The relationship between digital media use during pregnancy, maternal psychological wellbeing, and maternal-fetal attachment.

The widespread accessibility and use of the internet provides numerous opportunities for women to independently seek out pregnancy-related information and social and emotional support during the antenatal period. Given the heightened psychological vulnerability of the pregnancy period there is a critical need to examine digital media use within the context of the feelings that women have about themselves and towards their fetus. The current study examined the relationship between digital media use during pregnancy, psychological wellbeing and their maternal-fetal attachment using an online survey. Forty-eight pregnant women completed a self-report questionnaire on their reasons for using digital media, and standardised measures of self-criticism, negative affect, social quality of life (QOL), and maternal-fetal attachment. The mean age of participants was 29.4 years (SD = 5.26), with a mean of 24.3 weeks gestation (SD = 9.95). Information seeking, emotional support and social support were highly endorsed reasons for digital media use (85.42%, 66.67%, 62.5% respectively). However, digital media use was positively correlated with negative affect (p = .003) and self-criticism (p < .001). Digital media use was also negatively correlated with QOL (p = .007). There was no evidence of a relationship between digital media use and maternal-fetal attachment (p = .330). Digital environments may be an important social context within which a pregnant woman develops her own maternal identity and knowledge. There are a number of benefits and limitations of this medium for providing information and support for women during pregnancy. Enhancing the opportunities to promote pregnant women's wellbeing in this context is an important avenue for further research and practice.

Introduction

Pregnancy represents a time of transition that can be rewarding and challenging, both physiologically and psychologically [1]. Although pregnancy is regarded as a positive time by many women, common sources of reported distress include loss of sense of self, changing physical appearance and comparison to other women, concerns about not bonding with their baby, and the possible impact of the distress itself on their developing fetus [2]. A significant number of women experience mental health issues such as anxiety and depression in the antenatal or postnatal periods [3, 4]. Changes in maternal wellbeing occur across pregnancy and postpartum, with high maternal distress particularly prevalent during the third trimester compared to 12 weeks postpartum, and significant decreases in health related Quality of Life (QOL) across this transition [5].

The social context within which the positive and negative experiences of pregnancy are occurring extends well beyond in-person interactions. Digital media comprises of many forms of digital technology that allow for the dispersal of information including; informative websites and applications on a smart phone [6]. A large component of digital media is social media, which refers to internet-based channels of mass communication enabling interactions among users, with the content being primarily user-generated [7]. In the general population, digital media use (e.g., the internet) is widespread. An estimated 90% of Australians report that they are on social media, with adults spending an average of 2.6 hours per day using social media [8]. Similar figures are reported in the USA [9] and UK [10]. Within this context, pregnant women are increasingly using the internet to access social and emotional support [11-13], and as a source of information on pregnancy-related topics such as nutrition [14]. Although only one study [15] has examined the impact of technology on maternal mental health in pregnancy, finding limited association, the authors argue the importance of further investigating the type of technological activities undertaken to understand how they facilitate social support and wellbeing. Given that pregnancy is recognised as a time of heightened psychological vulnerability [16], and the limitless opportunities for accessing information and support from online sources, there is a critical need to better understand the relationship between digital media use and the wellbeing of women during this important life transition.

Social support plays an important role in maintaining psychological wellbeing during this time. Akiki et al. [17] found that women who receive greater social support from their family reported feeling significantly less anxious than those who did not. Pregnant women and new mothers have reported that they use and value digital media for providing access to emotional and social support from their family, friends, and other new mothers [11, 18], as well as an immediate source of information [12]. By connecting with other expecting and new mothers through online forums, there is the opportunity to discuss topics that a woman may not feel comfortable sharing with their family and friends or with others in face-to-face settings [19, 20]. In individual interviews conducted by Johnson [20], women who were becoming mothers for the first time reported gaining knowledge and support from reading other women’s stories in online mothering spaces. Although some women reported the usefulness of actively participating in online social interaction, by asking questions or commenting on other women’s posts, the majority of women reported benefiting from these online spaces while remaining anonymous and engaging only as an observer. In focus groups, women have also reported using apps and websites to obtain regular information (such as about stages of pregnancy), intimate information considered too private to discuss with friends or family, practical information on parenting, and to gain reassurance and support when worries arise [11, 12]. Research has also found that pregnant women are using the internet to skilfully navigate information and avoid anxiety caused through information-seeking [21], to find information independently and to gain additional information to that provided by their healthcare professional [14, 22].

While internet use appears to help meet the “information need” of women during pregnancy [22-24], online searches and behaviours that might be driven by a women’s need for reassurance about herself or her pregnancy could reinforce anxiety. For example, if a woman places high expectations on herself about how she should be feeling and what she should be feeling during pregnancy, it can lead to feelings of guilt and self-criticism [2]. Priel and Besser [24] found that measures of self-criticism were negatively correlated with social support in first-time mothers, with the authors suggesting that women with high self-criticism may see social support as limiting one’s autonomy and reinforcing their perceived inadequacy as a mother. Similarly, Felder et al. [25] found severity of depression and anxiety scores to be positively associated with self-judgement and isolation, and negatively associated with self-kindness. Increased self-criticism and decreased self-compassion have also been identified as risk factors for developing depression [26]. Given that women report using online forums, apps, and websites to gain reassurance and support when worries arise during pregnancy and early motherhood [11, 12], and to read other women’s stories [20], it is important to better understand the extent to which digital media use may interact with feelings of self-worth and self-criticism.

In addition to the psychological wellbeing of the woman as an individual, an emotional connection may also begin to develop during pregnancy from the woman towards her fetus. This emotional bond has been referred to as Maternal-Fetal Attachment (MFA) [27]. Although there is some contention over the best way to define this bond in terms of the traditional attachment relationship [3], MFA broadly refers to the mother’s attempts to love, care for, and protect her unborn child. It is during this process that a woman develops her identity as a new mother, develops an identity for her fetus, and learns about the relationship between herself and her fetus [28]. The extent to which women engage in behaviors that represent a relationship with their unborn child forms the basis of the child’s socialization process. When attachment figures do not exhibit nurturing and protective behaviors towards their infants, the infant’s social, emotional and cognitive development may be impaired [29, 30]. This same consequence can be seen if these behaviors are not observed during pregnancy, highlighting the importance of enhancing MFA [31, 32].

