Abstract
While the Internet has emerged as a significant resource for women negotiating the questions and circumstances that arise during conception, pregnancy and childbirth, it remains unclear what role the Internet plays in challenging the current biomedical paradigm and empowering women to make meaningful choices. This article explores how women use the Internet to manage their pregnancies and mediate their doctor–patient relationships, particularly examining the role of social class and personal health history in shaping such Internet use. Drawing from in-depth interviews with white middle-class mothers, the findings show that rather than using technology to resist the dominant biomedical paradigm, most women turned to online resources that affirmed mainstream medical authority and continued to rely on their doctors. By providing the means to confirm normalcy and take control in their reproductive experiences, the Internet enables socially privileged women to more fully perform the informed patient role in order to demonstrate their competence as mothers.
Introduction
Women on the road to motherhood today face a barrage of questions and uncertainties arising out of the increased number of choices in reproductive technologies and information sources related to fertility, pregnancy, and childbirth. Information and advice once provided by other women in one’s family and community now filter through a wide array of medical professionals, books, magazines, TV programs, and most recently, the Internet. These decisions are further complicated by the social pressures on mothers to conform to cultural expectations (Douglas and Michaels 2004; Hays 1996), including those applying to the use of scientific and medical knowledge (Apple 2006). For these reasons, negotiating the many health decisions surrounding expectant motherhood is an especially complicated endeavor.
In the midst of such pressures, pregnant women, like other patients, are turning to the Internet to help them navigate the decisions they must make about their health (Cline and Haynes 2001; Fox 2008, 2011; Fox and Jones 2009; Korp 2006; Pew Research Center 2003). Women consistently outpace men when seeking health information in general (Brown et al. 2002; Fox 2011), and they exhibit notably high levels of Internet use when gathering information about pregnancy and childbirth in particular (Fox 2011; Lagan, Sinclair, and Kernohan 2010). While many hope that such information-gathering will lead to healthier lifestyles and better decision making, how it actually shapes women’s experiences with their fertility and the American health care system is not yet clear.
This article explores how white middle-class women use the Internet during their experiences of conception, pregnancy, and childbirth and ascertains the degree to which such usage challenges the current biomedical paradigm, empowers women to make meaningful choices within that paradigm, and further shapes their identities as patients and as mothers. We first review the feminist and sociological literatures on birth and medicine with particular attention to the Internet’s role in doctor–patient relationships and its significance in relation to the feminist critique of medicalized reproductive care; we also explore the dual cultural narratives of the informed patient and intensive mothering. Then, using data from in-depth interviews with 32 new mothers, we identify key factors that motivate and influence the information-seeking habits of women who possess both class and racial privilege. Their personal accounts suggest that Internet usage for women with these advantages is often complex, driven by expectations to become informed patients, while relying on the authority of doctors and mainstream medicine to affirm their roles as good mothers. Further, their interactions with the Internet and their health care providers are shaped by their past reproductive experiences, suggesting that personal health history is a key facet of patient identity that must be considered when studying the ways different groups make decisions about their health.
The Internet’s Role in Doctor–Patient Relationships
Many have welcomed the Internet’s “democratizing impulse,” as it gives patients access to wider resources for information and support, and results in a “new medical pluralism” (Barker 2008; Cant and Sharma 1999; Cline and Hayes 2001; Ferguson et al. 2007; Hardey 1999). It is particularly valuable for women as some have shown how blogs and message boards provide access to alternative models of maternal health, and social and emotional support rooted in other women’s stories, advice, and encouragement, thus equipping them to better evaluate their choices and challenge expert knowledge (Hardey 2001; Lupton 1997; Ratliff 2009; Romano, Gerber, and Andrews 2010).
At the same time, several studies have critiqued the simple “information = empowerment” equation and questioned the degree to which the Internet subverts traditional relationships of power between doctors and their patients (Broom 2005; Henwood et al. 2003; Nettleton et al. 2004). While some studies show that the practices and outcomes of Internet use are fundamentally contingent on the severity of individuals’ health needs and their information literacy skills (Fox and Rainie 2002; Morahan-Martin 2004), others report that the Internet remains secondary in priority and trustworthiness when compared to individuals’ reliance on doctors, friends, and family (Bernhardt and Felter 2004; Lagan, Sinclair, and Kernohan 2010; Longo et al. 2009). Furthermore, because doctors are often resistant to the introduction of online information into doctor–patient encounters (Ahmad et al. 2006; Blumenthal 2002; Dow, Kearns, and Thornton 1996; Helft, Hlubocky, and Daugherty 2003; Muir 2002), patients avoid discussing their acquired knowledge with their doctors (Nettleton et al. 2004; Ziebland 2004). This self-censorship attests to the mutual recognition that the Internet’s potential to upset the asymmetry of power in traditional doctor–patient relationships has led to greater unpredictability and complexity in those interactions. This increased instability in the doctor–patient relationship takes on heightened significance when set in the context of feminism’s critique of the current biomedical paradigm of reproductive care.
