bill 2012) Within this change women have no autonomy/informed choice if the fall outside the criteria. The women most affected are women who had previous caesarean births – they are now excluded yet a large percentage of the excluded women had previous homebirth (s). Jene Kelly states that “you often find a woman who had first birth via caesarean, a homebirth or two (usually as caesarean due to medicalised birth practice) and now finds herself outside the criteria, unable to have another homebirth despite no changes in her circumstances.” (Email March 7th 2013)
To summarise, the current issues in Ireland are of choice, information, understaffing, financial and lack of communication of evidence based research at all stages of pregnancy and postpartum. Jo Murphy Lawless, Sociology lecturer at Trinity College Dublin states that on the 21st April 2011, during a lengthy debate on the Nurses and Midwives Bill in the Irish Dáil, the junior Minister for Health, Kathleen Lynch, defending the need not to make any further amendments to this bill, made the following speech which needs to be quoted in its entirety:
“I believe being pregnant and having a baby is not a medical condition. I hope as many women of a particular age as possible can meet with the joyous experience of this natural condition. We need to make it clear that it is not something to be terrified of. Although I do not believe our maternity services are in crisis, having had some interaction with them recently, I accept they may be a little overstretched. That can happen when there is an influx of people having babies at a particular time, for example. It is dangerous to use the word “crisis”, especially when one is talking about people who are vulnerable as they prepare to have babies. I do not think we should encourage women to panic. I believe in telling them the truth, but not in causing them to panic.”
(Dáil Éireann, 2011).
Murphy-Lawless states that this Minister is not a ‘truth-teller’ any more than are the HSE officials and obstetric consultants who promise that Ireland is one of the ‘safest places in the world’ to give birth while they cast adrift midwifery-led care. (Murphy-Lawless, J. 2011) In his 1983 lectures, Foucault writes that the “process of truth-telling has certain requirements.” (Murphy-Lawless, J. 2001) For the person who would be a ‘truth-teller’ it is a “fundamental requirement both that the speaker is ‘sincere’ in her belief and that the belief is also the truth” (Foucault, 2001:14). This differs significantly from a ‘regime of truth’ which is the way coercive power reinforces a series of deep untruths. “There is an historical problem of an embedded and deeply conservative obstetric profession which has remained largely unchallenged as the central influence on all levels, from the individual women to hospital policies to national policymaking.” (Murphy-Lawless, J. 2011) The legal issues which are at stake within the Nurse and Midwife 2010 Bill (Section 40) unless amended could potentially make independent midwifery obsolete. What the Section proposes is that it becomes a statutory requirement that all practising midwives carry indemnity insurance. If this section remains unamended, it would mean that any midwife who practises and is uninsured, can face criminal proceedings with a potential fine of 100,000 Euros and a ten year prison sentence. “No such draconian measure applies to any other health care profession, including doctors.” (Murphy-Lawless, Jo 2011). At present, Section 40 has not been amended and what we are seeing in contemporary maternity care is a direct result. The legal issues, insurance tied to Midwifery registration within strict criteria which confines giving birth to clock time is creating the system of conveyor belt babies and disempowered women.