Although limited research has examined links between MFA and digital media use, initial studies suggest that digital technology which provides opportunities for social and emotional support may be related to MFA, in the same way that traditional social support has been found to be related to MFA [33]. Using semi-structured interviews and focus groups, Ross [34] found that the interviewees enhanced their MFA through technologies that allow visualization of the developing fetus. Another study focused on the effect of ultrasounds on MFA, and found that there was a significant difference in MFA from before the scan to two weeks after [35]. These studies suggest that being able to visualize one’s fetus, either through an ultrasound or through digital media, may be associated with higher levels of MFA. Recent research suggests that the use of smartphone apps may increase a mother’s capacity for ‘mind-mindedness’, which may predict secure infant-caregiver attachment [36], indicating that the use of digital media may have positive consequences for the mother, child, and their developing relationship.

The literature reviewed above confirms the significant role that internet searches, online discussion forums, and apps, play in supporting the health information seeking and decision making of women during pregnancy [11, 12, 14, 21–23]. However, possible relationships between digital media use, women’s psychological wellbeing, and the developing maternal-fetal relationship during pregnancy have yet to be examined. The aim of the current study is to explore the relationship between social, emotional and informational support through digital media and a woman’s psychological wellbeing, including negative affect, social Quality of Life (QOL) and self-criticism, and MFA during pregnancy.

Methods

Participants

Participants were women recruited during the antenatal period. Inclusion criteria was being pregnant and having a proficient understanding of English to complete the surveys. The study was open to women of all gestational ages. For the purposes of recruitment, a Facebook post describing the study was generated. This included a brief description and a direct link to study consent information and survey. The recruitment post was posted on various mothering, pregnancy support and community groups on Facebook Australia-wide. Further recruitment was facilitated by the snowballing method. Recruitment occurred across a 3 month period, from May to July, 2018. Attrition was greatest at the beginning of the study, with 140 individuals indicating their consent to participate, but only about half of these (n = 72) completing the first questionnaire. To be included in these analyses, participants were required to complete the entire questionnaire package (final sample n = 48 described below). This research was approved by the University of Wollongong Human Research Ethics Committee (approval number 2018/162).

Measures

Digital media questionnaire

A Digital media questionnaire (see S1 Appendix) was developed for the purposes of this study. The questionnaire contained 13 preliminary questions, and 11 questions that were used to determine a Digital Media Use Score. Questions were informed by the themes of information seeking and providing reassurance that have been identified in previous research conducted with Australian women examining experiences of using digital media for pregnancy and parenting purposes [11–13, 37]. Preliminary survey questions asked participants to select the forms of digital media they used during this pregnancy, to order the relative importance of online and in person sources of pregnancy advice and resources, and to select their main reasons for digital media use. Follow-up questions on information seeking addressed timing of use, including in relation to doctor/midwife appointment, and reasons for doing this. For two questions, the opportunity for a free text explanation was provided if a yes response was given: “Do you use digital media to find information regarding the development of your fetus during this pregnancy?” and “Do you use digital media to find information regarding your health during this pregnancy?”. The frequency of digital media use for information seeking, and for social and emotional support was determined through six-point Likert scales (more than five times a day, two to five times a day, once a day, three to five times a week, one to two times a week and less than once a week). Three additional questions which focused more specifically the individual’s frequency of updating of social networking sites and perceptions on the credibility of social media profiles were not included within the current study analysis.

The final section of the questionnaire presented 11 statements which focused on the individual’s cognitions, subjective experiences and social comparisons made on digital media. Example items included, “I use digital media to interact with other parents-to-be”. Response options were given for these questions on a five-point Likert scale from (1 “never” to 5 “always”). Responses scores for these statements were summed to provide a Digital Media Use score, with a higher score indicating more frequent usage of digital media for pregnancy-related information and support. Reliability analysis for these 11 statements indicated acceptable internal consistency α = .95.

Depression, anxiety and stress scale-21 (DASS-21)

The DASS-21 is a 21-item self-report questionnaire that assesses psychological distress experienced over the past week [38]. The DASS-21 contains three subscales: depression, anxiety and stress. Respondents rate on a scale from 0 to 3 (never, sometimes, often, almost always) the extent each statement has applied to them over the past week. Examples of statements include: “I found it hard to wind down” and “I felt that I was using a lot of nervous energy.” As we were interested in using the measure as a broad indicator of negative affect, we generated a mean score rather than analysing each domain separately [39]. The range of these mean scores were 0 to 42, with higher scores indicative of higher levels of negative affect. The DASS-21 shows high reliability and internal consistency [40] and exhibited a high level of internal consistency in the current study, α = .95.

Depressive Experiences Self-Critical Subscale-6 (DEQ-SC-6)

The DEQ-SC-6 [41] is a six-item measure of trait self-criticism derived from the original Depressive Experiences Questionnaire [42]. Participants responded to statements on a seven-point Likert scale (1 “strongly disagree” to 7 “strongly agree”). The scores were summed and higher scores were indicative of higher levels of self-criticism. Examples of statements include “I find it hard to accept my weaknesses” and “I compare myself often to standards or goals”. Reliability analysis indicated acceptable internal consistency α = .86.

The World Health Organisation Quality of Life Scale (WHOQOL-Brief)

The WHOQOL-Brief was developed by the World Health Organisation (WHO) [43] as a shortened version of the WHOQOL-100, measuring quality of life, applicable across cultures. The WHOQOL-Brief contains 26 questions across four domains: physical, psychological, social relationships and environment. The items are scored on a five-point Likert scale, with mean scores derived for each domain and multiplied by four to be comparable against scores in the WHOQOL-100. As we were interested in social quality of life, only this domain was interpreted in the present study. Higher scores are indicative of higher social quality of life. The WHOQOL-Brief has good reliability and internal consistency [44], and exhibited a high level of internal consistency in the current study, α = .93.

Maternal-Fetal Attachment Scale (MFAS)

The MFAS is a reliable and valid 24-item scale developed by Cranley [28] to measure maternal-fetal attachment. One item that asks participants about self-harm behaviour was removed from the present study, due to the research not being conducted in a clinical setting and researchers being unable to provide appropriate action to participants’ responses. Higher scores on the MFAS were indicative of higher MFA. Reliability analysis indicated acceptable internal consistency α = .89.

Demographics form

The demographics form was comprised of 36 questions developed for the current study. It consisted of questions regarding personal demographics (age, country of birth, marital status, and education levels) and pregnancy-related questions (current gestational age, current and previous pregnancy history).

Procedure

Participants were invited to complete the anonymous survey online via the platform Survey Monkey. After clicking on the invite link, participants were presented with the participant information sheet followed by the consent form. Participants gave their informed consent by checking the “I agree” box on the bottom of the consent form. Participants could withdraw at any time by exiting the survey. No questions were compulsory to answer, and the questionnaire was voluntary and non-commercial. No incentive was given for participation.

