The early postpartum period for new mothers can be one of the most unique, challenging, and ideally joyous times in life, and is full of new responsibilities. Common concerns in this period include maternal physical and psychosocial issues, care of the infant, adjustments with the relationship with partner, as well as balancing new demands with preexisting responsibilities (Chivers et al., 2021). Women may feel isolated (Venta et al., 2021), overwhelmed, exhausted (Montgomery & Laury, 2019), and struggle to manage their new postpartum bodies (Liechty et al., 2018) in addition to needing to attend to the unique demands of their infants.
The early postpartum period, the first 12 weeks after birth, has been identified as an overlooked time lacking sufficient health care support for mothers in the United States (Tully et al., 2017; Verbiest et al., 2018). Maternity care in the United States is infant-centric with prenatal visits increasing with gestational age, however, following birth there are multiple of pediatric appointments for the infant while only one postpartum visit is standard. Even prior to the COVID-19 pandemic, the onus was on mothers to reach out for early postpartum support rather than support being readily available and accessible. The effects of COVID-19 on parents and families are still unfolding, though many highlight the need for a better provision of effective support (Saleh et al., 2022; Tsuno et al., 2022).
Social networking sites have been identified as an effective and increasingly popular way for mothers to connect virtually (Archer & Kao, 2018), providing a unique avenue to connect mothers to other mothers (Aston et al., 2018; Price et al., 2018). Women of childbearing age who are part of the Millennial generation and Generation Z have grown up with the internet. Connecting through virtual platforms on computers or phones and participation on social networking sites is second nature to them. Social media refers to electronic communication and online sharing on Facebook, YouTube, Twitter, and other similar sites, whereas social networking refers to individual's (or businesses) creation and maintenance of relationships on social media (Sandelowski, 2000, 2010; Shah, 2017).Mothers are some of the highest online users, with three out of four mothers accessing and using social media (Edison Research, 2019). Although research indicates mothers are highly active users of social networking sties (Baker & Yang, 2018), studies with samples of exclusively first-time mothers are limited. Increased understanding of the experiences of new mothers' engagement with social networking sites is needed to understand maternal behaviors and to augment nurses' abilities to provide improved postpartum support that is sensitive to the implications of COVID-19.
Purpose
The purpose of this study was to describe first-time mothers' experiences with online social networking sites in the early postpartum period, to explore how mothers use social networking sites to gain support, and to evaluate how those sites can aid or hinder maternal role transition.
Methods
A qualitative descriptive design was used for this study as described by Sandelowski (2000, 2010). Convenience and snowball sampling were used to invite English-speaking adult women 4 to 12 weeks postbirth, who considered themselves first-time mothers, and were active users of social networking sites. Individuals were excluded based on factors reflective of more unique experiences that would detract from the general exploration of the topic including adoption, preterm birth, admission to the neonatal intensive care unit, or mothering other children in the home. The study was approved by the IRB of University of North Carolina at Greensboro.
Participant recruitment was primarily virtual between November 2020 and January of 2021. Permission was sought from group administrators of regional Facebook mothering groups (with membership ranges from 900-6,000 members) for permission to post the custom graphic with study information. Posts were also made the primary investigator's accounts on Facebook, Twitter, and Instagram. Efforts were made to increase sample diversity (income, race, education) to compensate for limitations of recruitment through personal social networking profiles by providing a hard copy of recruitment materials to several local organizations that provided community-based care to diverse women.
Data Collection
Interested participants were provided with an electronic informed consent and screened for eligibility by the principal investigator. Twelve eligible participants participated in one semistructured interview conducted virtually by the principal investigator on Zoom between December 11, 2020, and January 19, 2021. Interviews ranged from 41 to 73 minutes in length and were digitally recorded and professionally transcribed. Participants were given an electronic $15 Amazon gift card incentive in appreciation of their time. The semistructured interview guide was developed based on the research aims and informed by Meleis et al. (2000) Transitions Theory.
