Childbirth on television: a scoping review and recommendations for further research

ABSTRACT Factual and reality television shows that depict childbirth are both commercially successful and controversial. Social debate focuses on the potential implications for women’s experiences of birth and their health. This scoping review critically analyses published literature to assess the state of knowledge about the influence of factual and reality television on the expectations and experiences of childbearing women, and to make recommendations for future research. Recognising the complexity of researching the relationship between the media and lived health experiences, we critically engage with the theoretical and methodological underpinnings of the published literature and its substantive findings. We argue that the field is limited by a disconnect between media studies and health studies. Feminist approaches have both criticised the medicalised view of childbirth seen to dominate mainstream media, and the valorisation of “natural childbirth” as a standard which also disciplines women. Very little research has engaged with pregnant women’s views and experiences. Future research should engage more rigorously with diverse women who are pregnant or have recently become mothers. Recommendations for future research also include transdisciplinary collaboration for methodological innovation, research about television production processes and research that takes social media and the changing nature of television into account.


Introduction
Health and medicine are popular subjects for television, both fictional and factual.While medical shows attract large audiences (Hannah Hamad 2016), they also raise questions about their influence on public perceptions of health services (Jan Van den Bulck 2002;Stephen Timmons and Stuart Nairn 2015;Kimberley N. Kline 2010) and on health behaviours (Laura A. Marlow, et al. 2012;Richard Mocarski and Kimberly Bissell 2016;Katherine A. Foss 2013).There has so far been little investigation of the relationship between media and childbirth experiences or behaviours (Luce Ann, Marilyn Cash, Vanora Hundley, Helen Cheyne, Edwin van Teijlingen, and Catherine Angell, 2016).
Birth was once considered taboo and hidden from the public sphere but has, since the 1990s, become highly visible across a range of media but particularly television (Imogen Tyler and Lisa Baraitser 2013).In 1952 US sitcom I Love Lucy was the first television show to feature pregnancy and birth when the storyline was scripted to coincide with Lucille Ball's real life pregnancy.The storyline attracted huge media attention and viewing figures: it was according to Newsweek "the day when TV history of the obstetrical sort was made."(Stephanie E. Bor 2013, 470-1) Today, televised childbirth is commonly found on mainstream television appearing in soap operas, historical dramas, reality television and documentaries.This is not to say that childbirth has found a settled place in mainstream media.Social and academic debate continues about how birth is represented, indeed whether it should be represented at all, and what influence such representations have on audiences or society more broadly.Such debate is particularly fierce in relation to factual and reality programming.
In the UK context, the programme that has garnered the most commercial success and public debate is One Born Every Minute (Channel 4 2010-).This long-running BAFTA awardwinning series aired its eleventh series in 2018.The series regularly features in Channel 4's top 30 watched shows of the month (e.g.June 2016 (BARB 2016)) and it has a strong following on its associated social media sites.Each episode usually follows three pregnant women, their families and midwives, as they give birth.The "fixed-rig" show places over 40 cameras in a maternity ward or midwifery unit, combining recorded footage and offsite interviews with the main protagonists.At the time of writing (December 2018) the show had 42.3 thousand followers on Twitter and 967,035 followers on Facebook.More broadly, One Born Every Minute has strong global appeal; the UK version has "sold options to over 140 countries."(Tanya Horeck 2016, 165) Despite commercial success, scholars and birth professionals have raised concerns about what influence televised childbirth may be having on the expectations, experiences and behaviours of childbearing women internationally.For example, our recent analysis of commentaries and opinion pieces from the UK birth community identified two key concerns: that mainstream televised birth is increasing fear of birth among women and that unsympathetic representations of midwives undermined trust in the profession; however, we concluded that these claims require a stronger empirical base (Julie Roberts, Sara De Benedictis, and Helen Spiby 2017).In this review article, we explore the evidence base in more detail.We present the findings of a scoping review of multidisciplinary, published literature around factual television and childbirth.We identify the disciplinary spread of the literature and the kinds of topics and issues addressed.Drawing on our own interdisciplinary lens that spans sociology, cultural and media studies and health, we critically evaluate the methods and theoretical perspectives employed in the field before assessing the state of the evidence about how television influences women's expectations and experiences of childbearing.Finally, we make some recommendations for future research.