Data analysis

Data was analysed using the Statistical Package for Social Sciences (SPSS). Pearson correlations and Spearman’s Rho were used to assess the relationship between overall digital media usage from the 11-Likert scale questions and each of the measures of psychological wellbeing (DASS-21, DEQ-SC-6 and social QOL), as well as the age of participants. Qualitative responses from the digital media survey were used to assess the reasons behind digital media usage during pregnancy.

Responses to open text questions were analysed using thematic analysis. This study adopted Braun and Clarke’s [45] procedure for using thematic analysis to analysis qualitative data within psychology. Provisional codes were identified by the first author (MS) to capture participant comments that were noteworthy and which featured regularly. These were checked by the second author (AM) and categorised into themes which were then reviewed by the research team to ensure they were reflective of the data’s narrative and research aims.

One-way between groups analysis of variance was used to compare the difference in MFAS scores between participants who used digital media for social and emotional support either less than once a week, between once and five times a week, and between once to more than five times a day. One item in the stress scale of the DASS-21 was written incorrectly, so answers to this item were treated as missing data. The mean score of the other six items of the stress scale were used in replacement for the missing data to enable correct scoring and scale use [39].

Results

Participant characteristics

Participants (N = 48) were between 19 and 43 years of age (M = 29.4, SD = 5.26), with the majority indicating that they were born in Australia. The remaining countries of birth were USA (n = 7), New Zealand, UK, Poland and Vietnam (all n = 1). A wide range of gestational ages were reported, ranging from 2 weeks to 39 weeks, with a mean of 24.3 weeks gestation (SD = 9.95). Table 1 outlines the demographic information of the participants.

Table 1

Participant demographics.

		Participants (n = 48)
Mean age in years (SD)		29.4 (5.26)
Place of birth	Australia	72.9%
Highest qualification
	University Degree	47.9%
	Vocational Qualification	22.9%
	Completion High School	10.4%
	Completing Year 10 or less	14.6%
Married		64.6%
Pregnancies
	Primipara	46%
	Multipara	54%
Gestation in weeks (SD)		24.3(9.95)
Planned pregnancy		72.9%
Pregnancy from fertility treatment		8.3%
Previous miscarriage		27.0%
Employment	Full time	41.6%
	Part time	27.0%
	Unemployed	25.0%
	On leave	6.3%

Table 2 presents a summary of mean, standard deviation and range of scores for outcome measures.

Table 2

Mean (SD) and range of scores on key wellbeing outcomes.

Measure	Mean (SD)	Range
Maternal-Fetal Attachment (MFA)	88.8 (12.33)	54–112
Total DASS-21	8.7 (8.53)	0–53
Social domain QOL	68.4 (20.55)	17.67–100
Self-criticism (DEQ-SC-6)	21.9 (8.58)	6–42

Digital media use during pregnancy

The majority (85.42%) of participants endorsed information seeking as a reason for using digital media during their pregnancy. Social support (66.67%), emotional support (62.5%), and sharing photos (43.75%) were also endorsed as common reasons for using digital media. Only one participant indicated that none of the listed reasons were why they used digital media, and provided their own response of “having down time”. The mean digital media use score was 34.7 (SD = 7.04; ranging 14 to 51), indicating that these participants were frequent users of digital media for obtaining pregnancy related information and support. As shown in Fig 1, a significant negative bivariate correlation was found between digital media use and age, r(46) = -.34, p = .018, with younger users more frequently using digital media for pregnancy information and support than older users.

Fig 1

Linear relationship between overall digital media usage for information and support during pregnancy and the age of participants.

In response to the question, “Do you use digital media to find information regarding your health during this pregnancy?” the following themes were identified: determining what is normal, and information and reassurance seeking (e.g. food safety, common symptoms and relief, nutrition and exercise). Table 3 presents example quotes for each theme. Eight participants (16.67%) indicated that they did not use digital media for information seeking regarding their health.

Table 3

Indicative quotes and their respective themes regarding digital media health information seeking during pregnancy.

Theme	Example Quotes
Strategies to manage physical and mental wellbeing during pregnancy	“Yes. Mainly concerning symptoms and how other mums found relief”
	“Google things I’ve been told after appointments to double check what I was told”
	“[I searched for] recipes and exercises”
	“How to deal with the extra emotions and anxiety”
Reassurance seeking	“Yes. Searching for whether symptoms are normal for the stage of pregnancy I am at…”
	“Not really. Health (sic) I would usually ask the doctor. I only google to find out if something is normal”
	“In regards to my chronic illness and new medicine to treat it and its affects on pregnancy”
	“Have been researching possible reasons for bleeding during pregnancy”

Table 4 presents common themes regarding why participants engaged in this type of information seeking, and the percentage of participants that endorsed each theme. The majority of participants indicated that they used digital media to find information regarding the development of their fetus, with only n = 6 (12.5%) participants indicating they did not use digital media for this purpose. A small portion of participants (n = 6, 12.5%) indicated that they were not likely to use digital media for information seeking before an antenatal appointment. For those likely to use digital media before an appointment, the most endorsed reasons for doing so were to prepare for questions (n = 33, 68.75%), to ease nerves (n = 33, 68.75%), and to feel knowledgeable (n = 32, 66.67%). Only two participants indicated ‘other’ reasons, and specified these as “reviews on doctor” and “just to get a general idea”

Table 4

Key themes in response to using digital media to track development of fetus and the percentage participants endorsed each theme.

Theme	Percentage
Track size and growth of fetus	70.83
Prenatal health, i.e. diet and exercise	14.58
Symptoms to expect	10.42
Not specified	4.17

Digital media use and MFA

A one-way between groups ANOVA was conducted to determine if MFA differed between three groups of digital media use for social and emotional support. Participants were divided into three groups based on their amount of digital media use for social/emotional support: less than once a week, (M = 90.8, SD = 3.85, n = 14), between one and five times a week (M = 88.5, SD = 2.85, n = 17), and daily use (M = 87.5, SD = 3.44, n = 17). The assumption of normality was violated for the less than once a week group (p = .047), however, the test is considered robust to violations given the sample size. There was no evidence to suggest that MFA scores differ as a function of usage frequency for social and emotional support, p = .788.

The size and direction of the relationship between the overall score of digital media usage and MFAS were analysed. The Pearson’s correlation was positive but non-significant, r(46) = .144, p = .330, indicating limited evidence to suggest a relationship between MFA scores and overall digital media use for information or support (see Fig 2).