Trustworthiness
Several techniques were used to enhance the trustworthiness following Lincoln and Guba's (1985) criteria. Credibility and confirmability were enhanced by use of an audit trail and field notes, and by a yearlong observation of public and private mother groups and maternal influencers on social networking sites to be able to recognize the phenomena. Transferability was facilitated by offering rich descriptions of the sample, circumstances, and context. Dependability was strengthened by having experienced qualitative researchers (coauthors) as research team members.
Data Analysis
Transcript analysis was an iterative process that followed the six phases of Thematic Analysis as described by Braun and Clarke (2006). Transcripts were read repeatedly during the familiarization phase, complete coding across the entire data set was done throughout data collection, followed by theme searching. Themes were reviewed and revised before being ultimately defined, named, and reported. By the sixth interview, it became apparent that there were loose clusters of topics forming, and data saturation was reached by the 12th interview. The final iteration of a thematic map (Figure 1) provides a visual representation of the organization and relationship of themes and subthemes. Coauthors were consulted throughout data collection and reviewed and confirmed data analysis.
Results
Twelve first-time mothers participated. Average age of mothers was 31 years (range 25-38) and for infants 9 weeks (range 4-12). Geographical representation was scattered over the east coast of the United States, with most participants living in North Carolina (NC) 7, followed by South Carolina (SC) 2, Tennessee (TN) 1, New York (NY) 1, and Florida (FL) 1. Most participants reported their race or ethnicity as White non-Hispanic (11); one identified as Latina. The sample was highly educated with the highest degree of education of seven participants a Bachelor's degrees and five who had a Master's degree. Ten participants were married, one described herself as partnered, and one was single; two participants were in same-sex relationships.
All participants indicated that they logged on multiple times a day to a variety of social networking sites primarily using Instagram (12) and Facebook (11); five participants indicated they used an account on the What to Expect app on their smart phones where they participated in a group of mothers with the same due date month (e.g., November 2020). Other social networking sites mentioned included Reddit, YouTube, Twitter, TikTok, and Glow.
Themes
Four themes were developed from the data to answer three research questions that guided this study. Each of the four themes conceptualized during data analysis is defined and described. As illustrated in Figure 1, each theme is a distinct domain representing patterns from data that were underpinned by a central concept. When viewed together as in this figure, they offer a story of the cumulative experiences of these first-time mothers moving from general to specific, ending with impact. The first theme, Habits of First-Time Moms Using Social Networking Sites, was constructed to express how first-time mothers interacted with and use online social networking sites during the early postpartum period by describing their general habits. The second theme explores what and where participants were doing on social networking sites by exploring their New Purpose Online as mothers. Theme 3, Taking it to the Moms, describes who the participants go to for support and how they use that support as first-time mothers. Theme 4, Impact on Motherhood, explains both the positive and negative influences that online social networking sties had on these participants in their maternal transition.
Theme 1: Habits of First-Time Moms Using Social Networking Sites
All participants were avid consumers of online social networking content, though when asked, the women struggled to provide a specific number of minutes or hours engaged. Social networking site usage was associated with infant activities; women logged in during infant feeding or napping sessions. Online habits reportedly increased following birth; social networking sites were accessed more frequently and at new times, both the day and night around every 2 to 3 hours, while adjusting to infant feeding and napping schedules and mothers increased their amount of time alone.
Frequent content access and reliance on social networking sites as a source of information and support was evident from the participants' descriptions, yet they themselves indicated that they rarely posted or commented in maternal groups. Reticence to initiating posts or commenting on discussions was attributed to their lack of experience as well as the plethora of existing information accessible to them online. As Laura said, I would say in the beginning I was really just receiving it [information] and I wasn't really participating. It's a lot of information, but I would say I mostly just consume, like I'm not putting any parenting advice out there, because what do I know at this point? Not very much.
There was a wealth of content available on social networking sites. Susie said I haven't [posted] because, normally, I can find someone else's questions. So, I don't have to. Often a topic or question has been posed in a group forum and by using the search function that information was freely accessible to participants.
