“Whatsapping” the continuity of postpartum care in Switzerland :

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“ Whatsapping ” the continuity of postpartum care in Switzerland:

A socio-anthropological study

Patricia Perrenoud

^a,b,

*, Caroline Chautems

^a,b,c

, Christelle Kaech

^a,b

aSchoolofHealthSciences(HESAV),DepartmentofMidwifery,AvenuedeBeaumont21,CH-1011Lausanne,Switzerland

bUniversityofAppliedSciencesandArts,WesternSwitzerland(HES-SO),RoutedeMoutier14,CH-2800Delémont,Switzerland

cUniversityofLausanne,FacultédesSciencesSocialesetPolitiques,CH-1015Lausanne,Switzerland

ARTICLE INFO

Articlehistory:

Received26January2021

Receivedinrevisedform24June2021 Accepted25June2021

Availableonlinexxx

Keywords:

Postpartumperiod(MESH) Mobileapplications Loneliness(MESH) Digitaldivide Continuityofcare Midwifery(MESH)

ABSTRACT

Background:DigitalmediasuchasApps,Internetandsocialnetworkshavebecomeintegralpartsofthe maternity experience formore thana decade. These media can support or undermine women’s experiencesashasbeenshownindigitalsociologyresearch.UsingImmediateMessagingApplicationsto provideinformationandsupporttowomenduringtheperinatalperiodisanemergingpractice.

Aim: Thisarticleanalyseshowhealth andsocial careprofessionals– witha focuson community midwives–andwomencommunicatebetweenpostpartumhomevisitsthroughImmediateMessage ApplicationsinSwitzerland.

Methods:A socio-anthropologicalstudy thatreliedonqualitative methodsincluding semi-directed interviewswithmidwivesandhealthandsocialcareprofessionals(n=30)andimmigrantwomen (n=20).

Findings:SincetheintroductionofImmediateMessagingApplications,womenandtheircarerconverse moreregularlybetweenpost-partumhomevisits.Womensendquestions,picturesandvideostothem, oftenallowingswiftresponsestotheirconcerns.Midwivesencounterdifﬁcultiesansweringwomen’s questionswhentheycannotbesolvedthroughquickcommunication(e.g.infantcrying).Tothem,texting frequencyformsaclinicalcluetowomen’smentalhealth.Notallwomencontacttheircarerthrough digitalmessages;immigrantwomenarelesslikelytoknowandusethisservice.

Discussionandconclusion:ImmediateMessagingApplicationsformapromisingcommunicationtool, complementarytohomevisits,andcontributetowoman-centeredcareandcontinuityofcare.Asan emergentpractice,ithasnotbeenframedbyaguidelineyet.Policymakersandpractitionersshould ensurethatitsusedoesnotcontributetounequalaccesstocare.

Statementofsigniﬁcance

Problemofissue

Digitalmedia havebecome integralpart of thematernity experience.Littleisknownabout howwomen andhealth and social care professionals use Immediate Messaging Applications(IMA)betweenconsultations.

Whatisalreadyknown

Womenuseanarrayofdigitalmediatolookforinformation andsupportduringtheperinatalperiod.Theirexperiences

arecontrasted.IMAseempromisingforprovidingcomple- mentaryservicesin-betweenconsultations.

Whatthispaperadds

Womenandhealthandsocialcareprofessionals–especially communitymidwives–communicateregularlythroughIMA when this option is made possible by professionals and institutions.This servicehelpssolvecommon postpartum questions swiftly, however not always. IMA use is also revealing of women’s postpartum loneliness. IMA is not usedbyallwomenalikeandmaycontributetoinequityin accesstohealthcare.

Introductionandbackground:digitalbeings

Thissocio-anthropologicalpaperanalysesthedigitalrelation- ships that health and social care professionals, in particular

*Corresponding authorat: HESAVSchool ofHealth,MidwiferyDepartment, AvenuedeBeaumont21,CH-1011Lausanne,Switzerland.

E-mailaddress:patricia.perrenoud@hesav.ch(P.Perrenoud).