Fig 2

Linear relationship between overall digital media usage for information and support during pregnancy and MFA scores.

Digital media use and psychological wellbeing

To determine whether a relationship existed between digital media use, negative affect, social QOL, and self-criticism, separate correlation analyses were performed. Regarding negative affect, DASS-21 scores were ranked to conduct a Spearman’s Rho test of correlation due to normality violations (p < .01). Results indicated the presence of a significant positive correlation between ranked DASS-21 scores and digital media usage, rs = .415, p = .003, two-tailed, n = 48. A Spearman’s Rho test of correlation indicated a negative relationship between ranked social QOL scores and the score of digital media usage, rs = .39, p = .007, two-tailed, n = 48. A Pearson’s correlation indicated a positive relationship between self-criticism (DEQ-SC-6 scores) and digital media use, r(46) = .50, p < .001. (see Fig 3)

Fig 3

Linear relationship between overall digital media usage for information and support during pregnancy and self-criticism scores.

Discussion

The aims of the current study were to extend understanding of digital media use by women during pregnancy, and to determine whether there was a relationship between usage, psychological wellbeing and the developing emotional connection to the fetus. In our online survey, pregnant women reported using digital media for social and emotional support and obtaining health information for several reasons including determining what was normal about their pregnancy symptoms, understanding the development of their fetus, and learning what to expect in their pregnancy journey. These findings are similar to the themes that have emerged from studies using focus groups [11, 12] and individual interviews [20] with pregnant women. The amount of digital media use was negatively correlated with age, a finding which is in line with a recent nationally representative survey of digital media usage where only 1.8% of 18 to 34 year olds stated that they did not use any form of digital media, compared to 7.8% of 35 to 49 year olds [8]. These findings highlight the importance of considering the contribution of digital media sources, alongside other traditional face-to-face programmes, when developing information and support for younger pregnant women.

Although obtaining social support is a commonly reported reason for using digital media [11, 13, 17, 18], which could serve to be protective against mental health issues, digital media use in this study was associated with higher self-criticism, higher negative affect and lower social quality of life. It is possible that women with higher negative affect increase their digital media usage in order to gain emotional and/or social support to help them through their experience of depression, anxiety or stress. Scherr and Brunet [46] in a study with younger Facebook users (74% female) found that the time spent on Facebook correlated with depression, but was mediated by the motives of distraction and relationship formation. These findings may suggest that individuals potentially use social media to distract themselves from their depressive symptoms, and to develop relationships to enhance social support. Considering the increased prevalence of depression and anxiety during pregnancy [47] this could explain why those who indicated higher digital media usage for information and support had higher negative affect. An alternate explanation is that higher digital media usage itself may be leading to higher levels of negative affect. Given that the internet provides opportunities to confidentially research and discuss sensitive topics and to be part of a community of people experiencing a similar life transition [19], further research is needed to understand why for some individuals online interactions may have a negative impact on their psychological wellbeing. Past research has found associations between higher social media site visits per week and increased odds of depression in a sample of 1787 adults [48]. A recent analysis of the feedback posted on online message boards has also highlighted the potential negative effect of information-seeking online during pregnancy. While Denton et al. [49] reported that women are receiving social support and information pertaining to medication safety from online forums, they are often subjected to judgment by other online users and report confusion over the differing information they found. Mitchell and Hussain [50] also found that problematic (dependent and addictive) smartphone use was positively related to excessive reassurance seeking. This trait of excessive reassurance seeking should be further examined within the perinatal period to determine whether it could explain the positive association between digital media use and negative affect found in the current study.

Digital media presents limitless opportunities to make comparisons between the self and how others are portrayed. For individuals who place high levels of expectations on themselves during pregnancy, rates of digital media use may reflect a need to validate their own behaviours and reassurance-seek [11]. Engaging in these comparison behaviours may lead vulnerable individuals to feelings of guilt, shame and overall self-criticism [2]. This may explain the present study’s finding of digital media use being negatively correlated with self-criticism. Further research needs to examine these variables together to determine the nature of the reciprocal relationship between digital media use and self-criticism, especially given that recent research has suggested women’s levels of self-criticism increase postnatally [51]. It is important to better understand whether digital media use is leading to increased levels of self-criticism during pregnancy, or if women who are self-critical are more likely to use digital media to reassure them than those who do not have high levels of self-criticism. Understanding the direction of the effect will provide opportunities for more tailored support for those engaging with digital media during pregnancy.

Despite past research indicating that women in the transition to parenting for the first time gained support through hearing or reading stories of other women online [20], our results indicated an inverse relationship where those engaging with higher use had lower social QOL. Vachkova, Jezek, Mares and Moravcova [52] found a clear downward trend of social QOL across all three trimesters and, as such, it is possible that those women who are experiencing poorer social QOL are relying more on digital media for emotional and social support than those who have better social QOL. This may explain why women in the current study who have higher social QOL have lower digital media usage as they may not require as much emotional and social support through digital media. However, this also means that accessing social and emotional support through digital media is not associated with increased social QOL and that it may not act as an appropriate substitute for face-to-face support from partners, friends and family. Considering the increasing digital nature of society, an important research direction will be to better understand how to best utilise face-to-face and digital interactions to support social QOL for women during pregnancy.

Although MFA is proposed to be driven by a mother’s desire to know, protect and care for her child [27], and women in the current study reporting using the internet to inform themselves about the development of their fetus, we found no evidence that digital media use was associated with MFA. It is possible that that the gathering of information and support online for pregnancy experiences is an individual-focused experience, rather than a behavior which reflects a woman’s developing “affiliation and interaction” [28 p.282] with her fetus. However, it is important to note that the current study had no minimum gestational age for participation. Previous research suggests that MFA begins developing from around 10 weeks gestation [53] and typically strengthens throughout pregnancy [54] as fetal movements increase [55]. Items on the MFA scale such as “I enjoy watching my tummy jiggle as the baby kicks inside” and “I poke my baby to get him/her to poke back” lack relevance to early pregnancy. An inclusion criteria of at least 20-weeks gestation or in the third trimester of pregnancy as used in previous research [27, 55, 56] would be important in developing further research on MFA and digital media use. The development of a revised MFAS for earlier stages in pregnancy is a potential next step for furthering our understanding of maternal psychological wellbeing throughout the pregnancy journey and the emergence of the attachment relationship.