The combination of high usage but limited identifiable input from participants can be thought of as an invisible footprint. Their presence may appear undetectable to the online community because the participants themselves were infrequent initial posters of questions or comments. Therefore, their names or presence are not evident, making them passive consumers. Participants expressed that they wanted to be able to find the information and support, but they did not necessarily want to actively participate by posting questions or comments online. They preferred access to a virtual maternal community that served as a repository of relatable content and human connection that was low maintenance. Fiona described an appreciation for a passive consumer-type relationship with access to the information. You can still interact and get responses from people who you may never talk to again. And that's okay because there are a million other people out there who will be there the next time for you and for that other person who you're no longer going to talk to again. It's not personal. The power to take or leave information without having the normal ongoing maintenance of a relationship allowed participants access to a variety of information and support that they needed on their own terms and without additional work on their part.
Theme 2: New Purpose Online
Prior to pregnancy and birth, social networking sites had been mostly reserved for amusement and online socialization, with some minor informational access. With a new baby, limited social interactions with the outside world due to COVID-19 social isolation guidelines, and new questions, participants described using online networking sites for a new purpose. Their reasons for repurposing them were underpinned by a sense of urgency in their desire to obtain time-sensitive and specialized information quickly during feeding and napping stretches of time. This offered access to content, newly relevant to them as first-time mothers, that was quite literally at their fingertips. Participants were occasionally surprised that social networking sites now functioned as a source of information. Wendy expressed that the main difference in her purpose was content, Before, I was looking on Instagram or social media in general just for, I guess you can say, pleasure. And now I actually look for information.
There was an overall appreciation for what could be processed during a short time frame. Carleigh said, ...it's all just bite-sized, so it's really easy for me to just quickly see it as I'm nursing him. That's kind of the only time I'm on my phone. Descriptive images and charts, also known as infographics, were preferred ways of having information presented because they were quickly digestible and consolidated information in an easy-to-understand format.
Participants sought posts about intimate topics that ranged from things that are just not common knowledge to first-time mothers to taboo topics that they might not call a provider for or feel comfortable asking in their peer or family group. Wendy described, Things that you might be a little embarrassed about, I guess. It's kind of nice to do a check-in anonymously first. And then once you see that there are 1,000 posts on this exact question, then you're like, "Okay. This is very common."
Many of these first-time mothers expressed an appreciation to stay in the loop in a general way to all thing's motherhood. Exposure to accessible information while home on strict quarantine was helpful because it helped them be prepared for both upcoming infant and maternal milestones. Stacey wanted to stay aware of what was to come: ... obviously, we're not anywhere near that point yet, but I just thought it was interesting to have an idea of what that [baby led weaning] meant because I had never even heard that term before.
Theme 3: Taking it to the Moms
The importance of peer-to-peer support from fellow mothers and the value of access to a virtual motherhood collective was discussed repeatedly by the participants. Women expressed that they did not want just anyone to contextualize their experiences or advise them. As Wendy said, I wanted to check in with other moms before overreacting ... so, yeah, I went to the moms. Fellow mothers were preferred as a primary source to help understand and process motherhood.
The mothers sought new group memberships and began following other individuals and influencers, which broadened their existing social networks. Nola articulated the impact of COVID-19 that other participants reported stating that social networking sites served as an extra way to connect with people in a time that we can't connect with people the way we normally would. In-person interactions due to the pandemic were extremely limited, and social networking sites provided an opportunity for human interaction.
Most women had joined at least one new group on Facebook related to mothering; many women had joined multiple groups. Group membership varied and was often a blend of regionally based groups and larger national groups. Local birth organizations like doula groups, birth centers, or groups organized by city or even neighborhoods gave women access to information that was specific to their region. Larger groups often centered around a specific identity, like breastfeeding or bottle-feeding, working mothers, baby products, exercise, or were organized by an organization (e.g., LaLeche League). Groups could be open or closed; participants indicated that they preferred closed groups. Closed groups provide a safe space for sharing experiences. Susie explained, ... closed groups are really nice, just because you know that, if you post something in there, it can't go out to the whole world. It's just the people in that group.... So, if you feel like you can open up and actually be more honest and stuff, admit that you're struggling without being like, "Okay. The entire world's going to know this."