Methods
A scoping review is a method of reviewing existing literature that is suitable for summarising existing research and informing recommendations for future research (Christina S. Han and John L. Oliffe 2016).Scoping reviews do not aim to synthesise research findings in a particular field but to provide a descriptive account (Hilary Arksey and Lisa O'Malley 2005).Scoping reviews are well suited to mapping existing literatures that range across disciplines and research designs; and also to identifying research limitations and gaps (Arksey et al. 2005).It may be particularly well suited when it is likely further research is needed in a field (Han et al. 2016).Therefore, a scoping review was judged best suited to address our aims: (1) To map existing literature around factual television and childbirth (2) To critically analyse existing literature around factual television depicting childbirth, with particular attention to research methods (3) To assess the state of knowledge about the influence of factual television on the knowledge, expectations and experiences of childbearing women (4) To recommend directions for future research We limit our focus to factual and reality television.This is in part a pragmatic decision to draw a manageable boundary around the review.However, it also reflects the historical gendering of television in the home and its link to the domestic sphere (Moseley Rachel, Helen Wheatley, and Helen Wood 2016), in this sense television is a particularly important site for analysis of the representation of childbirth within society.Despite the emergence of the internet and new media, television remains the second most used medium by UK adults (second to the mobile phone) and 92 percent of the UK adults with a television set watched TV at least once a week in 2015 (OFCOM 2016) (Ofcom Communications Market Report 2016: https://www.ofcom.org.uk/research-and-data/cmr/cmr16).We also draw this boundary to acknowledge that audiences engage with different genres of television in different ways (although media scholars also note the blurring of some categories and conventions) (Annette Hill 2007).
There is only one review article published to date about media and birth.This article takes a broad sweep of representations of birth in mass media-television, books, magazines, newspapers and YouTube videos-to ask "Is it realistic?"(Ann et al. 2016). Ann et al.'s (2016) review maps the field with a particular focus on how medicalised birth is represented and the implications for women and midwives.The review included twelve qualitative and five quantitative research studies and eighteen items from the grey literature including unpublished theses and commentaries.Of the published research studies included in the review, all were published as journal articles, and therefore the review misses research published in book chapters, a form of publication more favoured by the humanities.The review's authors conclude that women use the media to learn about childbirth in the absence of other resources and they problematize the overrepresentation of medicalised births and the relative absence of "normal" birth.They argue that midwives need to engage with media production to change the dominant narratives.Our review article presents a rather different map of the field, complementing Ann et al. (2016) with a more in-depth examination of television specifically and taking into account the wider multi-disciplinary literature.
We began with two seminal articles on the topic-Theresa Morris and Katherine McInerney 2010 and Camilla A. Sears and Rebecca Godderis 2011-and used Google Scholar to identify papers that cited these papers.Formal searching focused on the time period 2011-2017, chronologically following on from the influential articles identified and reflecting the dates within which One Born Every Minute, the show most relevant to our UK context, has been running.Taking into account time and resource limitations, searches were delimited to the English language, and to published journal articles and book chapters.Drawing on our knowledge of the topic from different disciplinary backgrounds, the following key words were identified: "birth", "childbirth", "maternity", "midwives", "midwifery", "obstretric*", "OB/GYN", "reality television", "reality TV", "factual television", "docusoap", "documentary" and "One Born Every Minute".We searched a range of electronic databases reflecting multi-disciplinary interest in this topic area: ASSIA, CINAHL, JSTOR Medline, PsychInfo, Project Muse and Web of Science.The journal, Studies in the Maternal, was hand searched as this open access journal was relevant to the review but is not indexed in any of the search databases previously mentioned.Search terms were combined into three searches.Where possible the abstract and/or title only were searched.Book chapters were searched in addition to journal articles as humanities scholars more readily publish in books (see Tim C. E. Engels, Truyken L. B. Ossenblok, and Erick J. Spruyt 2012).