Feminism and Medicalization
A primary target of criticism lobbied by the women’s health movements in the late 1960s and 1970s was the unequal power dynamics in the doctor–patient relationship. This feminist critique of women’s health care has argued that modern obstetrics and gynecology has medicalized physiological processes of female bodies, redefining them as pathologies in need of scientific expertise and management rather than viewing them as constitutive to the ordinary life cycle (Davis 2007; Ehrenreich and English 1978 [2005]). Specifically in the area of pregnancy and childbirth, “the triumph of the male medical profession” (p. 38) in the early twentieth century succeeded in convincing middle-class women to abandon the woman-centered model of care practiced by midwives and begin having their babies in hospitals by promising safer and less painful births (Wertz and Wertz 1977 [1989]). With this “medicalization of reproduction” (Reissman 1983) and subsequent expectations that women wholly rely on their doctors’ expertise, the concern was that “authoritative knowledge” ceased to be passed down through generations of women (Jordan 1978 [1993]) and that women had lost agency over their bodies and their fertility (Litt 2000; Martin 1992; Namey and Lyerly 2010; Rothman 1991). Consequently, efforts to raise awareness about the prevailing male and medical dominance over women’s bodies sought to help women reclaim control and ownership over their reproductive experiences primarily through the sharing of information (Green and Baston 2003; Viisainen 2001; Zadoroznyj 1999).
However, this narrative is complicated by the fact that women participated in and often welcomed medicalization, especially the use of anesthesia (Leavitt 1986; Longo et al. 2009; Rapp 2000; Wolf 2009). It is also complicated by the ways that race and class shape women’s experiences with fertility and medicine (Fraser 1998; Solinger 2005). Because of the history of sterilization abuse and the widespread distribution of the risky contraceptive Norplant, for instance, Black women have many reasons to distrust the mainstream medical system (Fraser 1998; Litt 2000; Roberts 1997), while white women are freed from those particular concerns. Also, given the costs and limited availability of health insurance, consumer choice is often a class privilege (Fein 1986; Smith and Moore 2008; Starr 1982). As a result, while working-class women tend to exhibit more fatalistic views of childbirth (Williams 1995), middle-class women take for granted a level of conscious control over their circumstances (Brubaker 2007; Davis-Floyd 1992; Martin 1992; Nelson 1986; Zadoroznyj 1999). Looking at how social class not only affects the material circumstances of women’s fertility but also shapes the cultural capital—the range of knowledge, skills, and dispositions (Bourdieu 1986)—women bring to their understanding of fertility (Williams 1995; Zadoroznyj 1999), let us consider how the particular cultural ideals of the “informed patient” and the “good mother” become salient factors in women’s reproductive experiences.
Cultural Ideals of Patients and Mothers
Having long problematized the authoritative status of doctors (Freidson 1970; Illich 1976; Starr 1982), medical sociologists have observed a process of deprofessionalization that has undercut doctors’ cultural authority and fueled the emergence of the informed patient ideal (Imber 2008). While the previously discussed women’s health movements may have helped galvanize the larger patient population to shed the Parsonian “sick role” of passive submission, parallel developments of an increasingly impersonal system of medical care along with the growth in corporate health industries have demanded that patients become involved and knowledgeable consumers of health care, and in turn, that doctors adequately equip patients with explanations and information that enable them to make informed choices (Barker 2008; Hardey 1999; Imber 2008).
The informed patient then is someone who exhibits her competence by being responsible, self-aware, vigilant, and savvy to the contemporary landscape in which expert knowledge has been destabilized and manufactured risk is integrated into everyday life (Beck 1992; Giddens 1991). The informed patient expects to work in collaboration with her doctor for she knows better than to be “unquestioningly accepting of expert opinion, but faces complex problems too difficult to solve on her own” (Barker 2008, 28). When translated to the area of reproduction, pregnancy and childbirth are rendered as medical processes demanding particular goods and services that address increased uncertainty and risk. In order to take on the informed patient role, pregnant women are encouraged to adopt a consumer orientation that relies on a high level of reflexivity, intentionality, and careful research (Nettleton et al. 2004; Slevin 2000; Taylor, Layne, and Wozniak 2004). As corporate health industries frame these goods and services as “personal choices,” women are apt to view their health care—and, subsequently, information about their health—as a commodity to be acquired (Kelly-Powell 1997). A key premise to this commodification of health care is that patients must possess sufficient capital—in the way of economic resources, social networks, and cultural knowledge (Bourdieu 1986)—to gain access to and act on this wide array of choices. In this way, a woman’s desire and ability to capably perform the informed patient ideal is strongly connected to her social location.