Traditional health care professionals were valued as a source of information, but participants indicated that what they needed was reassurance from fellow mothers, which was different from the type of support they received from health care providers. Wendy said, ... knowing it's okay clinically is nice, but also just seeing another person post the identical question was comforting. They were able to access information and support that woman might not receive from their providers.
Time was often of the essence; participants wanted information or support faster than the time frame that could be offered by health care providers. Susie explained, ... with social media and stuff, it's easier to find stuff faster instead of trying to call my doctor and wait for them to respond...I can go look online and be like, "Okay, make sure I'm not completely off-base here."
Theme 4: Impact on Motherhood
Social networking sties affected motherhood in both positive and negative ways. It was described as a way to find emotional support, information, camaraderie, and reassurance from fellow mothers. Several participants expressed the loneliness of early motherhood was heightened by the isolation felt from strict quarantine during COVID-19, and several participants described how being part of a virtual maternal community ameliorated the loneliness. Wendy said, that for her family it had been a ... strict quarantine year because I was pregnant or had a newborn. So, we haven't been doing literally anything. It's been very at home, not seeing friends. We went to a couple very outdoor, lots of distance from people a couple of times. But it's like been a very solo year. So, I think I would have been in a much worse place if I didn't have these [social networking site] resources right now.
Access to a modern motherhood collective served as an important touchstone of support that offered validation and reassurance and helped to orient these participants to the new normal of motherhood. In addition to orienting to a new reality of motherhood and gaining wisdom from the motherhood collective, several participants indicated that social networking sites served as a helpful source that defined motherhood in a more truthful way. Societal norms promote a form of perfection with a smiling happy baby and mother appearing to sail through motherhood without issue. New mothers in this study recognized this online and understood it for what it was-a falsehood. However, social networking sites were also able to offer a different, less perfected, and more truthful version of motherhood presented in comments and images that illustrated what they called the real side of motherhood. Tina explained, I feel like a lot of this stuff I follow is very realistic, where it's like, "Yeah, everything's a mess and that's okay. If you're even whatever, you're probably doing fine." ... I feel like that perspective is always very helpful for me. It's like you're alive, you're breathing, you're good. You don't need this whole image thing.
Struggles with body image, both pre- and postpartum, were brought up by several participants who indicated appreciated postpartum body positive content on social networking sites. Posts that reframed postpartum body changes as beautiful, because those changes are an important part of growing a baby, provided reassurance. Nola said, it's helpful for me to see people that do have postpartum stretch marks and their bodies haven't bounced back perfectly, because body image hasn't always been the easiest thing for me.
Social networking sites made motherhood easier through the provision of anticipatory guidance, empowerment and validation of experiences, and access to specialized content and support, all of which cumulated into increased self-assurance. Carleigh stated, it's hard to imagine my life without it...It definitely makes me feel more confident that I've turned over every stone in a way versus kind of just going off of what my sister-in-law would say.
These sites offered the ability for women to choose who they followed, yielding a curated feed that represented their needs and values. Susie explained how challenges for single mothers were very different than mothers who parented in a partnership. She was able to gain specific information that she found relatable to her circumstances by being a part of online groups that met under the shared identity of single motherhood. Access to other mothers and families that represented nontraditional norms was helpful because it provided increased exposure and parenting variations that were relatable. Another mother explained, ... it's nice to see other LGBTQ parents, just because it's a much different path to having a baby if you're not in a homosexual relationship.
Without access to online networking sites, early motherhood would have been more difficult. Laura stated, I feel like I would have less information but also less camaraderie with other people who are going through the same thing even though I have no real interaction with them other than consuming the content or viewing what they're doing. The ability to have a form of human connection and access to a shared experience and maternal identity was described by these participants as having a positive impact on their motherhood experience.