@patperrenoud(P.Perrenoud)

http://dx.doi.org/10.1016/j.wombi.2021.06.009

creativecommons.org/licenses/by/4.0/).

xxx–xxx

Pleasecitethisarticleas:P.Perrenoud,C.ChautemsandC.Kaech,“Whatsapping”thecontinuityofpostpartumcareinSwitzerland:Asocio- anthropologicalstudy,WomenBirth,https://doi.org/10.1016/j.wombi.2021.06.009

ContentslistsavailableatScienceDirect

Women and Birth

j o u r n a l h o m e p a g e : w w w . e l s ev i er . c o m / l o c a te / w o m b i

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community midwives, and women entertain through instant messagingapplications(IMA)suchastheubiquitousWhatsApp^TM duringthepost-partumperiod.

AsthesociologistDeborahLuptonhasextensivelyresearched [1],wehavewitnessedtheemergenceofadigitalsocietyformore than three decades,during whichourlives, cultures and social relationships have become increasingly entangled with digital technologies[1,2].Inhigh-incomecountries,mobilephones,social media andapps haveprogressivelyentered mostpeople’slives since 2007; allowing for social contacts to be created and maintainedata distance[1]. Ashighlightedintheworkofthe anthropologists Pinket al.,analysisof how digital technologies intervene in social actors’lives needs tobe undertakenwithin concrete social contexts [3]. Pink advises the avoidance of a conceptualandmethodologicalseparationbetweenthedigitaland the supposedly“in reallife” (IRL)interactions, for they arenot ontologically speaking separated [3]. Communicating through digital mediatriggerssocial actors’embodiedreactionssuchas thoughts,emotionsandactions[3].Inasimilarvein,scholarsfrom thesociologyoftranslationconsiderthattechnologiesthemselves do not have an impact on lives and events [4]. They have functioning features that offer a range of implementation possibilities andcontributemoreorless totheirsuccess. Social actorswillthentranslatethesetechnologiesandtheirfeaturesinto speciﬁcpracticeswithintheirsocialcontexts[4].Inthatsense,the uses of digital technologies can reveal the features of a given socioculturalcontextsuchastheonesurroundingthepostpartum periodinhigh-incomecountries.

IMA have started to attract the attention of health care providers for they are convenient to useand may allow swift communication between providers and women during the perinatal period [5–8]. Several studies have found promising resultsregardingtheuseofIMAforthefollowingpurposes:kindly remindingconsultationstowomen[5–8],conveyinginformation with regard to health during the perinatal period [5–9], complementing the care received during perinatal depressive episodes [5] or answering women’s questions regarding their children’sortheirownhealth[8,9].IMAinterventionsmaybeused individuallybetweenahealthcareproviderandawoman[5–7]or within groups of peers [8,9] and has beenexplored in diverse settingsincludinginlow-incomecountries[6,8,9]orwithwomen incomplexsituationssuchasadolescentmothers[8].Promising IMAuseduringtheperinatalperiodincludea considerationfor women’sneedsandpreferencesbeforeestablishingthecontentof messages senttothem[10] andoffertwo-wayscommunication thatallowwomentoaskquestionsorexpressneeds[5,8,9].

Despite these promising results, the critical perspective proposedbyDeborahLuptontoanalysethefeaturesandusesof digital toolsmustbekeptinmindforthesetoolsmayfosteror interferewiththehealthand well-beingofwomen[1].Appsin generalhavebeenusedto“nudge”womenintoadoptinghealthy behavioursforthesakeoftheirchild [11,12];they functionin a logic deemed neoliberal by social scientists, appealing to individual women’s own sense of responsibility and diverting attentionawayfromsocialdeterminantsandtheactionsofpolicy makers[11,13].Thiswidespreadtendencyhaslimitationsasnotall womenhavetheresourcesneededtofulﬁlsociety’sexpectations ofthem[11].Inthecaseofdigitalapps,includingIMA,information mayalsonotreachthewomenwho arein themostvulnerable socialsituationsorwhohavelowliteracyande-literacyskills[14].