4.2. UK Debate
In October 2013 Independent Midwifery registration in the UK will become legally bound to Insurance cover. Working outside the NHS, a choice for some 200 highly experienced Midwives has received the Gold Standard award from the UK Government, aligning with World Health Organisation guidelines for best practice with very successful outcomes of natural birth, involving little or no intervention. No clock time pressure and no drugs apart from nitrous oxide (gas and air) are used. Women choose to birth with a Midwife who provides full care during pregnancy, birth and the post natal period. A debate which has been some 20 years in the making(and indeed, further back) is now coming to a head and although these Midwives, backed by the Royal College of Midwives and Independent Midwives UK is no closer to securing affordable insurance cover. Media coverage, TV programme, weekly articles and the use of social media sites as a means of generating petitions and surveys are encouraging discourse between the UK government and Midwives. A protest outside of the Houses of Parliament in London on March 25th brought together a group of mothers, doulas, midwives, lawyers and health professionals. The argument is not that these Midwives are against insurance; it is simply that they cannot get it as no insurance company will provide cover at a reasonable rate. With only 200 Midwives working this way, figures around the ball point mark of £80,000 per year for PII are quoted. Insurance cover has not been possible for this group of Midwives since 1992. They have practised (successfully) without insurance, the women under their care signing disclaimers. The research shows that Independent Midwives work to an exceptionally high standard of care, yet under the new law this could have very dire results in an already stretched to the max, NHS maternity system. The fear is that if this happens, more women will ‘free birth’, without medical assistance which is highly dangerous to both mother and infant. Midwives could also begin to work ‘underground’ without the current support which they have of their supervisor of midwives (SOM) and mandatory training which ensures the continued upkeep and renewal of their skills. An indication of reverting to the dark ages could be imminent as women fight for their right to choose; the results however, could be catastrophic. There are many legal cases which can be followed, in the UK the case of IM Becky Reed is continuing to this day (please note Becky Reed not been found guilty of negligence) The legal issues surrounding birth are intricate and entrenched with ideologies and medical discourse, too detailed to go into here. Documentaries have been aired on mainstream TV in more succession than ever before with role models like Rikki Lake (The Business of Being Born, 2008) and Christy Turlington (Every Mother Counts, 2010) bringing a higher profile to the campaign and helping to steer it away from a seemingly radical group of ‘hysterical’ women. Home Delivery (2013) was aired on the 20th March on TV3 and was the first of its kind to present an hour long documentary on prime time TV of Midwives working independently. Following in the footsteps of highly viewed shows of One Born Every Minute and Call the Midwife which do indeed present community based care, Home Delivery presented home births in their entirety. In Ireland the similar show, From Here to Maternity (2010) provides a hugely successful show which films inside the Cork University Maternity Hospital and follows Midwives and Doctors on their daily duties and rounds, there has been much debate online from the home birth ‘community’ which draws attention to the fact that home births were only given 10 minutes of air time in all of the annual series from 2010 to 2013, in line with the highly medicalised system which we are currently in.
4.3. Hungarian Debate
Moving further afield the debate of Dr Agnes Gereb, Hungarian Obstetrician who is currently under house arrest for attending a home birth. Dr. Gereb left Obstetrics, retrained in Midwifery and setting up her own Independent Midwifery practice with years of experience behind her. The case of Agnes Gereb has sparked worldwide debate on the human rights issue of childbirth and initiated research papers, media coverage and worldwide recognition of a women’s right to choose where she gives birth. On 24 March 2011, the Budapest City Court sentenced Agnes Gereb to 2 years in prison, with a 5-year ban on practicing as an obstetrician/midwife. Agnes was targeted for providing homebirth services, which are criminalized in Hungary, despite the European Court for Human Rights asserting the rights of women to homebirth in 2010. (One World Birth. 2013). She has not been accused of malpractice other than attending home deliveries.
As aforementioned similar cases are on-going around the world which unfortunately cannot be gone into in depth here. In Ireland we had the case of community Midwife Ms Ann O Ceallaigh who was under similar proceeding after a 1997 injunction which prohibited her from practising. The Irish Independent reported on the 18th May 2000 that:
“The three complaints against Ms O Ceallaigh the inquiries into which are now quashed were made by the former Master of the National Maternity Hospital, Dr Peter Boylan, and by the matron of another Dublin maternity hospital. One of the complaints related to the birth of twin’s one child was born dead but Ms O Ceallaigh had said she was not the midwife responsible for that case and was only called in to assist another midwife at the last minute. No fitness to practice inquiry was initiated against that midwife.”