Significantly, social networking sites were not described exclusively as places of positivity and support. Participants described exposure to behaviors that they characterized as negative and unsupportive of their maternal journey. Whether they were experiencing mother-shaming personally or witnessed it online, new mothers expressed sensitivity to criticism and guilt imposed online. These new mothers expressed that they already felt judged enough by themselves, and they were sensitive to not adding a toxic online dialogue. Susie said, Life's hard enough as it is without the judgments of everybody else. It's like, as a mom, you're constantly already worried, "Am I doing the right thing? Am I being a good mom? Is my baby acting correctly? Am I missing something?" For first-time mothers in this early postpartum period, polarizing opinions on social networking sites appeared at times to hinder their maternal transition because it made them question themselves and their choices rather than offering a safe space to explore which infant and maternal choices were the right fit for their family and circumstances. Two examples of commonly polarizing topics include the breast versus bottle-feeding and fed is best, or to sleep training methods like attachment parenting or crying-it-out. Wendy explained, My worst thing was when I couldn't breastfeed, I got really depressed, like I was starting out I was a bad mom is what it felt like. She went on to attribute that in part to the social stigma about bottle-feeding that she described seeing online. Laura expressed But there's also so much, like, extreme stuff... there'll be, like, people who are like, oh, you have to sleep-train your baby. No, never sleep-train your baby. It's like people have very, very polarizing viewpoints, which can be confusing.
Participants described a range of reactions to negativity online that ranged from simple frustration to shame and sadness they attributed to internalizing toxic and judgmental opinions online. Stacey's reaction was on the milder end of the spectrum. Stacey said, Because if there's a bunch of people talking about how horrible something is, it doesn't necessarily make me have a negative response, but sometimes it's frustrating. Laura's experiences provoked a deeper emotional reaction and consequently forced her to question her choices in a way that was not productive. Laura said, ... this is the way, and every other way is wrong, it makes ... yeah, it makes me have this icky feeling inside, because it's like they're telling me what I'm doing is wrong, which logically I know is not true, but it doesn't leave a good emotional ... it doesn't leave good emotions.
The overall impression from the collective experiences of participants was that they had a high degree of understanding of the limitations of online interactions and proficiency in navigating away from sources that did not support their maternal experiences. Tina explained, I feel like I've intentionally built the following or the people I follow to serve that purpose rather than like ... I don't go on it to get stressed out. Several of the participants used the popular adage, take it with a grain of salt, to sum up their perspective on how to manage negative stereotypes and information online. Being savvy and lifelong users of social networking sites was perhaps an advantage, as many women expressed an ability to rationalize need to keep things in perspective before reacting to opinions and advice posted on social networking sites.
Discussion
Our results supported previous findings that mothers are active users of social networking sites (Baker & Yang, 2018). Participants expressed a strong desire for access anytime to relatable content online presented in manageable bite-sized chunks, such as infographics (Lupton, 2016). Mothers appreciated the convenience of quick and easily available information online (Aston et al., 2018), as well as access to a large network of fellow mothers (Nolan et al., 2015). A major function of social networking sites was to fulfill socialization and informational needs in a convenient and private way (Baker & Yang, 2018). Access to groups in which intimate or sensitive topics were discussed online was very valuable (Alianmoghaddam et al., 2019; Lupton, 2016) as social networking sties offered a safe space for mothers to have access to this content while being provided with some degree of anonymity (Teaford et al., 2019).
Unique findings were how intent first-time mothers were on inundating themselves with content and experiences of fellow mothers online without leaving a footprint. The mothers were adept at curating networks to surround themselves with online groups or influential individuals that resonated with their values and identities. Social networking sites offered a form of maternal empowerment to source information in way that was convenient and relevant to them. A connection with fellow mothers, as opposed to more traditional avenues (family, health care professionals), helped women feel less alone and a part of something bigger amidst a global pandemic. Like the findings of Nolan et al. (2015), participants expressed that having access to a large motherhood collective available online 24 hours a day, 7 days a week (24/7) was convenient to their 24/7 infant care schedule and that they were able to use social networking sites for both information gathering on demand and camaraderie. Though existing literature indicates that virtual social networking sites offer increased access to groups of mothers which can serve to reduce isolation (Teaford et al., 2019), our findings deepen an understanding of how valuable their access can be during early maternal transition.