Incontrastwiththeauthorsquotedabove,ourintentionswere nottoimplementaninterventionbasedonIMAuse,buttodescribe andanalysefromacriticalsocio-anthropologicalperspective[1,3]

howIMAmediatedcommunicationisusedspontaneouslybysome health and social care professionals with women. Preliminary explorationshaveshownthatthispracticehasemergedinFrench

speakingSwitzerlandduringthepostpartumperiod.IMAmediat- ed communication between women and community midwives appearstocomplement thecare providedduring thepostnatal periodbytheseprofessionals.Ouraimwashencetodetailthese practicesinourstudyaboutimmigrantwomen’suseofICTwhile includingthedifferenthealthand social careprofessionalsthat maybeincontactwiththemduringtheperinatalperiod.

Tocontextualiseourreflection,itisimportanttoprovidesome information abouttheSwissmaternitycaresystem.Asin most high-incomecountries,98%ofbirthsinSwitzerlandtakeplacein thehospital[15].Inthepublicsector,postnatalstaysinmaternity hospitalshaveshortenedfrom6to2or3daysafterbirthsincethe 1980s.Thisevolution mayberelatedtotheintroductionof the Diagnostic Related Groups system to finance health care in Switzerlandin 2012, which allocatesa paymentper diagnostic categoryinsteadofperinterventionorperdayofhospitalisation [16].Withoutadvocatingforlongerhospitalstaysafterbirth,and whileconsideringthatpostpartumhospitalstaysarestilllongerin Switzerlandthaninmanyothercountries[17],wewouldliketo highlight that these decisions were taken by hospital policy makers; women were not associated with them. In the Swiss healthsystem,theshorteningofthepostpartumhospitalstayhas beencompensatedbytheimplementationofpostnatalhomevisits madebycommunitymidwives.Womenandfamiliescanreceive upto16homevisitsfromself-employedcommunity midwives duringthefirst56 postnataldaysfor afirstchild orwhen ina complexsituation,and upto10visits forthesecond childand beyond [18]. These visits are fully reimbursed within the compulsoryhealthinsuranceschemeinscribedintheSwisslaw LAMALthusensuringaclosetouniversalservice[18].Themean numberofvisitswas7,5in2018[19].Duringthesehomevisits, midwivescheckthephysicalhealthofbothwomenandinfants, andprovidepersonalisedsupportregardingbreastfeeding,infant careandmentalhealth[20].Nursesandsocialcareprofessionals mayprovideadditionalservicesduringorafterthisperiod.When familiesliveinsocialdistress,sufferingfromloneliness,poverty, poorhousing,orlackofsupportingeneral,communitymidwives tend to provide additional tailoredservices [20]. Theycontact otherprofessionals suchas social workers,but alsotakedirect actionwhenneedsareurgent[20,21].Insuchcases,theymaybuy groceries or diapers, look for baby material or help with administrativeprocedures[20,21].

Thesechangesintheorganisationofmaternitycarehavebeen introducedatatimewhentheimportanceofthepostnatalperiod isincreasingly recognisedaskey forthehealth ofmothersand infants.Firstlybecausemorbi-mortalitylargelyoccursduringthis period [22]. The postnatal period is also a milestone in the experienceofmothersandtheirpartners,astartingpointinthe development of the relationship with their children [23].

Accordingly,postnatal mentalhealthhasbeenagrowingobject ofattentionforpractitionersandscholars.Mothers,andfathers, may experience psychological distress including anxiety or depressionduringthisperiod[23]andmaysufferfromloneliness [20].

In this context, the study of IMA mediated communication betweenwomenandhealthcareprovidersaspartofthesupport women may ask [24] and receive is important in order to understandwomen’sexperienceofthepostnatalperiod.Asour study was primarilyabout immigrant women’suse of ICT, our paperwillnotincludethedirectexperienceofSwisswomen,a pointdiscussedinthelimitations.