Searches were run in three iterations: June 2016; January 2017; and September 2018.At each iteration, search hits were saved to an EndNote library and filtered.We both reviewed titles and abstracts to ensure papers were relevant to the topic area.The following were removed from search results: duplicates; opinion pieces; theses; conference papers; reviews.There were no disagreements between researchers one and two on filtering decisions.Search results included a book chapter authored by Sara De Benedictis, one of the authors of this paper, based on her doctoral research (Sara De Benedictis 2016).The chapter met the inclusion criteria and was therefore included.It was analysed following the same process as for other included publications.
Selected papers were read in full to confirm they met the review criteria.No papers were excluded at this final stage.The filtering process resulted in a sample of eighteen papers or book chapters.As this is a scoping review, there was no attempt to exclude papers based on quality (Arksey et al. 2005); rather the limitations of the research literature are presented as part of the analysis.We "charted" the data from the sample of papers (Arksey et al. 2005) to provide general information about the studies and to address the research questions (See Table 1).

Topic, location and discipline
Of the eighteen texts identified, all but two focus on the US context (Camilla A. Sears  in Canada.This no doubt reflects, in part, the fact we delimited our search to English language publications. The highest number of papers were located in cultural/television/media studies (n = 11) with others found in sociology (3), public health (2), psychosocial studies (1) and psychology (1).As we will describe below, each discipline tends towards particular methods for exploring televised childbirth, guided by the types of research questions asked.There appears to be little dialogue between disciplines in this field.We return to this issue and its implications below.
While all of the articles and chapters took televised childbirth as a central concern, topics of interest within this varied.For some it was about the visual or narrative of the television shows (Winderman 2017), for others it is a vehicle for exploring theoretical issues around, for example abjection (Tyler et al. 2013), affect (Horeck 2016); or interactional practices (Jackson et al. 2017).For some researchers, the ways in which television reflects or reinforces social norms around birth and motherhood is at issue (O'Brien Hill 2014; Sears et al. 2011;Morris et al. 2010;Verena Siebert 2012;Feasey 2012), still others focus on how women make sense of televised birth (De Benedictis 2016;Bessett et al. 2018;Hall 2013).In a minority are those who research the role of television in health education and its potential for public health interventions (Kavanagh et al. 2012;Hans et al. 2011).These findings are summarised in Table 1.

Production, representation or reception
Television research has typically fallen into one of three categories: research into production, content and representation, or audience reception (Beth Montemurro 2007).Studies of health-related television, including birth television, overwhelmingly focus on representation (Bessett et al. 2018).Twelve of the studies we identified were concerned with the content of television shows and issues of representation.The remaining six were concerned in some way with audience reception, varying from text-in-action methods (Beverley Skeggs and Helen Wood 2012) to experiments measuring knowledge before and after viewing.There were no studies of media production in relation to birth, reflecting a wider trend in research around reality television (Montemurro 2007) and around media and public health (Lesley Henderson and Shona Hilton 2018).
There is a disciplinary split in the methods used to study birth on television reflecting different traditions as well as, to some extent, different concerns.Studies located in cultural studies, media studies and television studies predominantly draw on close readings or textual analyses of televisual texts (Sears et al. 2011;Feasey 2012;Verena Siebert 2012;O'Brien Hill 2014;Bull 2016;Horeck 2016;Takeshita 2017).The exceptions are Russell (2012) and De Benedictis (2016) who include fieldwork with female audiences alongside textual analyses.Research drawing on an exclusively audience reception approach are more likely, in this topic area, to be located in the social sciences and public health.Both approaches have value in adding to our understanding of televised birth and its implications for the social world.However, research that focuses exclusively on the content of media representations is often left with questions about how audiences might engage with this content.For example, Morris et al. (2010, 140) argue that "the influence of representations from reality-based birth television programs on the actual experiences and attitudes of pregnant women and practitioners, is a ripe area for study."Exactly how to do this remains challenging.