Previous literature has described online networking use for mothers as a complementary form of support (Archer & Kao, 2018). Yet these new mothers, in their descriptions of behaviors and patterns online, indicated that virtual social networking may play a more important role in their early maternal experience than previously recognized. First-time mothers were sensitive to their novice status and were unlikely to interact by posting or commenting online in groups or to individuals they followed outside of their personal network of friends and family. The online activity, though invisible, was often a first stop for many maternal and neonatal support needs.
The negative associations with online networking sites for new mothers have been noted previously (Archer & Kao, 2018; Liechty et al., 2018). Unique to this study was the adeptness at which these mothers seemed to identify misrepresentations or negative posturing online, and how they worked to mitigate that negativity. Many mothers expressed how they were selective of specific groups and individuals to follow in the first place so that what they saw on feeds then offered a more truthful or accurate reflection of motherhood and represented their own values or interests. They described skill with navigating the online environment to see less of what was unhelpful and more of what catered to their individual maternal needs and their own personal value systems.
Implications for Nursing Practice
Participants highly valued the peer perspective on social networking sites. Often, nurses are able to guide and support new mothers, communicating with first-time mothers at discharge, in the clinic, or home settings. Assistance with identification of the plethora of relevant groups or reputable influencers online could provide a head start to new mothers for accessing relevant online content. Nurses can be prepared to offer recommendations and encourage their patients to customize online participation based on their needs and interests. This unique form of online peer access is relevant, though not limited to, life in a pandemic world. Because mothers appreciated access to both larger national online networking groups as well as smaller, local groups, nurse familiarity with existing social networking sites, groups, and influencers is beneficial.
Nurses need to be well versed in recognizing mother guilt and shaming online and consider ways of offering more accurate information and perspectives. Nurses and nursing health care organizations should recognize the impact of strong position statements related to infant feeding or other early issues in the postpartum period. Targeted professional messaging should be supportive of the experience and honor the maternal journey, inclusive of maternal experiences.
Nurses are a part of one of the most trusted professions and often serve as a bridge between the dominant discourse and patient experience. Because participants found nurses as credible, there are opportunities for nurses to take on larger roles on social networking platforms. As we know virtual and time-sensitive access to information is highly valued, offering nurse-based telehealth is another opportunity for future research and development. Lactation, postpartum depression screening and support, new mother and infant care, are topics maternity nurses could provide education specifically to support needs of women in the early postpartum period. This education would avoid the siloed services provided in many current situations and be accessible online.
Limitations and Recommendations for Future Research
The sample is predominantly White women who make up only 51% of mothers nationally (Centers for Disease Control and Prevention, 2021). There is a risk of selection bias due to the recruitment method though mitigation attempts were made through additional recruitment within local organizations. Active users of social networking sites were recruited and are not fully representative of all first-time mothers.
Conclusion
Our findings contribute to a descriptive glimpse of experiences that some first-time mothers have as high, though invisible, users of social networking sites in the early postpartum period for information and camaraderie. Overall, participants found social networking sites an indispensable part of their maternal transition that made motherhood easier and reduced the isolation felt during the COVID-19 pandemic. Nurses should be aware of existing online opportunities to support new mothers and for future involvement online.
SUGGESTED CLINICAL IMPLICATIONS
* New mothers are avid users of social networking sites, and though their usage may be invisible online, it should be recognized an important form of social support and information during the early postpartum period (and during the isolation of a global pandemic).
* There is a plethora of online social networking groups that offer convenient 24/7 access to information, peer support, and camaraderie; nurses should be able to recommend credible sites and accounts.
* Social networking sites are customizable by the user; first-time mothers feel empowered and validated to be able to access information relevant to their type of birth, family structure, and unique postpartum and newborn needs.
* COVID-19 and social distancing have changed the way new mothers interact, online social networking sites offer valuable virtual forums for mother-to-mother and mother-to-nurse support.
* Nurses are trusted sources for health care information, they should be familiar with how first-time mothers use online social networking sites and consider opportunities for disseminating necessary new mother information on virtual platforms.
INSTRUCTIONS First-Time Mothers' Invisible Presence Using Social Networking Sites
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References