(The Irish Independent, 2000)
In the other two cases, the mothers and babies involved are alive and healthy and have no complaints against Ms O Ceallaigh. None of the complaints made against Ms O Ceallaigh were supported by the mothers involved. With debates around the world mirroring each other, the concern is that a monopoly of care is happening around the globe, tied to insurance companies and litigation. There are many more debates which could be written about here, each deserving their own enquiry. I feel it is important to mention the cases which relate strongly and are within our current awareness in Ireland. These are, 1. The case of Satvia Halapaanava and 2. The case of Mother A of which Waterford General Hospital sought a court order to compel her to have a caesarean (March 2013). Issues of choice over women’s bodies are forefront here, in reality whose choice is it over where and how a woman gives birth?
Not being medically trained, I cannot comment on the medical side of the arguments which are heated, emotive and give rise to many comments from mothers and medical personnel. However one thing is abundantly clear, maternity care has not differed much from its turbulent past and the dichotomy between obstetric care and midwifery continues.
- 5. Digital Media Technology
As previously seen in the AIMS 2009 study women are using new media as a means of sourcing information on choice of care provider and educating themselves of their rights within the mainstream centralised maternity system. To clarify a few aspects of digital media technology and the internet use this research is looking at and the areas which the HSE are involved with at present.
The term virtual communities were coined by Harold Rheingold in his 1993 book with the same title. Rheingold defined the term as “A network of people with mutual interests who interact in a conceptual space” (Rheingold, H. 2000, p4), specifically within social media. Since this time new media technology has advanced at such a pace that Facebook (as an example) has a monthly activity of 850 million users (Honnigman, B. 2013) The advent of virtual communities and social media has posed new challenges to our concepts of what defines community and with it is our sense of time and space. With globalisation enabling people to move around the world with relative ease the traditional family unit and dynamics of social structures is undergoing a considerable transformation.
Boyd, D et al (2007) defines social networking sites as web based services which allow users to;
- Construct an identity and profile within a bounded system.
- Create a list of users who they share a common interest with.
- Provide the ability to view connections of themselves and others within the system.
Using this framework of what constitutes social media, the potential for its use not only for individuals but also as a tool for governmental organisations as a way of providing expert advice and care will be explored. Research has shown that social media sites have given individuals a voice, enabling people to link with others who are having similar experiences and effectively helped initiate change within institutions which were traditionally closed off. (Ibid). Facebook, Zuckerberg states is not based on ‘toppling institutions’ as was referred to within the interview with Times Magazine editor, Richard Stengel.
The HSE currently has 2 Facebook pages; one for quitting smoking (plus a YouTube video for this) and one for teen mums. Two Twitter accounts; one for general business news within the HSE and one for management professionals, neither of which provide access to information on practical health and care. Current HSE policy on personal social media states; “Personal blogs created by HSE employees, including micro blogs like Twitter accounts, should have a clear disclaimer that the views expressed by the author in the blog are the author’s alone and do not represent the views of their employer.” (HSE, 2012). As it stands there are no HSE support pages via new media and social networks for maternity care and those that wish to blog or post are limited to what they can discuss. However in the HSE Digital Communications Strategy of 2011 it is stated that
“This Digital Communications Strategy proposes how the HSE will integrate digital and social media into all aspects of our work and will build a digital platform that will integrate patient information and our service now and into the future.”
Finland was the first country to make use of digital communications within their maternity services (2011) with Australia completing research the same year. What has come to light from these two papers is that social media is indeed a very successful means of accessing women as childbearing women and their families are regular users of the sites. Finland’s research showed that “This study showed that social media coordinated by a maternity clinic can effectively create a sense of virtual community, or a feeling of belonging to a group, and respond to the needs for social support of parents with small children.” (Palmen et al, 2012) Mirroring these findings, the Australian CISCO research showed that;
“By following these steps to deliver virtual maternity care services, healthcare organizations will be able to bring a traditional service area into the information age and in line with Expectations from an IT-literate clientele. Most important, they will improve prenatal and postnatal outcomes for patients, while significantly lowering costs for their organizations.”
(Gill et al, 2011)
Jene Kelly from AIMS said that the 2209 survey showed that the websites/social media and virtual communities most used by
parents on the web were;
“magicmum, rollercoaster, eumom, mumstown, meetmums, facebooks” (Kelly, J. 2013) I will provide a brief overview of each site here to gain insight into the types of information which is being sought and currently provided in 2013.