Methods

The results presented here are part of a larger socio- anthropologicalstudyledfromDecember2018 toJanuary2020 xxx–xxx

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inFrenchspeakingSwitzerlandandfundedbytheSwissNational ScienceFoundation(10DL1A_183123).Thestudymainaimswere todescribeandanalysethewaysinwhichimmigrantwomenuse Information and CommunicationTechnologies (ICT) during the perinatalperiodinSwitzerland.Thestudyincludedthreeaxesof exploration: ICTas meansoflookingfor information aboutthe perinatal period, ICT as means of communication within the transnational family,andlastlyICTasmeansofcommunication between women and health and social care professionals. The articlereportstheresultsofthisthirdaxis.Withtheaimofgiving an overall picture of the role played by information and communicationtechnologies(ICT)intheexperienceofimmigrant womenduringtheperinatalperiod,ourresearchteam(CCCKPP)¹ carriedoutanethnographicﬁeldworkincludingatriangulationof methods anddata[25]. Weconductedsemi-directedinterviews (CCCKPP)withimmigrantwomen(n=21)andhealthandsocial care professionals (n = 30) including midwives (n = 14). As communitymidwivesmentionedtheirfrequentuseofIMAwith women,werecruitedthemuntilwereachedsaturationregarding this speciﬁctopic.We alsoconducted ethnographic interviews, collectiveinterviewsandparticipantobservationswithimmigrant women (CC PP) to complete, compare and discuss the data producedbythesemi-directedinterviews.Inthispaper,wewill presentresultsdrawnfromtheinterviewswithhealthandsocial care professionals and immigrant women, with a focus on communitymidwivesandimmigrantwomen.

Theconstructionofoursamplewaspurposive.Wecontacted severalassociationsandpublicinstitutionsthatprovideservicesto immigrantwomenduringtheperinatalperiodthroughemail,and weaskedaboutthepossibilityofrecruitinghealthorsocialcare professionals and immigrant women for interviews. Whenthe recruitment was approved, we approached individual practitioners by email or telephone and provided the information documents for consent. Immigrant women were either approacheddirectlybyaresearcherina servicefacilityusedby them, or they were recruited by one of their health care professionals suchasa nurseora midwife.Particularattention nottointerferewithwomen’saccesstohealthandsocialcarewas takenbyeachresearcher.Interviewswereplannedonanotherday toallowwomentoreﬂectuponorwithdrawtheirconsentifthey wantedto;twowomenwithdrewtheirconsenttoparticipation withoutmentioningareason.

Health and social care professionals in our sample were midwives,nurses,socialworkersandadulteducators.Exceptfor community midwives and one nurse, these professionals only caredforimmigrantwomenandfamilies.Midwiveshadadiverse clientele including a lower or higher proportion of immigrant familiesdependingontheneighbourhoodwheretheypracticed.

Therefore,midwivesmentionedtheiruseofIMAwithSwissand immigrant women. Immigrantwomen wererecruited withthe aimofbuildingasuperdiversesample[26]includingwomenfrom diversenationalitiesanddiversesocialbackgroundssoastoobtain anoverviewofthediversityofICTuse.Ouraimwasnottoproduce a culturalistanalysisofhowimmigrantwomenuseICTassuch approacheshavebeencriticisedinanthropologyforstereotyping social actors’identities[26,27]. Forinterviewswithwomen,the documentscontainingtheinformationforconsentweretranslated from French into 7 languages (Arab, Albanian, English, Farsi, Portuguese,SpanishandTigrinya)chosenaccordingtothecurrent and local attendance of associations dedicated to immigrant mothers.Whenneeded,interviewswithmotherswereconducted with the collaboration of an interpreter. During the collective

interviews,eitheramidwifeoranadulteducatorwaspresentwith theresearchertoprovidecomplementaryquestionsandbecause womenappreciatedhavingatrustedpersonwiththem.Onthree occasions,individualinterviewswereconductedwiththefather also present, this option was let tothe preference of women.

Besides,severalinterviewswereconductedwiththepresenceof oneorseveralinfantsandtoddlerstofacilitatetheparticipationof women;thisledtosomeinterruptionsinthecourseofinterviews– toallowwomentocarefortheirchildren’sneeds–withoutcausing troublefortheproductionofdata.