"Media effects" research, concerned with the relationship between media and the public, between media (often television) and the views and behaviours of citizens, has a long and contentious history (Sonia Livingstone 1996).While social concerns about the influence of television on health continue, the question of how to demonstrate this empirically remains largely unresolved.It is therefore perhaps unsurprising that we found relatively little theoretical engagement with this issue in the literature reviewed here.
How televised birth shapes women's experiences is sometimes left implicit in those papers that sit in the humanities where research into representations is well-established and widely accepted.Sears and Godderis (2011) are a notable exception.The authors employ a "feminist-informed Foucauldian framework" to consider the implications of how birth is represented (Sears and Godderis 2011, 182).Drawing first on the notion of the "panopticon", they argue that reality television provides audience members with information about "ways of acting in the world."That is to say that reality television is a "disciplining technology," with the potential to influence behaviour through women self-policing how they perform birth (Sears and Godderis 2011, 185).Similarly Hall (2013) draws on "cultivation theory", more typically employed to explore the relationship between media and violence, to explain the potential influence of television on women's stories of birth.However Sears and Godderis (2011) make the most detailed attempt, within the literature that we have reviewed, to theorise how television shapes women's experiences of birth.They also recognise its limitations: "How, exactly, these representations of women and childbirth actually get taken up in real world contexts by audiences requires more empirical investigation."(2011,192) Audience reception approaches in the field of childbirth on television fall broadly into two categories: experimental designs and qualitative, interview studies.We would argue that the audience reception literature relating to televised childbirth has limited utility in addressing the key question posed by our review.This is partly because of the nature of the "audiences" that have been researched.Experimental psychology studies have relied on student populations, sometimes all female (Vitek et al. 2018), sometimes mixed sex (Hans et al. 2011;Kavanagh et al. 2012).While this practice is not uncommon, questions remain about the representativeness of student samples and the transferability of findings to the general population (Paul H.P. Hanel and Katia C. Vione 2016).These experimental approaches-showing students a television show or documentary and testing their knowledge about particular aspects of birth-also miss the complexity of how viewers engage with media in the wider context of their lives.Experiments in media "effects" have been criticised for the artificiality of the experimental situation and the short-term nature of any "effects" measured (Livingstone 1996).
Similarly, audience reception research about televised birth within a media studies tradition, has explored how women engage with, experience, or make use of televised birth but has paid relatively little attention to women's experiences at particular points in their reproductive lives.Russell (2012) conducted informal fieldwork with only six women who identified as mothers; Hall (2013) interviewed women who had experienced "high risk" pregnancy at any time in the previous twelve years; and De Benedictis (2016) conducted focus groups and text-in-action sessions with women of "different maternal subjectivities," some of whom were mothers and others who were not.Only Bessett et al. (2018) interviewed women who were currently pregnant to ask how they understood the influence of television on their expectations of birth.If we assume that audiences are active consumers of media content, who bring their own experiences and identities to televisual texts as they negotiate its meaning for them, it seems reasonable to assume that this process will be substantially different at different moments in their reproductive lives.The number of gradations remains an open question.
Hall (2013) points to reproductive experience as one factor by focusing on women with experience of high-risk pregnancies.The literature provides other clues about how parity or other aspects of reproductive history might shape how women engage (or not) with televised birth and the influence it may have on their expectations or future experiences of birth.Hall (2013) argues that women became more critical of televisual depictions of birth after they gave birth themselves.Bessett et al. (2018) delineate their findings according to the educational attainment level of participants.Participants with high levels of educational attainment were more likely to minimise the importance of reality television for informational purposes although close analysis of their interviews sometimes revealed more influence of RTV than they had acknowledged.Participants with lower levels of educational attainment were more likely to substitute antenatal education for reality television (although the accessibility and affordability of the latter is no doubt a factor here).There can be little doubt that a range of structural and interactional factors sit behind these findings but for our purposes, Bessett et al. (2018) point to the relevance of social position in addressing questions about the influence of television on women's experiences of birth.