This study has several strengths and limitations. A strength of the study is the heterogeneity of the sample, with the educational and cultural background reflective of the community the sample is drawn from. A limitation is that these findings may not be reflective of the experiences of women with high risk pregnancies, who may have very different information needs. Future studies should examine pregnancy risk profiles. Previous studies have used focus groups and interviews with small numbers of participants [11, 12, 21] or discourse analysis of mothering boards [19], while the current study’s methodology allowed for a larger sample size and included validated self-report measures of psychological wellbeing and MFA. Other limitations include participant self-selection and the potential for response biases as a result of using online recruitment and survey methodology. However the purpose of the study was to examine when and how expectant mothers use digital media, not whether they are using digital media or not. An online approach further aligns with the high prevalence of digital media use in society, and increasing evidence that online research opportunities provides access to population groups that may be harder to reach in person (e.g. [57]) such as women at all stages of pregnancy. This study also had a high attrition rate, which may limit the generalisability of the data: approximately half of those who consented to the study, failed to complete the first survey. It is possible that a proportion of those participants who dropped out are those who use digital media regularly, i.e. interacting on Facebook, but do not use it for information and support during pregnancy. Advertising on Facebook may also have attracted women who ultimately did not have the time to complete an entire survey, whereas other digital media forms such as mothering boards may be a more successful mode of recruiting participants who were willing to spend time completing in depth usage surveys (e.g. [19]). Further research should consider multiple online forums for recruitment. A further limitation is that the developed digital media questionnaire, although informed from questions used in other studies [13, 36], was not validated by consumers.

Conclusions

Digital media use provides opportunities for individuals to seek out information and support, as and when it is wanted and needed. Despite evidence that pregnant women are using digital media to gain information and emotional and social support, outcome measures suggest that higher use of digital media can have a potentially negative effect on psychological wellbeing. In the current study, higher digital media use was correlated with higher self-criticism, lower quality of life, and high negative affect. The direction of these relationships requires further investigation. Increasingly, attention is being drawn to the need for the websites of governments and leading industry providers to contain pregnancy health-related information (e.g., about nutrition, sleep, physical activity) that is up-to-date with current research-led guidelines [14, 58]. Further research is needed to better understand how internet sources inform, support, or potentially challenge, the psychological wellbeing of individuals during pregnancy (see also [49]). It is crucial that all women have access to high-quality research-led information and the psychological support they need during pregnancy, irrespective of whether they choose to obtain that information through in-person interactions or through digital interactions.

Digital media questionnaire.

(DOCX)

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Dataset.

(XLSX)

Click here for additional data file.

11 Mar 2020

PONE-D-20-05764

The relationship between digital media use during pregnancy, maternal psychological wellbeing, and maternal-fetal attachment

PLOS ONE

Dear A/Prof Herbert,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

This study describes how women were asked about their use of digital media to assist them in knowledge, and reassurance-seeking during pregnancy. As such, it is a relevant and contemporary topic for maternity care. This manuscript has potential; however, it needs revision before I would send it for peer review. I suspect that much of my comment here relates to transitioning from a thesis to a journal publication. I would be happy to see a revision that covers the following. Future peer-review may identify other areas to be addressed.

General comments

Although PLOS One does not specify this, I would encourage you to avoid the term “statistically significant” and replace it with commentary like “there was limited evidence to support…” or “we found no evidence of a difference …” See https://community.cochrane.org/sites/default/files/uploads/inline-files/Interpreting%20statistical%20significance.pdf

For example, in line 14 of the Abstract, you could write: “There was no evidence of a relationship between digital media use and maternal-fetal attachment” (and give data as evidence, see below)

Referencing in text: The Vancouver style, as I understand it, only imports the reference number in sequence as you have mostly done, rather than listing more than one author. For example, line 45, “Akiki, Avison [13] found …”  needs to read as “Akiki et al [13] found …”.

ABSTRACT

The survey is noted, however, no detail is provided about how findings were analysed, eg, mean, SD, assigning “formulated meanings” to comments, etc. No actual results are provided, only a comment about no association.

Measures, lines 131-134: I don’t understand how the questions used could result in free text responses. They appear to indicate the need for a “yes/no” response. How, then, did you ask women to provide free text?

RESULTS

Table 1 is usually the summary of participants’ characteristics. You could then reduce the commentary of these in text.

The current Table 1 only contains a small amount of data, which could be combined with the data in Table 3. Indeed, much of the text could be converted to table here, also incorporating the linear relationship analyses – the latter are currently figures which would not add anything to a journal publication and need to be removed. The detail in Table 2 is interesting – however, it would be helpful to have more detail in the methods section about what “formulated meaning” is, how many people go through the comments to determine this and how consensus on these meanings is achieved. You could provide a second quote for each of the three areas here. Also, there could be the potential to provide some quotes that did not support the “formulated meanings” and how you dealt with these.

In reporting mean and standard deviation, please use one decimal point for the mean and two for the SD. You can summarise the comments about not meeting normal distribution – you have noted that the test used was robust given the sample size. For the ANOVA results, you only need the p-value, rather than all the detail.

Discussion

This is good overall.

Line 320, the word “psychology” should be “psychological”.

Line 381, the word “reflects” would be better as “aligns with” as you initiated this method, rather than it reflecting the mode of survey that participants responded to when provided with a choice of mode.

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Kind regards,

Christine E East

Academic Editor

PLOS ONE

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Reviewers' comments:

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24 Apr 2020

Dear Christine E East,

We appreciate your feedback and opportunity to revise our manuscript for submission at PLOS ONE. We have responded to each comment below, with line number references given to relevant changes in the attached ‘Revised Manuscript with Tracked Changes’ document.

General comments:

• Although PLOS One does not specify this, I would encourage you to avoid the term “statistically significant” and replace it with commentary like “there was limited evidence to support…” or “we found no evidence of a difference …” See https://community.cochrane.org/sites/default/files/uploads/inline-files/Interpreting%20statistical%20significance.pdf

• For example, in line 14 of the Abstract, you could write: “There was no evidence of a relationship between digital media use and maternal-fetal attachment” (and give data as evidence, see below)

• Referencing in text: The Vancouver style, as I understand it, only imports the reference number in sequence as you have mostly done, rather than listing more than one author. For example, line 45, “Akiki, Avison [13] found …” needs to read as “Akiki et al [13] found …”

Authors’ response:

We have made your suggested changes to the language used when reporting statistical significance (examples of such changes on lines 307 – 310; 322). We have also updated the Vancouver referencing style in the manuscript to suit the journal’s referencing requirements.