In addition to performing her identity as a patient, a woman entering motherhood must negotiate another script found in the prevailing ideology of intensive mothering (Hays 1996). On this model, “the proper approach to raising a child” requires mothers to be primary caregivers, to spend “copious amounts of time, energy, and resources on the child,” and most important for our purposes here, to “acquire detailed knowledge of what experts consider proper child development” (Hays 1996, 8-9). To the extent that the expectations of intensive mothering become internalized, they function as a Foucauldian “technology of the self” which disciplines and regulates individuals from the inside out (Martin 2003). In this way, such technologies of the self exert their power by making “natural” those inclinations, dispositions, and practices that are in fact culturally constructed. Like the informed patient ideal, this cultural narrative of who is or is not fit to be a mother is also implicitly racialized and classed (Collins 1999; Hays 1996; Roberts 1997; Solinger 2005), so that women with race and class privilege are more favorably positioned to attain the ideals of intensive mothering. For instance, Roberts has shown how pervasive cultural stereotypes of “welfare queens” and domineering matriarchs have created a “lurid mythology of Black mothers’ unfitness” that casts Black women’s fertility in pathological terms (Roberts 1997, 21). Further, these images not only free white women from being labeled unfit mothers based on their racial identity, they often provide the comparative basis against which white women’s mothering is valued (Solinger 2005). Because of the way racial and class politics figure into cultural narratives of maternal identity, women are likely to experience the pressures of good mothering in ways particular to their social location.
The convergence of intensive mothering and informed patient ideals works to create a particularly powerful technology of the self for white middle-class pregnant women. Given the isomorphism between intensive mothering’s emphasis on appropriate and time-consuming parenting and the informed patient’s ideals of vigilance, reflexivity, and obligation, we argue that these pregnant women experience the combined dictates of these two identities as moral imperatives, so that expertise and knowledge about one’s choices are no longer merely matters of consumer-savvy and one’s personal sense of well-being but laden with responsibilities of making the best choices for one’s child. In exploring how white middle-class women use the Internet to negotiate the careful combination of information gathering and acknowledgement of medical authority prescribed by the informed patient role, we argue that these online practices foreground the multiple ways that the economic, social, and cultural capital particular to class privilege are critical to how these women seek to demonstrate their fitness for the job of motherhood.
Methods
The data for this analysis were collected as part of a descriptive study on the information-seeking habits of women in five areas of early motherhood: conception and fertility; pregnancy; labor and delivery; child’s feeding and nutrition; child’s health and safety products. The findings are based on in-depth interviews in which women discussed how they found information about their particular circumstances and concerns within their experiences of conception, pregnancy, and childbirth. Thirty-two women were interviewed between November 2008 and March 2009. Using a snowball-sampling technique, two of the researchers began by contacting women in their existing social and professional networks who were pregnant or who had given birth within the past year. These initial sources were then asked for referrals to other women who fit the selection criteria. 1
Participants in the sample ranged in age from 24 to 36 years. All but one identified as Caucasian. With the exception of one person, all the participants were college educated, almost half of whom held advanced degrees. Most participants had household incomes of $80,000 or more. The greater majority lived in the Southeast region of the United States. 2 About one-third of the sample already had at least one older child before this recent pregnancy or birth (See Table 1 below).
Demographic Profile of Participants
Clearly, the generalizability of these findings is limited by the sample’s homogeneity in class and race. However, rather than generalizing from this small sample, we view this group of women as representative of the social strata best positioned to amass and strategically utilize the information and support available online to manage their reproductive experiences. With material circumstances, cultural capital, and information literacy that enables them to not only choose from, but also take for granted, access to a wide array of resources, services and practices—such as fertility treatments, childbirth education classes, prenatal testing, or birth plans—these women represent the social strata most likely to reflect the image of the good mother as informed patient. In particular, our findings suggest that paying attention to the Internet usage and its impact on white middle-class women’s reproductive experiences can help show that race and class privilege not only grants access to means of control in one’s reproductive health care, but in turn reifies the cultural expectations for motherhood that women in these privileged groups place on themselves.
Furthermore, a critical feature of this sample is its wide range in personal experiences of conception, pregnancy, and childbirth. The similarities in the participants’ demographic background allow a focus on the ways pregnant women’s health history might shape their relationship to information-seeking online and medical authority. While 10 participants experienced no significant maternal or fetal complications, nine dealt with infertility, with several opting to pursue in vitro fertilization. Eight participants experienced miscarriage in prior pregnancies. One had a full-term, stillborn child and another had decided to terminate conjoined twins in utero. For women most likely to have the capital necessary to alter the traditional doctor–patient power dynamic, we explore how this variance of experience becomes a meaningful factor that influences their information-seeking practices (See Table 2 below).
Participants’ Personal Health History
Participants may experience more than one complication, thus are counted more than once.