Theinterviewswereconductedinplacesthatsuitedresearch participantsandthatguaranteedconfidentiality,eitherinaclosed roominoneoftheassociations,inourmidwiferyschooloratthe participant’s home if so wanted. The semi-directed interviews lastedforameanof63minforhealthandsocialcareprofessionals and46minforimmigrantwomen.Thisdifferenceindurationmay belinkedtothefactthathealthandsocialprofessionalsaretrained tobereflexiveandmayhavehadotheropportunitiestoparticipate in researchinterviews. Aninterview guidewas constructedfor eachtypeofparticipant;however,participantswerealsoencour- agedtofollowtheirthreadofthoughtbyreformulationsfromeach interviewer. The semi-directed interviews were recorded and transcribed after consent. Three women refused to have the interviewrecordedandoneaskedtheresearchertoerasetheaudio recordingandtodeleteasegmentofherinterviewthatshefound too intimate to share after second thought. The ethnographic interviews and participant observations were transcribed in a fieldworkjournal.Interviewsandfieldnoteswerecarefullyrevised inordertomaintainparticipants’confidentiality,especiallywhen immigrant women had particular trajectories that could make themrecognisable.Whendeemednecessary,wewithdrewsome detailsthatcouldallowtherecognitionofwomenorprofessionals.

Thisisalsothereasonwhywepresenttheparticipantsofourstudy withtheirmeansand rangesofages(women,professionals)or experience(professionals)intheresultssection.

The analysis of the data was conducted using the software

MAXQDA^TMandincludedadeductiveandinductiveapproachofthe analysis(CCCKPP).Thedeductiveapproachconsistedofcreating threemaincategoriesaccordingtotheresearchaxesmentioned above.Theresearchteamthenanalysedthetranscribedinterviews andﬁeldnoteswithaninductiveapproachandcreatedcategories and sub-categories (CC CKPP). On several occasions, theteam discussedandreﬁnedthecategoriestopreservethemostrelevant ones.DuetotheCOVID19pandemic,ourteamhasbeenunableto userestitutions as a method toconfront and complement our analysis. Thefunctioning ofthe associationsand institutionsin whichthestudywasconductedweretoodeeplydisturbedtoallow suchaprocess.

Theresearchprotocolwasvalidatedbytheofﬁciallocalethical committees(CER-VD/CCER-GE–Number2018-02081).Informed consentwasobtainedfromparticipantsafteracarefulexplanation oftheresearchaimsandproceduresincludingtherighttorefuseor withdrawfromthestudy.Asvalidatedbytheethicalcommittee, womencouldchoosebetweenwrittenconsentororalconsentin thepresenceofawitnesswhowaseitherahealthorsocialcare professionaloraninterpreter.

Our interdisciplinary research team included three women researchers: oneanthropologist and midwife(PP,PhD, primary investigator),oneanthropologist(CC,PhD)andonemidwife(CK, PhD-stud).AsPhDsin anthropology,PPand CCaretrainedand experiencedintherealizationandanalysisofthedifferenttypesof interviewsandobservationsusedinthisresearch;CKhadachieved aneducationalmoduleinresearchmethodsincludinginterviews andwassupervisedbyherseniorcolleaguesduringthestudy.The speciﬁc composition of our research team allowed us to pay attention to women’s needs and preferences, to professionals’

1Initialsoftheauthors.

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viewpointsandtokeepacriticaldistancefromthediscoursesand attitudes of midwives and the other health and social care professionalsinourstudy.

Results

Studyparticipants

Thirtyhealthandsocialcareprofessionalsparticipatedinthe semi-directedinterviews,includingfourteenself-employedcom- munitymidwives.Themeanageoftheprofessionalswas44years old(range33–59yearsold),andthemeanyearsofexperiencewas quite high at18 (range5–35 yearsof experience). This canbe explained ascommunitymidwivestendtostarttheircarrierin maternityhospitalsandseveralofthepractitionersinterviewed hadrequiredcomplementaryqualiﬁcationsfortheirpositionssuch as,forinstance,adiplomaincounsellingorreproductivehealth and contraception. The health and social care professionals included six social workers,sevennurses,two adulteducators, onedirectorofinstitutionandthefourteenmidwives.