Magicmum is a forum which is open to conversations and information seeking. It is a virtual community where mums to be and new mums can make contact and support each other. It has no central contact number as does not seem to be ‘manned’. There are various headings of previous conversations for example ‘Bleeding in early pregnancy, how long?’ where mothers have posted worries and concerns and other women who have had the same experience reply.
Rollercoaster is a website which provides parent forums as Magicmum but also contains articles on many aspects of pregnancy and beyond and is a comprehensive source of information. Although articles are not authored and therefore are not written by health professionals they link to sites such as http://www.bump2babe.ie which is information provided by the maternity hospitals and covers a wide range of questions which are essential for early stages of labour.
A website similar in style and content to Rollercoaster.ie. It is easier to navigate with clear headings for forums and articles. Again there is no author cited, no references made and no contact us page.
Mumstown.ie is a website, similar again but the first where you can ask questions directly to a student midwife. This is the first site which contains more advertising of products and is generating money. It also has a contact us page, an about page, is regularly updated and clearly is managed by a central source who was on Dragons Den in 2007.
This website brings something new, adding a blog to the similar website style parenting forum. The focus is social and on connecting mothers- it provides an online directory as well as up to date articles which are not usually seen in mainstream media.
Facebook is the online virtual community which links all these forums above with a wider audience. In February 2013 there were 9.1million active users worldwide.
The HSE website provides details of the closest maternity hospital, opening hours and services. There are no links to the above forums. AIMS Ireland – The Association for Improvements in Maternity Care is perhaps the most comprehensive website with up to date information and services for women and their families. It is where women can vocalise what they want to see in a changing environment of care and is actively managed albeit voluntarily.
5.2 Professional Use of new media technologies
Reflecting the questionnaire showed some interesting areas with varied use and food for thought. The midwives and care coordinators were much more proficient at using various forms of media technology, whereas the consultants were less likely to avail of them and relied more on print. However, all of the consultants showed forward thinking attitudes towards the technology, expressing a desire to know more about them and how to implement them within the maternity care system. Rofessor Greene, for example stated that the use of blogs and Facebook had potential use within the maternity service. He also wanted to highlight the positives within the current system, despite staff shortages. The midwives, care coordinator and mothers showed much more knowledge on social media sites like Facebook and Youtube. The feeling was much more ‘active’ and aware of issues and debates going on within the local community. Foreward thinking within these areas also showed relevant with knowledge of up to date research by one midwife as to the use of social media to provide breastfeeding tips and advice via videos on YouTube which would spread quickly via Facebook. One mother also stated that the internet was a wonderful tool for keeping connected with debates and issues, especially if in a remote and isolated part of the country. The importance of the use of ‘virtual community’ for those more isolated cannot be stressed upon enough.
5.3 Parental use of new media technologies
Parental use differed in that the intention is more to connect and gain advice rather than to give it. The two mothers stated that social media was very important as well as highlighting TV programmes like From Here to Maternity on RTE for providing and understanding and acceptance of hospital procedures. They both requested more access via the web to alternative antenatal classes than those offered at the hospitals, availability of information regarding choice and areas which facilitate information sharing, petitions, positive birth blogs as well as an area for support for those finding things difficult. Post natal depression is a serious societal concern with lack of social interaction and isolation playing a large part. Through social and virtual online communities, other mothers can be reached at any time, night or day.
5.4 New media technology as an implement for change?
As an implement for change and from the small survey conducted here, combined with the overview of historical relevance and current debate we can see how social media is used to access information, create debates, organise rallies and provide support. With the current economic climate affecting many people, the internet can and has been a literal lifesaver. To follow in the footsteps of countries like Finland, Australia and New Zealand who already employ such systems would enable those in more need to be accessed. With the majority of parenting aged people digitally aware and competent, and with many away from the nuclear family, digital networks and the use of technology has never been more important. Where once women gained support from their mothers, aunts, sisters and grandmothers, we are now away from these networks and relying on internet systems and hospital professionals to guide us. All adding to the burden on the health services and financial system I can see a proper implementation of the media as a way forward for all concerned to benefit.