The interviews ranged in duration from 30 to 60 minutes, and were conducted one-on-one by phone or in person at participants’ homes, workplaces, or neutral public settings. Participants were first asked to share as much or as little as they felt comfortable about their decision to have a child, and if relevant, their decision to undergo fertility treatments. Then, participants were asked to describe their selection of health care provider, any complications experienced during pregnancy, and plans for childbirth. If they had already given birth, the participants were asked to discuss the birth experience and subsequent decisions made in selecting a pediatrician and various practices and products common to early childhood needs such as feeding, health, and safety. With particular attention paid to the processes of information seeking, the interviews specifically explored how and why women used the Internet during pregnancy, what types of information they sought and how they evaluated it, particularly in relation to the information they received from their primary health care provider.
Interviews were recorded, transcribed, and analyzed following the inductive approach of grounded theory (Bartlett and Payne 1997; Strauss and Corbin 1990). Strauss and Corbin’s guidelines were followed for open coding in the first reading of the transcripts to determine salient categories in the participants’ reproductive experiences and Internet use. Analyses focused on how much medical intervention participants’ maternal or fetal circumstances involved; the quality of their relationship with their doctors, social networks, and family; and their degree of reliance on other information sources such as books, pamphlets, the Internet, etc. Next, axial coding was performed to examine the connections between participants’ reproductive health histories, dispositions toward research, and intensity of Internet use.
For this analysis, low and high intensity of Internet use was determined according to the participant’s own description. Nonexistent, occasional, or regular searches online such as checking weekly updates on fetal development were considered low intensity. Active participation in online message boards or “obsessive” searching (as self-described by several women) was deemed high intensity. Using this schema, half of the participants were categorized as low-intensity seekers, while the other half were high-intensity seekers. Women with complicated health experiences were those who experienced any of the following: prior fertility or pregnancy-related medical intervention; maternal–fetal testing results suggesting major complications; pregnancy-related complications; any cases involving consultation of specialists. Women with uncomplicated health experiences were those characterized by uneventful pregnancies that did not require any additional medical intervention. With this criteria, approximately two-thirds of the participants had complicated reproductive experiences, while the remaining one-third were considered uncomplicated. Informed consent was obtained by all participants. In the following section, we will explore key uses of the Internet that both shape and reflect how white middle-class women understand and make decisions about their conception, pregnancy, and childbirth experience. Pseudonyms are used to protect participant confidentiality.
Searching the Web for Reassurance
One of the primary ways that the Internet functions in pregnant women’s lives is to confirm not only knowledge but also perceptions and experiences of what is “normal” in reproductive experiences. As one would expect, this desire for reassurance and confirmation of one’s normalcy is particularly evident among first-time mothers. The sheer newness in physical and psychological experience of becoming a mother for the first time is not only fraught with some excitement and anxiety, but these emotions also can be exacerbated by competing normative visions of what pregnancy and childbirth ought to entail and what risks are involved. Therefore, with every notable change, questions such as “Is it Normal?” and “Is it going to be OK?” loom large in women’s minds. In this study, while participants often spoke of seeking information and reassurance from medical professionals, family, and friends, along with pregnancy guidebooks like What to Expect When You’re Expecting and Pregnancy: Week to Week, they also turned to the Internet as well.
Even at the stage of conception, one woman looked online to address her uncertainties:
I was on the Internet all day. Like, any sign I was wondering if that was a sign that I could be pregnant, thinking every month I was pregnant. Or even how to get pregnant, like how long the sperm was in you. I was just constantly on the Internet looking at how to get pregnant and what I should be doing.
Another participant explained how joining a cohort of women online became a source of community that provided a comparative basis for her experience:
I actually used BabyCenter a lot, in fact, it was an obsession. . . . But it was funny because everyone was due about the same time that was in my group . . . and we could compare with other people’s situations, especially before anyone found out if they were having a boy or girl, they wanted to find out, “Well, did you?” [and] “Were there certain signs for when you found out?”
In anticipation of learning the sex of her baby, this participant became caught up in her online group’s discussions of the expectations and outcomes of the 20-week ultrasound. In this way, marking this stage of “normal” prenatal care becomes ritualized through the comparison of choices in routine medical procedures (“Well, did you?”), and comparison of reactions to and interpretations of those events (“Were there certain signs for when you found out?”).
With the exception of two individuals, all of the study’s participants used the Internet to seek health information. As reflected in prior studies (Bernhardt and Felter 2004; Lagan, Sinclair, and Kernohan 2010; Morahan-Martin 2004), most of these women—especially those experiencing first-time pregnancies—used commercial information websites such as WebMD or BabyCenter to keep track of projected fetal development. For specific concerns or problems, participants tended to use search engines such as Google or Yahoo! to find answers. Mainly motivated by a desire to confirm that “I’m not the only one” or “I’m not doing anything wrong,” most did not look beyond the first two pages of search results. It is critical to see that these desires for reassurance reflect neither a lack of trust nor complete reliance in medical expertise. Rather, women want to know that what they are already doing and believing matches the practices and beliefs of other mothers, along with fitting within the accepted medical paradigm. Compelled to ensure that their chosen efforts at appropriate motherhood are shared ones (Hays 1996), such standard practices of monitoring one’s pregnancy is not only consistent with the informed patient ideal but also feeds off women’s determination to perform the role of the good mother.