Asintended,thetwentyimmigrantwomenwhoparticipatedin the semi-directed interviews form a superdiverse sample [26]

including women with diverse social and educational back- grounds. Inorder torespectthewomen’sprivacyand senseof safetyduringandafterourstudy,wedidnotdirectlyaskfortheir legalstatusinSwitzerland.Womenwithadiverserangeoflegal statusparticipated,includingwomenwithoutalegalstatus,but due tothis ethicaldecision we cannot describethe number of womenwith,forinstance,aworkingorrefugeestatus.Themean ageofwomenparticipatinginthesemi-directedinterviewswas30 yearsold(range20–37).Themediandurationofwomen’sstayin Switzerlandwas2years(rangelessthanayearto10yearsforone participant). Twelvewomenwerefirst-time mothers,fivewere secondtimeandonethirdtime;fortwowomenthisinformation wasmissing.Allwomenwiththeexceptionoftwolivedwiththeir child’s father or were married. Eight women had a university degree, five women had an intermediary occupation such as secretaryorsocialworkerandsevenwomenhadnotachieveda certificationafterschool.

Inthisﬁrstpart,wedescribetheuseandabsenceofuseofIMA mediatedcommunicationasexpressedbyhealthandsocialcare professionals.Ascommunitymidwiveswerethepractitionerswho used IMAwithwomen themostand withthewidestrange of practices,specialattentionwillbededicatedtotheseprofessionals.

Otherprofessionalswereusuallymorereluctanttocommunicate between consultations or worked in institutions that advised against the use of IMA to answer women’s questions. The professionals’reﬂectionsconcerntheuseofIMAwithimmigrant women as well as with women considered non-immigrant by them suchas Swiss or Frenchwomen. In the secondpart, we describetheuseandabsenceofuseofIMAmediatedcommunica- tion byimmigrantwomen only, due totheaimsof ouroverall study,apointreﬂecteduponinthediscussion.

UsesandabsenceofusesofIMAmediatedcommunication Healthandsocialcareprofessionals’experienceofIMAmediated communicationwithwomen

Thehealthandsocialcareprofessionalswhoparticipatedinour studyalluseinstantmessagingapplications(IMA)tocommunicate withwomenandfamilies,howevernotonthesamescaleandwith twodistinctfeatures.SomeinstitutionsandprofessionalsuseIMA two-ways:fromwomentotheinstitutionandtheprofessionaland fromtheinstitutionandtheprofessionaltowomen.Inthisﬁrst case,professionalsgivetheirmobilephonenumbertowomenand allowthem tocontacttheircarerbetweenconsultations.Other

institutionsandprofessionalsuseIMAmediatedcommunication onlyone-wayfromtheinstitutionandtheprofessionaltowomen and families. In this secondcase, institutionsand professionals dedicateIMAtoorganisationalpurposessuchasthearrangement ofappointments.Our focuswillbeontwo-ways IMAmediated communication.

AscommunitymidwiveswerethemostregularusersofIMA withwomen,theirdiscoursesareover-representedintheresults.

Thenurseswho workedininstitutionsthatallowedtheuseof IMA tended to have similar representations and practices as midwives.

For community midwives in Switzerland, communication through IMA has become a part of day-to-day practice. First, IMAareusedtoorganisemidwives’postnatalhomevisits.

Atonepointeverywomaninformsmethatshehasgivenbirthand thatsheisplanningtogobackhome.Iaskthemtosendmeatext messagetoallowmetogetorganisedandplantheﬁrsthomevisit forthedayafterthedischargefromthematernityhospital.[Semi- directedinterview(SDI)4CommunityMidwife(CM)]

Second, community midwives and less frequently other professionals useIMAtoremainavailable betweenhomevisits or in-clinic consultations. They share their personal mobile number with women and suggest them to send a messageor calliftheyhavequestionsbeforethenextvisit.

Yes,yes,yes.Ialwaysshowthemmyphonenumber«hereismy phonenumber,youmaycallme”.Toallwomen.[SDI20CM]

According to midwives, most messages sent by mothers throughIMAconcern thehealth of thebaby,feedingpractices, cryingepisodesorsleepingpatterns.Mothersmayattachapicture totheirquestion.