Abstract comments:

• The survey is noted, however, no detail is provided about how findings were analysed, eg, mean, SD, assigning “formulated meanings” to comments, etc. No actual results are provided, only a comment about no association.

• Measures, lines 131-134: I don’t understand how the questions used could result in free text responses. They appear to indicate the need for a “yes/no” response. How, then, did you ask women to provide free text?

Authors’ response:

We have included further details about the key findings in the abstract, including means, standard deviations, and significance values. We have elaborated in the measures section of the methods, to clarify that the questionnaire had the option of providing free text qualitative response (see lines 147 – 150). The digital media use questionnaire is now included as supporting information.

Results comments:

• Table 1 is usually the summary of participants’ characteristics. You could then reduce the commentary of these in text.

• The current Table 1 only contains a small amount of data, which could be combined with the data in Table 3. Indeed, much of the text could be converted to table here, also incorporating the linear relationship analyses – the latter are currently figures which would not add anything to a journal publication and need to be removed. The detail in Table 2 is interesting – however, it would be helpful to have more detail in the methods section about what “formulated meaning” is, how many people go through the comments to determine this and how consensus on these meanings is achieved. You could provide a second quote for each of the three areas here. Also, there could be the potential to provide some quotes that did not support the “formulated meanings” and how you dealt with these.

• In reporting mean and standard deviation, please use one decimal point for the mean and two for the SD. You can summarise the comments about not meeting normal distribution – you have noted that the test used was robust given the sample size. For the ANOVA results, you only need the p-value, rather than all the detail.

Authors’ response:

Thank you for your recommendations to the results section. We have taken your feedback on adjusting mean and SD decimal points and re-considered how we presented information in-text versus table form. As there were several variables in participant characteristics that we believe would have been difficult to present in table form clearly we decided to leave Table 1 as is and the participant characteristics in written form,

We agree that the term formulated meanings was a poor choice. We have revised this section to explain how the thematic analysis was conducted in line with Braun and Clarke’s (2006) procedure. Further details are now provided in the methods data analysis section of the manuscript (see lines 220-226). We also provided additional quotes in Table 2 of the results to illustrate the themes and associated meanings we identified.

Discussion comments:

• This is good overall.

• Line 320, the word “psychology” should be “psychological”.

• Line 381, the word “reflects” would be better as “aligns with” as you initiated this method, rather than it reflecting the mode of survey that participants responded to when provided with a choice of mode.

Authors’ response:

We have revised these grammatical errors.

Kind regards,

Corresponding Author, Associate Professor Jane Herbert

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

14 Jul 2020

PONE-D-20-05764R1

The relationship between digital media use during pregnancy, maternal psychological wellbeing, and maternal-fetal attachment

PLOS ONE

Dear Dr. Herbert,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The reviewers propose a number of areas to address, including the need to describe in greater detail the gaps in the research evidence relating to psychological wellbeing and digital media use during pregnancy and further description of the thematic analysis and contribution of the participants.

Please submit your revised manuscript by Aug 28 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

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An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Christine E East

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Please see attached document for my comments.

Reviewer #2: This manuscript reports on the relationship between digital media use during pregnancy, psychological wellbeing and maternal-fetal attachment which is an important issue in contemporary maternity care and seeks to improve our understanding of the use and effect of digital media for pregnant women.

The strength of this paper is a clear focus on the experiences of women when engaging with digital media throughout pregnancy.

This paper has potential to provide valuable insight into the views and experiences of pregnant women in the use of digital media.

There are several opportunities to strengthen the quality of the manuscript.

Abstract:

Line 35 – The statement ‘There are a number of benefits and limitations of this medium for providing information and support for young women during pregnancy’ should be revised as this is not supported by the evidence in the paper. There is insufficient evidence to support the statement that only ‘young’ women use this medium.

Introduction:

Line 46 – You have made a statement about the diagnosis of perinatal depression. There is no relevance demonstrated between this statement and the study. Unless there is a connection made, I would suggest removing this statement.

Line 58 - Suspected typo (eg 12) as a reference. Please address.

Line 71 – “women reported gaining knowledge and support by sharing their own stories and hearing other women’s stories”. I would suggest this evidence supports the use of online formats for this interaction. This needs to be clarified otherwise it is assumed you are referring to face to face.

Measures:

Line 140 – Was this questionnaire validated by consumers? If so, this should be mentioned. If not, this should be addressed.

Line 178 – “The WHOQOL-Brief was developed by the [36]” – Reference to the World Health Organisation (WHO) should be standardised throughout the paper.

Results:

Table 2 Line 268 – This study lends itself to thematic analysis of the views of women. However, this table does not demonstrate clearly what the views of women were and what themes emerged. The theme “Information and Reassurance seeking” seems to also be supported by the comment “Searching for whether symptoms are normal for the stage of pregnancy I am at…” but it has been attributed to a different theme “Determining what is normal” which is also reassurance seeking. Reconsideration of the themes and the analysis in general is recommended as the examples used do not support the thematic analysis described.

The quote “Not really. Health I would usually ask the doctor. I only google to find out if something is normal” should have (sic) inserted after ‘Health’ as the sentence does not make sense without this.

Discussion:

Pregnancy risk profile should be mentioned here as a limitation to this study. Women who are considered high risk have a very different experience of pregnancy (including information seeking) than low risk women. This needs to be acknowledged as a limitation of this study because this has not been considered.

Overall this manuscript requires major revision before it could be accepted for publication particularly with respect to the thematic analysis and contribution of the participants.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: Yes: Noushin Arefadib

Reviewer #2: Yes: Fiona Faulks

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

13 Nov 2020

Thank you for the thoughtful comments and suggestions from yourself and your reviewers. We appreciate such helpful and timely feedback. We apologise for the long delay in our resubmission, which was due to the impact of the pandemic on our workforce. We thanks the reviewers for their time and valuable feedback on this manuscript. We believe we have addressed all issues raised by reviewers. We have responded to each of the points raised below, and substantially revised the presentation of our thematic analysis and the contribution of the participants as requested. We believe this has strengthened the paper conceptually and empirically, and hopefully better communicates our findings.

Reviewer 1 Background

You describe clearly the reasons why examining the relationship between digital media use and psychological wellbeing are really important. However, there isn’t a lot said about what is actually missing in the research evidence and why it’s important to address this specific gap. Please describe in greater detail the gaps in the research evidence relating to psychological wellbeing and digital media use during pregnancy. Does any existing research touch on this? (See for example Ginja et al., 2018. Associations between social support, mental wellbeing, self-efficacy and technology use in first-time antenatal women: data from the BaBBLeS cohort study). You do this rather clearly in lines 119-122, describing gaps in the research pertaining to MFA and digital media use. I recommend including something similar regarding psychological well-being and digital media use.