While women with uncomplicated reproductive circumstances sought information on the Internet to verify that their experiences were within the scope of what is considered “normal,” others who experienced complications in their fertility or pregnancy also used the Internet to manage uncertainty and confirm the normalcy of their particular experience. By validating their own struggles through other women’s personal accounts of similar challenges, the Internet became a crucial source of support and healing. As one participant admitted, she looked to message boards after her diagnosis of infertility to “alleviate the fears that it is not just you.” For several participants who had miscarriages, reading other women’s stories and interacting online with others who also had experienced loss brought significant comfort. As one woman shared:
I only knew about the Baby Center [sic]. So I went on there and I didn’t realize how many people had miscarriages. I think that is something that most people think, “it only happens to me,” and I thought that. But . . . I ended up finding out that a lot of people had the same situation as me. And about two months after when I started trying again, I found The Nest Baby online . . . which was really neat because they had a whole online support group for . . . trying to conceive after loss which was really cool. . . . I started to read some of their posts . . . and just started talking to people as well.
In this way, even though maternal or fetal complications may locate women outside the normalized ideals of the pregnancy experience, especially those expressed in the week-by-week fetal development narratives, online access to others’ personal testimonies gives women a second chance to employ strategies of normalization, thereby identifying themselves within the company of other good mothers (Brubaker 2007; Hays 1996).
As much as the Internet successfully confers a sense of normalcy and validation of women’s personal experiences, the vast range of stories and information available online can also create an unpredictable terrain that women must carefully negotiate. With the anonymity and social distance of online interactions allowing individuals to share highly personal details with little social cost, expectant women who seek information online can be easily exposed to “horror stories” that catalog the risks involved in pregnancy and childbirth. These accounts cause some to “freak out” as several participants lamented, and lead them to become the “worried well” as they fret over unlikely scenarios and risks (Barsky 1988; Imber 2008). Because pregnant women must—and according to the prevailing ideology of intensive mothering, are morally obligated to—ensure optimal health not only for themselves but also for their children, the fear-inducing effects of such stories can be exacerbated. As one woman who had undergone in vitro fertilization admitted: “I very easily can scare myself by things you can find on the Internet. So, I worried and I still worry about fertility drugs that I have to take and what effects that will have.” Another participant who experienced a miscarriage explained:
I ended up reading all those stories about people who lost their baby and trying circumstances. . . . I had to stop doing that kind of thing. And because there’s all that information that’s available to you, through blogs or through the Internet, you can type in one keyword and get all kinds of things. My husband made me quit because he kept finding me in tears.
Across these varying contexts in which women seek reassurance online, it is clear that standards of normalcy are, on the one hand, highly relative and informed by each woman’s personal reproductive experience. On the other hand, as the Internet increases women’s capacities to vigilantly monitor their health status, it reinforces a highly reflexive approach to one’s reproductive experience that conforms to the idealization of birth experience common to privileged women (Zadoroznyj 1999). Further, such vigilance mirrors the ways that popular commercial information websites frame “normal” pregnancy in terms of medical information (i.e., what to expect at the next doctor’s appointment, what medical risks each stage carries, etc.) and consumer choices so that a woman’s main job is to manage risk through the acquisition of the right products, the right information, and the right relationship with her health care provider (Seigel 2006). Therefore, as the Internet allows women to educate themselves about their health care, it also works to institutionalize a new set of expectations and standards of competence to which women must adhere in order to be considered savvy informed patients and, at the same time, capable mothers.
Going Online to Take Control
In Lagan, Sinclair, and Kernohan’s study (2010), 99.3 percent of pregnant women reported acquiring information “on their own” as the primary reason for going online. Notably, this reason outranked supplementing their doctor’s view, checking information for symptoms, control over decisions, and gaining confidence to talk to their doctor. In the following narrative of how Internet use became an integral part of one participant’s diagnosis and decision-making process, we can see how desires to acquire information on one’s own easily become felt obligations.
Three years ago, Joanne had given birth to her first child after nine months of struggling to conceive. Now, she had spent an entire year trying unsuccessfully to get pregnant again and decided it was time to take control of her situation:
I thought that I might have endometriosis. So I went and did a Google search on endometriosis, and found that I have like every symptom. So from there, I went to the doctor. And before he even examined me, he said I was going to have to have surgery because he thought I had endometriosis. He was pretty sure. And so from there, I had surgery and I was doing a lot of searches trying to find as much information as I could, because I was labeled as infertile at this point.
Having been told that her first child had been a “miracle,” she explained that it “ended up opening a whole new realm for trying to have a baby and . . . for at least two months, I was glued to the Internet doing searches trying to figure out what were the best options for me.”