6 Summary and Conclusion
In review of the survey research we can ascertain that social media in the form of virtual communities can indeed ease the strain on hospital waiting times and overstretched staff. If new media technology was used to create breastfeeding videos, antenatal classes, tours of the labour ward, postnatal depression videos and to virtually meet consultants, midwives and health professionals, providing a familiar face could effectively lessen prenatal anxieties and reduce physical visits and current strain. With online forums and discussion panels where women can speak to someone directly, 24 hours a day it seems to be a viable option for the vital transformation of the health service. Virtual communities, as highlighted are increasingly providing a platform where mothers can connect with other mothers at any time, night or day as and when is needed. Within these networks and forums mothers seek advice from other mothers going through the same anxieties and questions, regaining a sense of empowerment in their new found role. What is in question is the validity of information being provided as the majority of the forums are not led or managed by a health professional and this raises cause for concern and something which if the HSE was to employ could potentially reduce their strain, economics and increase satisfaction for all concerned.
All participants, from the varying backgrounds expressed an interest and need for facilitating change and awareness within the services through new media. The levels of proficiency are varied and time constraints need to be taken into consideration.
In light of the given information new media technologies are a viable move forward for providing information on choice, professional advice and reducing hospital and HSE strain. They are by no means a substitute for physical care but have the potential to significantly aid communications including legal policies and procedures. What is restrictive is the HSEs limited knowledge of how these forums work and a general uneasiness to the nature of the internet itself. More research is needed as to how this can proceed within guidelines and with accordance with evidence based practice in conjunction with the World Health Organisation to ensure healthy parents, families and new-borns for the future of society in the digital age.
The study shows that there are many different avenues for new media technology to be used and because if this, difficult to compare. More research is needed to define potential further use. Despite efforts of desk research and questionnaires specifics do need to be worked with to ensure a smooth transition.
In conclusion to the report I feel as though the intention of providing an inventory has been reached. A ‘photo’ has been taken of the different mediums of new technology, legalities, history and current debates. I feel that if more work was to be conducted this provides a useful foundation from which to build upon.
7.1 Participants names
There were 10 questionnaires emailed out, 9 of which were returned. These participants were chosen to display a varied response. They were;
- Professor Higgins, Father and Consultant Obstetrician at Cork University Maternity Hospital (CUMH).
- Professor Hewitt, Consultant Obstetrician at CUMH.
- Professor Louise Kenny, Mother and Consultant Obstetrician at CUMH.
- Professor Greene, Father and Consultant Obstetrician at CUMH.
- Dr Patricia Leahy Warren, PHD. Mother, Senior Midwife, Lecturer and Health care coordinator at UCC.
- Clare Boyle. Mother, Lactation Consultant and Midwife, Kinsale, Co Cork.
- Mary Cronin. Mother and Independent Midwife, Kinsale, Co Cork.
- Siobhan Malone. Hospital birth mother, Co Cork.
- Wendy Condell. Hospital birth mother, Co Clare.
- Maria O’Sullivan. Home birth mother and doula Cork City. (The only questionnaire not returned).
1. Are you a (please highlight):
Health care coordinator
2. Do you use new media in your above role? (E.g. Twitter, Facebook, YouTube,)
3. Do you use this media to access information/ mothers and fathers/ clients?
4. Are you currently using new media to keep up to date on current debates and perspectives within maternity services?
5. Which debates are you following?
6. Could you see new media being used more within maternity services?
8. The main issues of debate today seem to be choice, information and under staffing. Can you see new media helping to affect positive change here?
10. Any other comments.
7.3 Table of Results
Hayles, K. “How We Read: Close, Hyper, Machine.” Association of Departments of English Bulletin 150 (2010): 62-79. Print.
Begley-Merz, B. Email communication dated March 23rd 2013.