Televised birth is a feminist issue
Childbirth programming is focused on women and the body, and is arguably "television for women."(Rachel et al. 2016) It is therefore perhaps unsurprising that televised birth is a feminist issue.Within the humanities, feminist approaches dominate in relation to this topic; ten texts are explicitly located in a feminist frame (Sears et al. 2011;Morris et al. 2010;Russell 2012;Verena Siebert 2012;Tyler et al. 2013;O'Brien Hill 2014;De Benedictis 2016;Horeck 2016;Takeshita 2017;Winderman 2017), reflecting a long-standing interest in birth among feminist scholars and activists.However, this is not to say that feminist articles in our review sample take similar stances on the issues at hand.
Our review found two potentially opposing views.Earlier feminist critiques of mainstream televised birth focus on the ways in which reality television reinforces established social norms around medicalised births, showing women as passive in labour and depicting technocractic obstetric care as heroic, as saving the day (Sears et al. 2011;Morris et al. 2010).This is a finding that continues to be replicated in feminist work (Russell 2012;Verena Siebert 2012;Horeck 2016;Tyler et al. 2013).It reflects wider, international concerns about rising rates of intervention in labour and birth (Tracy Humphrey and Janet S. Tucker 2009) as well second-wave feminist politics that has tended to reject the medicalisation of a "natural" life event (Ann Oakley 1984) and to campaign against medicalised, technocratic childbirth that may be iatrogenic and risks alienating women from birth (Beckett Katherine 2005).
However, there are others working in a feminist tradition, who question the valorisation of "natural" birth.For De Benedictis (2016), the implicit hierarchy of birth modes in One Born Every Minute, prompts viewers to make negative judgements about women on the small screen who do not "achieve" vaginal birth.She argues that One Born Every Minute positions interventions in labour as "morally questionable," "unnecessary, risky or as a last resort" (p123).O'Brien Hill (2014) celebrates the representation of older mothers in One Born Every Minute who are shown being assertive about their right to pain relief.She argues that choice is an "illusion": "This pressure to 'achieve' a natural birth intersects with the 'good mother' myth and the myth of remaining in control in labour."Bull (2016) perceives a kind of nostalgia for 1970s feminism in the articulation of ideas around "natural birth" in Scandinavian televised childbirth, and instead argues that the boundaries between "natural" and medical birth models are less clearly defined that the rhetoric might suggest.These latter approaches might argue that the natural childbirth rhetoric "rests on the assumption that both women and childbirth have a true essence or nature that is respected by the natural childbirth movement but violated by the medical establishment."(Katherine 2005, 259) This is problematic not only for gender politics but also for women who choose or need intervention in their labours and may feel that they have "failed".The natural childbirth movement risks being another disciplining force for women, rather than a source of empowerment (Claudia Malacrida and Tiffany Boulton 2014; Jane Clare Jones 2012).
These two approaches have in common a desire to protect women's autonomy and to see labour care meeting women's needs.However, interestingly they see almost opposite problems with the way that birth is represented on television and so suggest different avenues for remedy.They are also limited by a reliance on representational politics, which while valuable, may struggle to engage at a micro-level with lived experience (Skeggs et al. 2012;Rachelle Chadwick and Don Foster 2014).The following section reviews the state of knowledge about how factual television shapes women's expectations and experiences of birth.
Influence of factual television on the knowledge, expectations and experiences of childbearing women: the state of the evidence Ann et al. (2016, 5-6), in their review, argue that women turn to reality television to learn about birth in the absence of other sources and that the absence of "uneventful" birth on television predisposes them to focus on risk and accept medical control and interventions.We interpret the field more cautiously.
Research in the tradition of representation notes a lack of diversity in the depiction of mothers and of birth.Women who give birth on television are overwhelmingly white, heterosexual, able-bodied, married (Sears et al. 2011;Morris et al. 2010;Feasey 2012).Televised birth is medicalised and technocratic (Horeck 2016;Sears et al. 2011;Morris et al. 2010;Winderman 2017) (although some argue that UK television depicts a more balanced view than US television, or that there is a melding of the medicalised and "natural" models of birth (Feasey 2012;Bull 2016).)Within this, women are represented as passive, lacking agency in birth and appearing to have little role in decision-making during labour (Jackson et al. 2017;Morris et al. 2010;Sears et al. 2011;Verena Siebert 2012).Some less mainstream televisual texts are credited with providing access to alternative, more empowering, discourses of birth, for example of home birth (Takeshita 2017).