After Joanne’s diagnosis, her Internet use was driven by a consumer orientation as she felt the need to sift through the many choices in fertility treatments available to her. She decided to undergo in vitro fertilization and discussed the Internet’s role in that decision-making process:
If I had not had the Internet and just had to rely on the information the doctor gave you, I really don’t feel confident that that is all there is to the story. I never feel confident that they are going to tell you every single thing that you need to know. So I thought it was my job—if I was going to do this—to learn about it.
Joanne felt that being a good mother meant making it her “job” to initiate her own line of research and supplement the doctor’s information. As an informed patient, her lack of confidence in her doctor is significant because it was not borne out of any negative encounters. Rather, Joanne’s skepticism stemmed from her assumption that doctors are careful gatekeepers of knowledge who filter what they present to their patients. While she continued to value her doctor’s role in managing her health, she believed that it was her obligation to go online and learn more for herself, and more importantly, she possessed the cultural capital to do so.
Joanne’s use of the Internet confirms Ziebland’s (2004) assertion that because of the unprecedented convenience of information online, researching health information emerges as a means to “display a particularly modern marker of competence and social fitness” in order to satisfy the “felt imperative to be (or present oneself as) an expert and critical patient, able to question advice and locate effective treatments for oneself” (p. 1792). This “felt imperative” is further amplified when it overlaps with the opportunity to demonstrate the ideal mother who can skillfully interact with and assimilate scientific information (Apple 2006).
At the same time, pregnant women’s inclinations to seek information on their own may be also motivated by dissatisfaction with the quality of information or care offered by their doctors (Lagan, Sinclair, and Kernohan 2010). Several participants in the study felt rushed during doctor’s visits or a lack of support from their doctors. For one participant, Karen, her Internet use became part of her search for alternative discourses as she grew increasingly dissatisfied with the obstetrician she had randomly selected because she was new in town:
I won’t choose the same OB again if we have a second child. She was very busy. . . . She was not extremely helpful. I would come in with a list of questions for her and she would go through the list [as] quickly as possible with her hand on the door, waiting to leave.
Experiencing little support from her obstetrician when Karen sought meaningful engagement, she went online, read books, took Lamaze classes, hired a doula, and researched natural childbirth on her own. When asked about talking with her doctor about a birth plan, Karen replied:
I don’t think she would have been receptive to that. I talked to her about natural childbirth stuff and she said, “Yeah I kind of tried that with my kid. It doesn’t really work. You can do what you want to do.” . . . She didn’t say no. Obviously, she couldn’t say no. She just didn’t care one way or the other. She was just like, “Well isn’t that nice you want to do natural childbirth.” So nothing came from her as far as the natural stuff.
As her due date approached, the relationship further declined when her obstetrician recommended that Karen induce labor:
She was afraid that I was going to get too big. And that was really the one thing I didn’t want to do. I did not want to have an induction. I was okay if I ended up needing other things, but I didn’t want a c-section and I didn’t want an induction. . . . I figured the baby was going to come out when the baby was ready to come out. And I didn’t want to push it for my convenience or for doctors’ legal issues. And for the c-section, it was the same thing. I just kind of preferred that it would all go as naturally as possible.
For Karen, the Internet became a powerful means of self-education when she found herself at odds with her obstetrician. However, it is important to note that her resistance to her obstetrician’s prescriptions did not necessarily translate into a desire to challenge the authority of mainstream medicalization. In fact, Karen acknowledged that her own medical background as a veterinarian led her to seek out medical or scientific information from commercial or government websites rather than look to personal blogs and message boards—in her words, “the average-person sites.”
By having mainstream medical perspectives made more accessible and user-friendly through commercial information websites, the Internet appears to reproduce, perhaps even exacerbate, the dominance of the biomedical paradigm of reproduction rather than encouraging women to resist it. In this way, the Internet’s role in unsettling the doctor–patient relationship may be better understood, not as a direct critique of mainstream medical models, but rather as a by-product of women’s attempts to prove themselves both as informed patients and good mothers at the same time. Karen and Joanne’s efforts to seek information online demonstrate how white middle-class women performing these two roles in tandem can amass and utilize medical information in order to make informed decisions about what of their doctors’ advice to accept and what to reject (Apple 2006). Information, and the ability to sort through and apply that information for the health of one’s child, allows these women to demonstrate their competence in negotiating these two scripts while still working within the dominant medical system. 3
These examples suggest that how much the Internet is able to help women live up to the cultural ideals of the informed patient is dependent on how effectively women can amass the necessary cultural capital to negotiate the expanse of health information that is available online. Therefore, rather than empowering middle-class women toward autonomy and control in their reproductive experiences, the Internet becomes an integrated part of the technology of the self internalized to enforce the ideals and expectations of the informed patient and intensive mothering narratives. However, even within this social group, women’s Internet usage varied according to their personal health history. It is to this dynamic that our attention now turns.