Response: New text [line 61-62] has been added: Although only one study [15] has examined the impact of technology on maternal mental health in pregnancy, finding limited association, the authors argue the importance of understanding the type of technological activities undertaken to understand how they facilitate social support and wellbeing.

Reviewer 1 Grammar / spelling / structure-

Response: All suggested revisions have been made as requested

Reviewer 1 Omitted references and information

Line 79-80: “Despite these advantages, online behaviors also have the potential to reinforce anxiety, for example if the internet is being used as a means of excessive reassurance-seeking”. Please provide a reference for this sentence.

Response: The text has been revised and reference added.

Line 81: Please provide context to the percentage figure presented by sharing the total participant numbers in the study you refer to. Or just say “most” without providing a percentage figure.

Response: We have removed the percentage figure and have kept the statement most: “…found that most participants reported that their search for information was unrelated to antenatal appointments”.

Line 119-120: “Much of the current research on digital media use during pregnancy has focused on examining why pregnant women use digital media and what sources they use.” Please provide a reference for this sentence. Which studies have looked at this?

Response: We have revised this text [line 130-132]:

“The literature reviewed above confirms the significant role that internet searches, online discussion forums, and apps, play in supporting the health information seeking and decision making of women during pregnancy [11,12,14,21,22,23].”

Line 131-133: Please provide additional information on how participants were recruited. For example: “A Facebook post describing the study was generated. This included a link to the study survey…”etc.

Response: The revised text [line 143-148] now states:

“For the purposes of recruitment, a Facebook post describing the study was generated. This included a brief description and a direct link to study consent information and survey…. Recruitment occurred across a 3 month period from May to July, 2018.”

Line 133: please explain what you mean by ‘local’. Please name the specific location or just say Australia-wide.

Response: The revised text [line 146] now states:

“The study information was posted on various mothering, pregnancy support groups and community groups on Facebook, Australia-wide.”

Line 143-144: “Questions were informed by those used in focus groups and interviews in previous studies.” Please describe what these studies were about and provide a rationale for the decision to draw on these studies to develop questions for this particular study.

Response: Further information has been provided on the rationale to use these studies [line 158-161]

“Questions were informed by the themes of information seeking and providing reassurance that have been identified in previous research conducted with Australian women examining experiences of using digital media for pregnancy and parenting purposes [11, 12, 13, 37].

Line 146-149: Was this a yes/no response option? Or free text? Please explain further. Describe the number of questions that allowed a qualitative response.

Response: The description of the digital media questionnaire has been revised, and the number of questions and response type better identified. Lines 161-179.

Line 160: Please provide a reference for the DASS-21.

Response: The text has been revised and reference provided (line 184-5]

Line 178: “The WHOQOL-Brief was developed by the [36] as a shortened version of…” Please describe by who. Should this be ‘developed by the world health organization’?

Response: This text has been revised [line 202-205]:

“The WHOQOL-Brief was developed by the World Health Organisation (WHO) [43] as a shortened version of the WHOQOL-100, measuring quality of life, applicable across cultures. The WHOQOL-Brief contains 26 questions across four domains: physical, psychological, social relationships and environment.”

Line 178: “The WHOQOL-Brief was developed by the [36] as a shortened version of…” Please describe by who. Should this be ‘developed by the world health organization’?

Line 194-195: Please explain why socio-economic data was collected and why it is not referred to anywhere else in the study.

Response: The reference to socio-economic was an error and has been removed. The text has been revised [line 220-222]

“It consisted of questions regarding personal demographics (age, country of birth, marital status, and education levels) and pregnancy-related questions (current gestational age, current and previous pregnancy history).”

Line 329-330: “Although obtaining social support is a commonly reported reason for using digital media, which could serve to be protective against mental health issues…” Please provide a reference.

Response: References have been added.

Reviewer 1 comments - Results

Line 232-246: Please put the participant’s characteristics in a table.

Response: A new table has been included in the manuscript outlining the participants demographics (Table 1).

Line 253: Was this participant able to share their specific reason?

Response: The revised text is:“Only one participant indicated that none of the listed reasons were why they used digital media, and provided their own response of “having down time”.

Line 247: Please remove “n =”.

Response: Unfortunately we have not been able to identify where this is in our text.

Line 279: Please describe what the ‘other’ reasons were.

Response: The revised text is: Only two participants indicated ‘other’ reasons, and specified these as “reviews on doctor” and “just to get a general idea”

Reviewer 1 Comments Discussion

Line 334-336: Was the Scherr and Brune study about pregnant women? Please expand on this.

Response: The study was not with pregnant women, it was with a general population sample with a mean age of 28.7 years.

The text now states [lines 359-361]: Scherr and Brunet [46] in a study with younger Facebook users (74% female) found that the time spent on Facebook correlated with depression, but was mediated by the motives of distraction and relationship formation."

Line 336-337: “This suggests that individuals may use social media to distract themselves from their depressive symptoms, and to develop relationships to enhance social support.” IS this a personal hypothesis or a finding from a study? Provide evidence for this statement.

Response: This sentence has now been revised [line 361-363] to state:

“These findings may suggest that individuals potentially use social media to distract themselves from their depressive symptoms, and to develop relationships to enhance social support.”

Line 343-344: “…individuals for whom online interactions have a negative impact on their psychological wellbeing.” This statement is very definitive. Online interactions could potentially increase the likelihood of certain outcomes. Please revise this sentence.

Response: The text now states [line 367-370]:

“Given that the internet provides opportunities to confidentially research and discuss sensitive topics and to be part of a community of people experiencing a similar life transition [19], further research is needed to understand for some individuals online interactions may have a negative impact on their psychological wellbeing.”

Line 347: Is this study about potential negative psychological effects? Was it about pregnant women? Please explain this more clearly.

Response: This study aimed to explore and further understand whether there was any association between the social, emotional and informational support pregnant women receive through digital media use and whether that is related to their psychological wellbeing. As this body of literature is relatively new and limited it is too early to determine whether there is a positive or negative association.

Line 351: Please explain what is meant here by “problematic smartphone use”.

Response: The text now states [line377-379]:

“Mitchell and Hussain [50] also found that problematic (dependent and addictive) smartphone use was positively related to excessive reassurance seeking.”

