Much of the literature in this scoping review fell into a category of media-effects research that suggests that audiences do not critically engage . This ‘hypodermic needle approach’ to media research is based on behavioural-effects theory that tends to rely on a basic understanding of cause-and-effect and assumes that all media audiences are passive. Such studies frequently utilize strongly challenged, if not discredited, theories of direct or causal media effects, which can be problematic because they fail to take into consideration more recent and critical approaches to audience research. One key issue with audience reception is that is not easily observable, except in fragmentary or indirect ways . McQuail also reminds us that audiences are a product of social context and media provision, meaning that an audience can be defined in overlapping ways, and media use reflecting wider patterns of lifestyle, daily routines and time allocation . It would be naive to suggest that women are not influenced by TV programmes; however there are larger, more complicated issues at play in the choices that pregnant women are making. It is this literature that is missing from our body of knowledge and hence the current review.
The research conducted thus far fails to take into consideration that the relationship between cause and effect is not one way. There are many external influences that need to be considered: socioeconomic and environmental factors, fear of childbirth and lack of first-hand knowledge of childbirth. Media representations of childbirth and labour merely reflect the ideologies of society. Ideology refers to an integrated set of frames of reference through which we sees the world and to which all of us adjust our actions . Ideology controls what we see as natural or obvious and colours what we see a particular birth, or a midwifery consultation or our antenatal visit . Temple relying heavily on effects-research argues: ‘different people use the same media in different ways and for different purposes, making it likely that a newspaper will have different effects on different people. People have a well-developed capacity to suppress, forget, distort or misinterpret messages to fit their view of the world’ .
Medical/social model of childbirth
The debates about media portrayal link to the two paradigms of childbirth: the ‘social’ or ‘midwifery’ and the ‘medical’ model [56, 58]. Proponents of the social model adhere to the notion of a physiological labour and a vaginal birth with little or no external intervention  as being a normal and therefore a ‘good thing’ in itself; a model traditionally championed by midwives. The medical model, the dominant discourse, encourages women to make use of medical technology, such as monitoring and anesthesia to help reduce the perceived risks and fears associated with giving birth, and in the process move away from labour and birth as physiological processes. Proponents of the medical model argue that childbirth is only safe in retrospect , encouraging us to see childbirth as inherently risky for mother and baby. To reduce this perceived risk, a medical birth tends to occur in hospital with electronic fetal monitoring as well as a range of interventions such as forceps or caesarean sections, and typically supervised by a doctor .
Media representations often portray technology and interventions as contributing to the medical profession’s success in reducing the risk and uncertainty associated with childbirth . The problem with the promotion of interventions is that there is a paucity of evidence around the routine use of many such childbirth interventions. Leading women to believe that maternity care is designed to ‘manage’ or avert the risks for mother and baby, but often risk management is merely ‘covering’ the hospital/staff in case of litigation [17, 38, 58, 59].
It is important to take into consideration the societal ideological viewpoints of childbirth and labour, for instance, in the US, the predominant approach is the medical model; whilst in the UK both models have currency although the medical model is dominant. Some argue that UK midwives are working in a ‘blame culture’ that propagates the medical model . Changing this ideology, starting with its portrayal in the media can only be accomplished if midwives engage with popular discourses about the risks and dangers of childbirth that appear on popular reality and fictional television shows. One example of active midwifery input into fictional television is that of Terri Coates, the midwifery advisor on the BBC’s successful television drama Call the Midwife, and more recently advisor on a midwifery television drama in Bangladesh .
What needs to be taken into consideration is the notion of natural versus medicalised childbirth. Some argue that women prioritise their baby and their own safety, worry about losing control, prefer services that offer, ‘high rates of straightforward birth with guaranteed midwifery support throughout labour and a low need to admit babies to special care baby units’ and want good postnatal and breastfeeding support; thus, suggesting that a medicalised childbirth on television, might not carry over into real life (, p. 894). In the US, ‘nonmedicalised representations of pregnancy and birth [on television] would be largely absent and marginalized when they were presented, thereby being hidden from, or distorted in public discourse’ . This discourse is merely a replication of US social views that having a baby with the aid of a doctor is safer than with a midwife [5, 22]. During the 1990s US midwives tended to be depicted as self- involved, disengaged, unhelpful, and generally mean ‘caregivers’ antagonistic to a woman’s family and friends . Shallow states: ‘… the media has consistently caricatured birth as a horrendous and frightening process that anyone in their right mind would want to avoid at all cost. So who can blame women when terrified, they come to the hospital asking for an elective caesarean section’ . Fear surrounding birth, and particularly the fear of birthing outside the ‘safety’ of a hospital, may be responsible for early labour admission and the subsequent cascade of intervention [37, 38, 62].
Handfield et al. concur that childbirth in Australia has also been portrayed on television as frightening, overrepresenting deaths and dramatic life-threatening complications . It could be argued that the medical establishment puts forth a medicalised discourse, such as the one that causes fear in women, to maintain power and control over how and where women give birth. Robotham on contacting the BBC after watching particularly concerning scenes on television programmes, Casualty and Holby City, learnt that there were nurse and medical advisers, but midwifery input was lacking . This reinforces that the discourses surrounding midwifery in the media are not dominant and that seeking out a doctor is the safest way to deliver and prove that one is a ‘good’ mother. Hence midwives must engage more with media producers to ensure normal birth has a place in British-created television programming.
This review has shown that depictions of childbirth and labour indicate that women face social anxieties around their pregnancy. By watching reality television to gain an understanding of what childbirth might be like, viewers must: ‘reflect on ways they themselves must conform to the cultural institutions that surround them. People must submit themselves to the power carried within prescriptions to think and behave in normalized and normalizing ways’ , p 194.
The most commonly watched shows tend to dramatize pregnancy and birth and over represent obstetric complications and the need for interventions . Women who watch reality TV about childbirth, learn how they should and should not react, i.e. they are socialized into a particular model of childbirth. The latter process is not unique to childbirth, as Kingdon found in the study of representation of depression in the media . Whilst Lupton studying the portrayal of infants in popular media in Australia highlighted this inevitably creates unrealistic expectations of infants in real life .
Television can act as a bridge when a life change or transition is occurring, alleviating women’s social anxieties about childbirth . However, fear of birth scores were highest amongst Canadian students who attitudes were shaped by the media . It is clear from our review that women are watching television to learn what to expect during birth, to reassure themselves that they are doing their pregnancy ‘right’.
Underlying all of this is the societal discourse that suggests that it is safer for women to participate in medicalised childbirth, rather than risk a midwife-led birth (in US) or labouring/ birthing at home (in UK). To offset the encroachment of the medicalised model of childbirth, midwives must watch reality and fictional television where childbirth is the focus to be in a position to alleviate fears and answer questions posed by pregnant women. Secondly, midwives and childbirth educators must engage with media producers to create more realistic portrayals of childbirth and labour.
Strengths and limitations of this research
This review searched and assessed the literature on the effects of the media on childbirth perceptions. The evidence of media influence generally was of low quality. This scoping review only used a selection of the poorly graded evidence to illustrate the key issues. In brief, Consequently many assertions put forward in the academic literature about media influence on perceptions of childbirth are unproven since few studies have measured the impact that such representations have on women and health professionals.