Embodied Knowledge and Internet Use
As previous studies have argued, despite the type of medical pluralism that exists online, many patients are satisfied to trust their doctors exclusively and have no desire to take responsibility or seek information for themselves (Henwood et al. 2003). As one participant in the study remarked:
I am not an Internet junkie and . . . I am not one to over-research and I only look at things once they come up. And I trust what people tell me, if I have a question about plumbing, I am going to call a plumber and trust what they are going to tell me. The same was true with my doctor.
Another woman explained that because she “loved” her doctor and believed that “her word was gold,” she felt little need to search for information online. While satisfaction with exclusive reliance on one’s doctor may be related to an individual’s personal dispositions as the first participant suggested in distancing herself from the “Internet junkie” label, the fact that these two women quoted above did not experience any complications in their respective fertility or pregnancies suggests that personal health history and embodied experience shape women’s information-seeking practices as well.
In this study’s analysis of how personal history factored into women’s Internet use, women with more complicated reproductive circumstances were more inclined to not only rely on the expertise of their doctor but also aggressively seek information online (see Table 3 below). This finding indicates that women with complications were not content simply to submit to their doctors’ authority. Rather, their online searches suggest an active desire to manage perceived risks on their own and acquire control over their reproductive experiences. However, as the following example demonstrates, these women combined their impulses to seek information online and depend on medical authority, thus expressing simultaneous distrust and reliance on medical expertise.
Personal Health History and Online Information-Seeking Intensity
After trying to conceive for a year, Hillary went to consult her doctor, who then referred her to a fertility specialist. Until this point, she had not felt inclined to go search for any type of health information online. Things changed, however, when the specialist suggested that Hillary consider intrauterine insemination (IUI):
I was not ready for that yet. My husband was ready to do it, but I just didn’t feel like I was ready yet. That was probably in September. And in October, I got pregnant . . . and then had a miscarriage. I felt pretty good about the fact that I didn’t go in for the IUI because obviously something [else was the cause]. Probably stress related. . . . So that is when I started looking online for articles because [my doctor] had really pushed us to do fertility, and I felt like, maybe that was not necessary. So I started looking online at websites where people had posted their stories, and also just googling infertility, cycles, that sort of stuff, IUI—all the stuff we had come across but not really researched.
Hillary was initially satisfied to rely on medical expertise, but when skeptical about the specialist’s recommendation—especially given her embodied experience—she went online to search for other options. Like other women whose prior reproductive experiences fuel a heightened sense of personal efficacy (Browner and Press 1996; Zadoroznyj 1999), Hillary trusted the legitimacy of her own health experience and was emboldened to assert more ownership over her health care by going online to research alternative reproductive options. However, because she was reluctant to directly challenge the specialist, she demonstrates how patients can be both actively involved in managing their health care but constrained in developing a full partnership model of doctor–patient relationships.
From this, we can see that personal health history can function in two ways: first, women with complications may find themselves more reliant on medical expertise in order to address their needs. Second, they may feel compelled to acquire more information than the traditional doctor–patient relationship provides. As Hillary’s case clearly demonstrates, these two functions are certainly not mutually exclusive. In a subsequent pregnancy, Hillary exhibited the same tension between skepticism and dependence on medical experts when faced with the prospects of fetal complications.
During a standard ultrasound to determine the sex of the baby, two choroid plexus cysts—commonly regarded as soft markers for Down syndrome—were noted. Because markers noted in prenatal screenings often go away on their own, her doctor gave Hillary and her husband the standard recommendation to “wait and see.” However, as she explained, Hillary and her husband found this situation unbearable and turned to the Internet for resolution on their own terms:
We always go to our doctor for information. But she specifically said, “Do not look up information about these things because it is only going to scare you. I am making an appointment for you with the perinatal specialist.” . . . We actually had an appointment within the week. It was really fast. And [our doctor] even said, “My son had one [marker] and it didn’t go away until after he was born . . . but it went away and didn’t cause a problem.” But she said that she had never seen two before, and that kind of concerned her. And so I was devastated. And we came home and [my husband] said, “Screw that, I am going to look it up.” And I said, “Don’t look it up. I don’t want to know. I don’t want to know.” And he goes, “Well I won’t tell you then.” And he WebMD’d it and he also looked at message boards of people who had. I don’t know if it was a site about it, but a bunch of parents had messages and really, it was all phenomenal information because all of them basically said, it’s no big deal. . . . He read some of the stuff to me and it was all really good stuff. The parents who had posted on the message boards had said, “Our son had two and he was fine. No problems, they went away.” Well, come to find out that a lot of babies get choroid plexus.