Line 356-359: Overall, the distinction between ‘social media’ and ‘digital media’ use becomes blurred throughout the discussion. This needs to be addressed, perhaps through a definition of what entails ‘digital media’ in this study. Were you looking specifically at social media? It’s not very clear.

Response: Thank you for this feedback. We have now added in the introduction [lines 52-56] the following explanation:

“Digital media comprises of many forms

of digital technology that allow for the dispersal of information including; informative websites and applications on a smart phone [6]. A large component of digital media is social media, which refers to internet-based channels of mass communication enabling interactions among users, with the content being primarily user-generated [7].

We have also replaced instances of social media with digital media as appropriate throughout the manuscript.

Line 363-364: Revise sentence.

Response: This hanging sentence has now been revised. Line 396-398 in the revised manuscript

Line 370-371: Is the study referenced here about pregnant women? Please specify.

Response: We have clarified the participants in this study [Line 396-398], who were women in the transition to parenting for the first time

Line 389-392: The study did, however, collect data on participants’ gestational age. Is it not possible to use this data to examine a relationship between MFA and gestational age? Why was data on gestational age gathered otherwise?

Response: We only used information on Gestational Age in the current manuscript as a way to describe the range of pregnant women who took part in the study (along with whether this is a first or later pregnancy and a planned pregnancy). As we did not restrict participation to a particular gestational age range, our range is from 2 weeks to 39 weeks. Thus some women will have participated in the study prior to the emergence of MFA [from around 10 weeks [53] or after movements have been felt [55], and with it strengthen across time afterwards [54]. We therefore decided not to include an examination of the relationship between GA and MFA in the current manuscript given that it is a small dataset. We acknowledge in the limitation section [line 421-423] “An inclusion criteria of at least 20-weeks gestation or in the third trimester of pregnancy as used in previous research [27, 55, 56] would be important in developing further research on MFA and digital media use.”

Line 403: Please explain this limitation in greater detail.

Response: We now refer directly to the issues of self-selection and potential responses biases as a result of the online data collection and survey methodology used. Line 434-435.

Consider the representativeness of your sample in your limitations.

Response: New text added [line 426-430]

“A strength of the study is the heterogeneity of the sample, with the educational and cultural background reflective of the community the sample is drawn from. A limitation is that these findings may not be reflective of the experiences of women with high risk pregnancies, who may have very different information needs. Future studies should examine pregnancy risk profiles.”

Reviewer 1 comments - Conclusion

Line 422: Please replace “opposite effect” with “potentially negative effect”.

Response: Replaced

Reviewer 2

Reviewer 2 comments Abstract

Line 35 – The statement ‘There are a number of benefits and limitations of this medium for providing information and support for young women during pregnancy’ should be revised as this is not supported by the evidence in the paper. There is insufficient evidence to support the statement that only ‘young’ women use this medium.

Response: The word 'young' has been removed.

Reviewer 1 Introduction

Line 46 – You have made a statement about the diagnosis of perinatal depression. There is no relevance demonstrated between this statement and the study. Unless there is a connection made, I would suggest removing this statement.

Response: This statement has been removed.

Line 58 - Suspected typo (eg 12) as a reference. Please address.

Response: Typo removed

Line 71 – “women reported gaining knowledge and support by sharing their own stories and hearing other women’s stories”. I would suggest this evidence supports the use of online formats for this interaction. This needs to be clarified otherwise it is assumed you are referring to face to face.

Response: This study description has been revised to clarify that these were online forums, and that the majority of women were not engaging actively in interaction. [line 77-82]

“In individual interviews conducted by Johnson [20], women reported gaining knowledge and support from reading other women’s stories in online mothering spaces. Although some women reported the usefulness of participating in online social interaction, by asking questions or commenting on other women’s posts, the majority of women reported benefiting from these online spaces while remaining anonymous and engaging only as an observer”

Reviewer 2 Measures

Line 140 – Was this questionnaire validated by consumers? If so, this should be mentioned. If not, this should be addressed.

Response: New text in the limitations [line 448-450]

“A further limitation is that the developed digital media questionnaire, although informed from questions used in other studies [13,36], was not validated by consumers.”

Line 178 – “The WHOQOL-Brief was developed by the [36]” – Reference to the World Health Organisation (WHO) should be standardised throughout the paper.

Response: This text has been revised [line 202-205]

“The WHOQOL-Brief was developed by the World Health Organisation (WHO) [43] as a shortened version of the WHOQOL-100, measuring quality of life, applicable across cultures. The WHOQOL-Brief contains 26 questions across four domains: physical, psychological, social relationships and environment.”

Reviewer 2 Comments: Results

Table 2 Line 268 – This study lends itself to thematic analysis of the views of women. However, this table does not demonstrate clearly what the views of women were and what themes emerged. The theme “Information and Reassurance seeking” seems to also be supported by the comment “Searching for whether symptoms are normal for the stage of pregnancy I am at…” but it has been attributed to a different theme “Determining what is normal” which is also reassurance seeking. Reconsideration of the themes and the analysis in general is recommended as the examples used do not support the thematic analysis described.

Response: We thank the reviewers for this advice and have reviewed the thematic analysis and the themes that emerged to more clearly demonstrate the findings. The themes that emerged are now explained as [Table 3, line 291]

Strategies to manage physical and mental wellbeing during pregnancy

And

Reassurance seeking

Additional indicative quotes have been added to the two themes so that the reader can understand more about the types of responses women provided.

The quote “Not really. Health I would usually ask the doctor. I only google to find out if something is normal” should have (sic) inserted after ‘Health’ as the sentence does not make sense without this.

Response: Added (sic) as suggested

Reviewer 2 Comments - Discussion

Pregnancy risk profile should be mentioned here as a limitation to this study. Women who are considered high risk have a very different experience of pregnancy (including information seeking) than low risk women. This needs to be acknowledged as a limitation of this study because this has not been considered.

Response: We thank the reviewer for this suggestion. New text added to the limitations [line 428-430]

“A limitation is that these findings may not be reflective of the experiences of women with high risk pregnancies, who may have very different information needs. Future studies should examine pregnancy risk profiles.”

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

1 Dec 2020

The relationship between digital media use during pregnancy, maternal psychological wellbeing, and maternal-fetal attachment

PONE-D-20-05764R2

Dear Dr. Herbert,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Christine E East

Academic Editor

PLOS ONE

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3 Dec 2020

PONE-D-20-05764R2

The relationship between digital media use during pregnancy, maternal psychological wellbeing, and maternal-fetal attachment

Dear Dr. Herbert:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Christine E East

Academic Editor

PLOS ONE