Itcanbeaquestionorapictureofsomethingandsheasksmy opinionaboutit.[...]Igetpicturesoftheirbaby’spoo,ofthe baby’s dry skin or toxic erythema. Milk crust sometimes, the umbilicalcordbleedingalittlebitafteritfelloff.Thenacoupleof questions.Isitnormal?WhatshouldIdoaboutit?Often,westill haveanappointmentplanned,butsometimes[mothers]can’twait twotothreedaysuntilthevisit.[SDI15CM]

Mothersmayalsoaskquestionsabouttheirownhealth.

Picturesofbloodclotsonsanitarytowels.[...]Alwaysthesame topicscomeagainandagain.[...]ButItellthem:“callmeifyou losebloodclots”.Insteadofcalling,theysendmepictures.Andhere withaﬁngerputnexttothebloodclot[toshowitssize].[SDI21 CM]

In theexamples above,newbornshave benignand common conditions that nevertheless worry the parents. Professionals hypothesisethatSwissparentsdonothavemuchexperienceof infant care prior to becoming parents when compared with immigrantwomen.

Frankly,no[immigrantmother]haseveraskedmehowto[givethe babyabath].[...] When Iworkedat thematernity hospital, immigrantmotherswouldjustgoahead,theywouldn’task:“how doIhavetoholdmybaby”.Theyprobablyhaveseenotherscaring forbabies.Inmanycountries,womenhavecontactswithinfants beforebecoming amother. In Switzerland, some mothers have nevertouchedababybeforehavingtheirs.It’sperturbingforthem.

[SDI16CM]

IMAmediatedcommunicationisdeemedhelpfulwithregardto women’spostpartummentalhealth.

Yes, I tend to ﬁnd it helpful. If theyhadn’t sent the picture, I wouldn’thavebeenabletoreassurethem.Likethis,intwoseconds.

Theymighthavehadabadnight.[...]It’shelpfulbecausepartof myroleistoreduceanxiety.Andthiscanalsobedoneinbetween homevisits.[SDI21CM]

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MidwivesalsoseeIMAmediatedcommunicationasawayof improvingthecontinuityofcare(CoC)providedtowomenduring thepostnatalperiod.InSwitzerland,CoCthroughoutpregnancy, childbirthandthepostnatalperiodhasonlybeenimplementedin aminorityofcases,usuallyforwomenoptingforabirthoutsidea hospital setting. However, a shorter form of continuity is implemented through the postnatal home visits, usually done bythesamemidwifethroughoutseveralweeks.

Ioftenﬁnishmyhomevisitbysaying“wewillseeeachotherina coupleofdays,butifthereisanythinginbetweenyoucancallme”. [...]“Orsendmeamessage”.[...]Iﬁndthatitbringsalotof support to families.To havesomeone almost always available.

[...]Ithelpswomenthataremoreisolatedtofeellessalone.It contributestothecontinuityofcare.[...]Whenyouseeawoman over four to six weeks, sometimes more, this communication between visits forms a sort of circle around the mother, a complementarypresence.[SDI25CM]

Other health and social care professionals in our study mentionedimmigrantwomen’slonelinessasasalientfeatureof theirsocialsituation.Inoursampleandinlinewithourresearch objectives, loneliness was primarily a concern with regard to immigrant mothers; however, midwives considered that many womenfeellonelyduringthepostnatalperiodregardlessoftheir nationalorigin.²

The self-employedmidwives we interviewed all used some levelofIMAcommunicationwithwomenandfamilies.Theother healthandsocialcareprofessionalssuchasnursesorsocialcare workers tended to be more reluctant to use IMA in between consultations;theyhadbeenadvisedagainstitbytheiremploying institution or through their professional education. Overall, professionals who worked in smaller institutions such as associations were more prone to use IMA than professionals whoworkedinbiggerinstitutionswithmoremarkedhierarchical structures.

