Imagine placing a microphone in a room filled with tens of thousands of expectant mothers gathered to talk about their pregnancies and experiences with previous births. Around you would be first-time mothers and fifth-time mothers, poor mothers and rich mothers, white mothers and black mothers. What would you say to this audience to educate them about the implications of rising cesarean section rates?
This isn't a hypothetical question. These rooms exist virtually on Internet parenting forums. Each day, thousands of mothers across the United States go online to talk about every aspect of their pregnancies and birth experiences, including c-sections.
These online conversations present a unique opportunity to uncover women's narratives, or underlying beliefs, about c-sections. Narratives shape how we perceive the world, interpret new information, and drive decisionmaking and behavior. Understanding these narratives provides insights that can help health care organizations and advocates communicate with mothers so they can make informed decisions about c-sections.
The California Health Care Foundation (CHCF) is implementing a multipronged strategy aimed at lowering c-section rates. Insurance reform and provider education are essential to reducing c-section rates, but patient engagement — communicating with mothers about their options for childbirth — is critical.
To aid in these efforts, CHCF engaged Monitor 360, the narrative analytics and strategy firm, to explore the attitudes and perceptions expressed by American mothers about c-sections. We created a data set of thousands of posts from prominent parenting forums that contained organic conversations among mothers related to c-sections. We then used our narrative analytics methodology to analyze these posts, distill the narratives, and quantify each narrative's impact on the conversation based on how frequently it was expressed.
We identified nine distinct narratives that make up the narrative landscape on c-sections (see table of Abridged Narrative Descriptions). The landscape is diffuse: no single narrative dominates, so advocates have a range of openings to interject information into the conversation in a way that connects organically to what mothers already discuss.
The most prevalent narrative, "painful and unpleasant" (20%), reflects mothers recounting the challenges of the c-section procedure and the recovery process. Next comes "hoping for a vaginal birth" (19%), which captures mothers expressing a preference for a vaginal birth. And the third most common narrative, "sometimes it's medically necessary" (13%), was neutral toward c-sections, acknowledging that they are often unavoidable and advocating for other women to pick a trustworthy doctor to help make that determination.
A common trend persists throughout the dialogue on c-sections: The conversation is story-driven, with mothers sharing their personal experiences about birth and rarely citing medical data or scientific evidence. For advocates seeking to influence the dialogue and educate mothers, this is a critical factor to keep in mind. That's why merely releasing medical information to this community is unlikely to gain traction in these conversations. Instead, information should be paired with personal stories about — or better yet, shared by — mothers who adhere to the narratives you seek to highlight.
Strikingly absent from these thousands of conversations is discussion of how the choice of a hospital affects the likelihood of a cesarean; some hospitals have much higher c-section rates than others. Mothers do, however, often discuss doctor choice, which provides an opening to introduce hospital choice into the conversation. Lead by discussing the factors to consider when choosing a doctor, and then pivot to the importance of looking at the team around that doctor — the hospital he or she is associated with — to ensure it has an acceptable c-section rate.
While these general trends hold up across different audience segments, there is a demographic divide between mothers who say they hope for a vaginal birth and those who actively seek information to increase their chances of having one. Low-income mothers more commonly say they want a vaginal birth than middle-income mothers (32% vs. 16%), but middle-income mothers more frequently seek out hospitals friendly to vaginal birth after cesarean, or VBAC (17% vs. 7%). This same trend can be seen when comparing mothers of color to white mothers. African American mothers say they want a vaginal birth at higher rates than white mothers (39% vs. 18%), but three times as many white mothers seek out VBAC-friendly hospitals (15% vs. 5%).
This suggests that low-income mothers and mothers of color are more likely to lack a sense of control over their plans for delivery. Connect with these mothers by framing information in a way that "meets them where they're at." For example, use phrases that make women who feel powerless feel empowered: "You can influence what happens in your pregnancy. Here's what you need to know to avoid an unnecessary c-section."
Three M's to Remember
Altogether, the insights from the narrative landscape point to three key elements to effectively engage mothers:
- Messenger: Use repeat mothers as spokespeople to humanize relevant statistics in ways that will resonate. The voice of experience is invaluable.
- Message: Create a new narrative about the short- and long-term consequences of having a c-section, including immediate health complications and the increased likelihood all future births will be c-sections.
- Moment: Influence mothers' decisionmaking early in pregnancy, when they are choosing doctor and hospital, and early in labor, when c-section discussions are likely to take place.
The narrative landscape on c-sections suggests that while most mothers would prefer a vaginal birth, many are unaware of all of the consequences of a c-section or of available resources to help avoid one. Using the power of resonant narratives to engage with mothers can help advance the goal of reducing c-section rates and empower more women to make informed decisions about how best to give birth to their children.
For more information on this study, the video of a presentation by Monitor 360 is below and the presentation slides can be downloaded (PDF).