Underpinning this research is an understanding that representations have consequences in the social world (Jenny Kidd 2016).The literature reviewed reveals both hopes and fears for television in relation to childbearing.The most prevalent fears are that dramatic representations of birth may increase fear of birth or that a predominance of medicalised birth on television both reflects and shapes lived reality (Morris et al. 2010;Tyler et al. 2013).However also in the literature are suggestions that television might prepare women for birth (Feasey 2012), "provide other ways of knowing" about birth (Horeck 2016, 174) or "democratise' information about birth."(Tyler et al. 2013) Alternative productions are more often linked to the potential to increase demand for midwifery-led care (Hans et al. 2011) or their production is advocated, recognising the power of the media but the inadequacy of mainstream broadcasting.Hall (2013) calls for more variety in depictions of birth, including depictions of postnatal depression, poor maternal or infant health, with the implication that access to representations that reflect one's own experiences would be beneficial to women.
Reception studies are divided along methodological lines.Quantitative approaches are employed in public health research, examining the role of television in influencing intended place of birth (Hans et al. 2011), in knowledge of birthing practices (Kavanagh et al. 2012a) and fear of childbirth (Vitek et al. 2018).Two of these studies (Hans et al. 2011;Vitek et al. 2018) found short-term effects on knowledge and attitudes among their participants.Longer term effects were not investigated, and as noted above, participants were convenience samples of students rather than people for whom birth television had specific saliency.The most recent paper, from Vitek et al. (2018, 3) argues that to date, "No studies report empirical evidence for the effects of birth reality TV." (Vitek et al. 2018, 3) Although their location in experimental psychology appears to shape their notion of the "empirical".
We identified four qualitative studies that may directly add to our understanding of how women receive, respond to, or interact with televised birth.Such studies have argued that women actively position themselves in relation to televised birth, making sense of it in the context of their own experiences as well as being capable of rejecting some of its messages (Russell 2012).From these four studies there is some evidence that birth television influences women's expectations of labour and birth, shaping preferences and the value placed on particular birth practices (De Benedictis 2016;Bessett et al. 2018), and potentially leading to a sense of loss when expectations are not met (Hall 2013).
Research based in textual analysis and content analysis overwhelmingly argue that mainstream televisual representations are dominated by the medical model of childbirth and reinforce the medicalisation of labour.The assumption therefore is that television works to delimit women's understanding of what is possible in relation to birth and keeps certain practices or choices in the margins.Interviews with women who watch televised birth suggests a more complex picture.Some women accessed information about "birthing alternatives" (such as water birth) even when they were not seeking it (Bessett et al. 2018, 488); other women learned what they did not want (Russell 2012).
While One Born Every Minute has been criticised for normalising medicalised birth, De Benedictis argues that female viewers (who were not all mothers) were aware of the value that the show and broader society places on intervention in labour as "morally questionable" to the extent whereby some participants making judgements about women on the screen who had a caesarean birth (2016,123).While televised birth has been accused of increasing fear of birth, Hall (2013, 8) finds that women who experience high-risk pregnancy or premature birth sometimes felt grief prompted by mainstream representations with "happy storybook endings."They were critical of television programming that neglected stories like their own.
Notwithstanding the theoretical and methodological issues, the literature provides relatively little evidence of how television might specifically shape women's knowledge, expectations and experiences of childbearing.Taken together, these studies suggest that there may be an influence of televised birth on women's expectations and experiences of birth but that the location of the audience is hugely influential in how birth on television is received and made sense of and therefore sweeping claims about the influence of televised childbirth on women's expectations, experiences and health and unlikely to be useful.