Though she found emotional relief through other parents’ comments and stories found online, Hillary still did not experience complete reassurance until she received word from the perinatal specialist: “The specialist made us feel a hundred times better and of course, by the time we went for our next checkup, it was gone.” Therefore, while the Internet has the potential to reassure women in their uncertainties, the kinds of information that will resonate with them and how they will incorporate it into the doctor–patient dynamic is sensitive to each woman’s particular needs and prior reproductive experiences (Fox and Rainie 2002; Henwood et al. 2003; Lupton 1997; Nettleton, Burrows, and O’Malley 2005). For Hillary, she was sensitive to risk, proactive in seeking information, longing for emotional reassurance, skeptical of authority, but still dependent on the legitimacy of an expert’s viewpoint. The Internet strategically helped her to manage her emotions during the waiting periods in between encounters with her doctors. Hillary’s circumstances and actions are indicative of not only the reproductive options that come with economic privilege but also the sense of efficacy and control commonly exhibited by middle-class women (Nelson 1986; Zadoroznyj 1999). Yet even with these abundant resources, Hillary never mentioned bringing the information she had acquired online into her doctor–patient encounters. She was content to employ the Internet privately to manage her emotions and expectations. As Nettleton, Burrows, and O’Malley (2005) argued, some people “do not necessarily want to be ‘empowered’ or become ‘experts’ in illness or disease, and all the responsibility that this might confer” (p. 974). In this way, the reality of everyday practices within doctor–patient relationships does not live up to the visions of collaboration implicit in the informed patient role. Instead, in the modern patients’ drive to reduce risk and uncertainty, they are always moving between the desire to depend on established medical authority and taking action on their own (Lupton 1997).
Conclusion: Mothers as Informed Patients
As the Internet becomes increasingly integrated into women’s journeys through pregnancy and childbirth, this study’s findings suggest that women’s motivations to seeking information online are extremely varied and complex. Among women positioned near the top of the social hierarchy—and thus privy to a fair degree of agency and control when managing their reproductive experiences—reliance on Internet resources often does not indicate an abandonment of traditional doctor–patient relationships. Undoubtedly, several participants found other women’s personal accounts and alternative discourses of pregnancy and birth to be extraordinarily meaningful and empowering. However, the majority of women who turned to the Internet seeking reassurance and control in uncertain circumstances relied on resources that affirm mainstream medical authority while casting normative childbearing in terms of making the right consumer choices.
Rather than using their information gathering online to replace traditional sources of medical authority, the participants in this study employed that knowledge to complement the trust they invested in their doctors and in the mainstream biomedical paradigm. In their doctor–patient relationships, participants often walked the tightrope between being resistant and compliant, skeptical and dependent, a skill that requires enough cultural capital to negotiate both the complexities of the health care system and the universe of health information online. Therefore, rather than embodying technological empowerment, we argue that these pregnant women’s Internet use better represents a fully reflexive performance of the informed patient role employed to demonstrate their competence as mothers. We also suggest that a key component to the successful assimilation of those identities is class privilege and that the performance of these identities function as a technology of the self, which works to internalize and maintain the class structure out of which the informed patient and ideal mother ideologies emerge.
Clearly, there is much more to learn about how women’s use of the Internet works in relation to the biomedical paradigm, normative discourses of reproduction and mothering, and structured inequalities of contemporary American society. Our data suggest that paying attention to the kinds of information and social interactions women are utilizing to make health care decisions can tell us much about the skills necessary to negotiate such a varied terrain. Also, in addition to race, class, nationality, and age, future research might consider the ways that women’s embodied experiences and professional status may shape how women use the Internet and how such usage functions in the medical system. Understanding how the Internet facilitates and constrains women of particular social locations in their abilities to make meaningful health care decisions is one way to expose the normalization of the informed patient narrative and how it affects all women’s journeys to becoming mothers.
Footnotes
Authors’ Note:
The authors thank Joya Misra, her editorial staff, and five anonymous reviewers for their extremely helpful comments on earlier drafts of this article. The authors also thank Ashley Kirzinger and Emily Wascom for their work transcribing interviews. This work was supported by the Doris Westmoreland Darden Professorship and the Remal Das & Lachmi Devi Bhatia Memorial Professorship of the Manship School of Mass Communication, Louisiana State University.
Notes
Felicia Wu Song is a cultural sociologist and Assistant Professor in the Manship School of Mass Communication at Louisiana State University. She is author of Virtual Communities: Bowling Alone, Online Together (Peter Lang, 2009). Her research focuses on the intersections of digital technology, community, identity and consumer culture.
Jennifer Ellis West earned her Ph.D. in English from Louisiana State University in 2011 in Rhetoric, Writing, and Culture. Her dissertation, Birth Matters: Discourses of Childbirth in Contemporary American Culture, reflects her interests in rhetorics of science and medicine, feminist science studies, and medical humanities. She is currently Adjunct Professor of English at Mississippi College.
Lisa Lundy is an Associate Professor in the Manship School of Mass Communication at Lousiana State University where she teaches public relations. She earned her PhD in 2004 from the University of Florida. She currently serves on the editorial board for the Journal of Applied Communications.
Nicole Smith Dahmen is an Assistant Professor at the Manship School of Mass Communication at Louisiana State University. Her research focuses on ethical and technological issues in visual communication. She also has a special interest in health and science communication.