Bynham, W.F, Hardy, A, Jacyna, S, Lawrence, C, Tansey, E.M. The Western Medical Tradition 1800-2000. Cambridge University Press, New York. 2006. Print.
Foucault, M. 1976. The Birth of the Clinic: An Archaeology of Medical Perception. Tavistock Publications: London. Print.
Macadam Connell, B. Childbirth and Alienation: A study of the Implications of Medicalised Childbirth. 1993. Department of Sociology, UCC. Print.
Murphy-Lawless, J. The Silencing of Women in Childbirth or Let’s hear it from Bartholomew and the Boys in Women’s Studies Int. Forum: Vol. 11. No 4 pp293-298 1988. Printed in the USA.
Stacey, M. The Sociology of Health and Healing. Unwen Hyman Ltd: London. 1988. Print.
Thomas, K. Man and the Natural World: A history of the modern sensibility. Pantheon: New York. 1983. Print.
Rich, A. Of Women Born: Motherhood as Experience and Institution. Virago: Great Britain. 1977.
Association of Radical Midwives. “New Vision of Maternity Care.” Association of Radical Midwives. 2013. London, UK. Print.
AIMS “What Matters to You?: a Maternity Care Experience Survey.” AIMS Journal, Volume 23, No 2, 2011. Web.
Dáil Eireann (2011) Nursing and Midwifery Board of Ireland. “Nurse and Midwives Bill 2010”. Houses of the Oireachtas. Vol. 730. Print.
Dáil Éireann (2011) “Dáil Éireann Debate, Nurses and Midwives Bill 2010: Report Stage (Resumed)”. Houses of the Oireachtas. Thursday, 21 April 2011, Vol. 730 No. 5, page 6. Web. www.http://debates.oireachtas.ie/dail/2011/04/21/00006.asp Accessed 7th March 2013.
Foucault, Michel. Fearless Speech. Edited by Joseph Pearson. Los Angeles, CA: Semiotext(e). 2001. Print.
Hunter, N. “Maternity Care- What Women Want.” Irish Health. 20/2/13. Web. www.irishhealth.com. Sourced April 10th 2013.
Irish Independent. “Midwives Legal Battle ends with Positive Court Ruling.” The Irish Independent. 18/5/2000. Web. Sourced from www.independent.ie March 10th 2013.
Muphy-Lawless, Jo. “Childbirth Adrift in Ireland”. AIMS Journal, Volume 23, No 3, 2011. Print.
Royal College of Midwives. “State of Maternity Services Report 2012”. Royal College of Midwives. 2013. London, UK. Print.
Websites Referred to
Digital Media Technology
Boyd, D; Ellison, N. Social. Network Sites: Definition, History and Scholarship. 2007. Journal of Computer-Mediated Communication, 13(1), article 11. Print.
Gill, M and Grant, J. “Virtual Maternity Care How Social Networking Technologies Can Improve Prenatal and Postnatal Outcomes, and Lower Costs”. September 2011. CISCO Internet Business Solutions Group. Web. http://www.cisco.com. Sourced March 25th 2013.
HSE. “Social and Digital Media Policy and Guidance for HSE Employees”. National Communications Directorate. April 2012. Web. http://www.hse.ie Sourced March 20th 2011.
HSE. “Overview of HSE Digital Communications Strategy”. Digital Communications Directorate. November 2011. Web. http://www.hse.ie Sourced March 20th 2013.
Palmen, Marilla, Kouri and Pirkko. “Maternity clinic going online: Mothers’ experiences of social media and online health information for parental support in Finland.” Journal of Communication In Healthcare, Volume 5, Number 3, October 2012 , pp. 190-1989. Print.
Rheingold, H. The Virtual Community: Homesteading on the Electric Frontier. 2000. MIT Press: London. Print.
Stengel, R. Interview with Mark Zuckerberg. Time Magazine. October 19th 2012. Web. www.time.com Sourced March 27th 2013.
Websites references and accessed March 8th 2013:
 The participant’s names and the questionnaire are provided in appendix 2.