Recommendations for future research
Media influence is a preoccupation of the birth community (reference removed) and has made the headlines in the UK popular press.There is a dearth of rigorous research that takes into account the complexity of the influence of television on lived experiences and the methodological complexity of researching this issue.We offer our recommendations for future research based on the findings of the scoping review.

Talking to pregnant women and new mothers
Surprisingly little of the published research in this field has employed interpretivist methodologies to explore women's views and experiences.Our review suggests that qualitative research with participants who are pregnant or new mothers could add to understanding of how watching birth on television shapes some women's childbearing experiences.Future research should take into account demographic differences, multiple cultural and trans/national contexts and diverse experiences of birth in producing a complex picture of the health and social implications of televising birth.The voices of women who take part in childbirth shows are also so far absent in the research literature.

Interdisciplinarity
A number of scholars have noted the need for interdisiplinarity, to encompass health research, media studies and sociology (Bessett et al. 2018;Nick Couldry 2015;Clive Seale 2003), in order to address methodological challenges and demonstrate the influence of television on women's lived experiences.Our review suggests the urgent need for interdisciplinary collaboration to address the issues raised by televised birth with rigorous research in order to move social and academic debates forward.Health researchers often appear unaware of methods and methodological debates in the humanities and, as Nick Couldry has argued, sociologists and media approaches also have limitations in isolation that risk making questions of connecting media with lived experience intractable: As forty years of media research have shown [. . .] this is a very tricky problem that remains in part unanswered.Little wonder, then, that sociologists often find it easier to ignore media "effects" altogether, and media researchers often find it easier simply to assume the priority of media factors [. . .]The result is that a potentially interesting debate between sociology and media research about how to think through, on both micro and macro levels, the mechanisms by which media messages are embedded in social action has not really begun (Couldry 2015, 15) New interdisciplinary collaborations may present opportunities for methodological innovation and childbirth on television offers one site where this work could usefully be progressed.

Production
To date the television industry and media production processes have been neglected within the literature around televised childbirth.Certainly there are challenges in terms of access, and media industries can be cautious of researchers (Chris Paterson, David Lee, Anamik Saha, and Anna Zoellner 2016).However, analysing the processes of media production can provide insight into how culture, power, and the political economy shape health-related media (Henderson et al. 2018).Hendersen has explored the process of production fictional representations of mental health on television through interviews with industry professionals and story consultants (Lesley Henderson 2018;Henderson et al. 2018).Her work provides insights into the power dynamics and the processes of negotiation within media production and some of the limitations experienced by mental health experts in working with the media to produce progressive representations.Similar work around the production of televised birth could reveal factors shaping the representations of birth and potentially identify levers for change.
The changing terrain of television Henderson et al. (2018, 375) call on health researchers to engage with the "changing nature of 'the media'" and the methodological challenges this entails.In 2011, Sears and Godderis note that viewers of A Baby Story are encouraged to visit the channel's website and find an online community to discuss parenting and family life.Yet, the literature reviewed omits consideration about how the changing terrain of television might affect the way viewers' negotiate and understand childbirth on television.We agree with Luce et al.'s (2016) call for further research into how new media might shape understandings of birth and calls for further research on this area.However, more than this, television is changing and it may be necessary to engage with how multi-platform viewing shapes viewer engagement with birth on television or how viewers engage with social media that is directly related to birthing television (whether it is produced by the production company or by viewers).
Contemporary technological changes, such as the rise in personal computers, mobile phones, on demand websites and apps and social media platforms, means that we are in the age of "convergence culture" (Henry Jenkins 2006).Jenkins (2006) defines convergence as "the flow of content across multiple media platforms, the cooperation between multiple media industries, and the migratory behaviour of media audiences who go almost anywhere in search of the kinds of entertainment experiences they want."(Jenkins 2006, 2) In the "post-broadcast television" terrain (Jinna Tay and Graeme Turner 2010), multi-platform viewing is altering the way that people view and, potentially, experience television programmes.In regards to how convergence culture impacts on viewers' negotiation of representations of birth on television, we suggest two key areas for further research.
Subsidiary websites of television programmes have a role in shaping how birth is represented in the public sphere.For example, One Born Every Minute's website on Channel 4 has a wealth of further information on the show and birth, such as articles and additional video clips.This is symptomatic of how reality television plays an integral role in encouraging viewers to be interactive and seek out information that might more traditionally be offered by state health services (Laurie Ouellette and Jame Hay 2008, 476).Yet, we know little about the ideologies within this subsidiary media content and how viewers engage with this content, as well as how this forms knowledge about birth.
The digitisation of television viewing through social media platforms is shifting how "live" programmes are consumed.Many television programmes, including One Born Every Minute, now encourage audience engagement with official hashtags for Twitter.For example, in later series, the Twitter hashtag, #oneborn, is superimposed onto the opening credits and as the show begins after each commercial break, prompting the viewer to interact on Twitter.This sees audiences voice their opinions on the proceeding action, and engage with other viewers, in the mediated public sphere suggesting that "[t] he relationship between Twitter and television is increasingly symbiotic."(Fabio Giglietto and Donatella. Selva 2014, 260) Whilst audiences have always been active in the negotiation of meaning with television texts, audiences are now able to be "participatory" in media (Livingstone 2012)."Twitter talk" offers potential insight into "media and everyday life" as users often discuss television programmes beside "home and family life, work, the weather, current affairs and anything else that interests them."(Ruth Deller 2011, 222) Of the paucity of literature on birth on television, a considerable amount of this scholarship argues that televisual birth representations are problematic in terms of how the "good" birth and mother is constructed and how this is related to broader power structures and inequality (O'Brien Hill 2014;De Benedictis 2016).Thus, analysing television audiences on Twitter would give a broader understanding of how birth representations are negotiated publicly, and how power relations operate within these negotiations.

Discussion
Childbirth on television has attracted critical attention from a range of disciplines spanning the humanities, social sciences and health sciences.Our scoping review noted the diversity in the field in terms of research methods and research agendas.The potential for television to shape women's expectations and experience of birth seems to be a common concern but there is little agreement about where the issues lie.There is a wide range of quality in research in this field and we have explored some of the limitations of the methods employed.There is relatively little published evidence that directly addresses how birth on mainstream television might influence women's experiences.The literature does however point to some of the factors that might be relevant to how different women make meaning from such programming.We ended with some recommendations for future research based on the gaps we have identified in the literature as well as the methodological challenges.
This scoping review was limited by our search strategy.We are aware that we have not included those studies that centre on pregnant women's information seeking more broadly and that may include insights about television (e.g.Deanne K. Martin, Sandra M. Bulmer and Christian M. Pettker 2013; Gillian Thomson, Kathrin Stoll, Soo Downe, and Wendy A. Hall 2017).That is because these articles which do not mention television specifically in their title or abstract, were not identified by our search strategy.We have however, extended the work of Ann et al. (2016) by taking into account book chapters that were not included in their review.Although scoping reviews do not exclude articles or chapters based on quality, we have added to the literature with a detailed consideration of the theoretical and methodological issues in the field.We consider this essential to progressing research in this field.
We take seriously the concerns of the birth community about how birth is shown on television and the impact this may have on women in terms of shaping their choices and experiences (reference removed).There is much less information available about women's views on televised birth.Much more research is needed to understand if and how such programming is influencing the lived experience of birth.It will be vital to understand the complexity of any potential influence for women with a variety of reproductive experiences, and to contextualise this in a broader culture of birth.
Kali Vitek and L. Monique Ward 2018;Jennifer G. Hall 2013;Danielle Bessett and Stef Murawsky 2018)or the UK context (Maria Verena Siebert 2012; Tyler et al. 2013; Georgina E. O'Brien Hill 2014; De Benedictis 2016; Clare Jackson, Victoria Land, and Edward J. B. Holmes 2017) contexts or a comparison of the two (Rebecca Feasey 2012; Horeck 2016).The exception are Sofia Bull 2016 work on childbirth on Scandinavian television, in comparison with the UK and USA, and Dominique Russell 2012 audience reception study

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