In thecase ofmidwives,IMAmediatedcommunicationmay continue beyond the postnatal follow-up. Some women ask questions from time to time totheir midwife. They also send goodnewssuchaspicturesorvideosofthemwiththeirinfantor showingtheirinfantachievingdevelopmentalmilestonessuchas sitting,eatingsolidfoodorwalking.Thesetestimonieshighlight the importance of the bond between midwives and families createdthroughtheCoCgrantedduringthepostnatalperiod.

LastweekIgotamessagefromamotherwhotoldme:“Hey,I’m John’smother;Igavebirthoneyearago.Ihaveaquestion”.Iwas

“Well ok”. I really think that the link between midwives and mothers can bestrong. In generaland for motherswhohada hardertime.[SDI20CM]

Insomecases,IMAmayfacilitatethecontinuityofcontactuntil thenextpregnancyandbirth.

Icaredforthiswoman’sﬁrstpost-partum.Sincethen,wehavekept intouchthroughWhatsApp^TM.So,sheaskedmetobehermidwife forhersecondbaby.Shehadmovedoutofmyzoneofwork[...], butIdidherfollowup;youalsodoitforawoman[inhersituation, arefugee].[...][Wearestillincontact;her]secondbabyisnine monthsold.[SDI20CM]

Thesetestimoniesmaybringaformofclosuretoprofessionals, whenfamilieswhowereindifﬁcultsituationseventuallythrive.

Ithinkaboutthismotherwhohadanunexpectedpregnancyand whohadbeenindenialforseveralmonths.Everybodywasvery worriedabouther.Hereyouseethispicture[ofthemotherandher baby, sent by the mother to the midwife and shown to the researcher]. The picture is revealing. She looks so maternal, [smiling],discoveringmanynewthingsandwhenIseeherlikethis, Ifeelreassured.[...]Shekeepsintouchwithmeandsendsnews.

[SDI15CM]

DifficultiesencounteredwithIMAmediatedcommunication IfcommunitymidwivestendtofindIMAmediatedcommuni- cationusefultocomplementface-to-facecare,theyalsoencounter difficulties to address the questions they receive. First, not all situationscanbesolvedoralleviatedthroughtextmessages.

Thisiswhathappensthemost:«hehasbeencryingforhalfanhour andIcan’tcalm him.WhatcanIdo?»[...]Insuchcases,you cannotreallyhelpwithatextmessageorevenaphonecall,butit happensthough.[SDI25CM]

Someprofessionals,oftentheoneswhowerealreadyexperi- encedwhenIMAwerelaunched,ﬁndcommunicationthroughIMA lessclearorlessvaluablethaninpresencecommunication.

Beforetextmessages[wereinvented],womenwouldcallus[...] It’s easier to makea phone call [...]. It’s difﬁcult to explain everythingwithtextmessages.[SDI5CM]

Asshownabove,thequestionsparentsaskthroughIMAtendto concern benign health issues – even if they worry parents genuinely –and canbe addressedbymidwivesor nurseswith little hesitation. However, some questions imply uncertainty;

professionalsmaythereforeworryaboutoverlookinganinfant’s healthissue.

Itisdifﬁculttoanswersometimes.Ifamotherwrites«shevomited milk»,oftenitisjustaslightregurgitation.However,youhaveto checkbecauseifshereallyvomits,itmightbesomethingelse,not justregurgitations.So,Ioftentakethetimetocallthem,sowecan talkand Ican obtain more details tounderstand her question better.[SDI26CM]

Some professionals may also be wary of possible litigation actionsagainstthemformakingerrorswhilejudgingthehealthof anewbornthroughtextmessages,picturesorvideos.

It’stricky.[...]Aconsultationdonefromapicture?Whatifthe baby really has a problem; if something happens afterwards?

[...]WhenIanswerwithatextmessage,everythingiswritten.

[...]HenceIanswerthem:«itisalittlebitcomplicatedtojudge fromapicture.Atﬁrstsight,itlookslikesuchandsuch,butIcan’t be certain». [...] When they send you videos of the baby breathing,Iavoidansweringwithatextmessage.Icallthem.[SDI 21CM]

According toparticipants in ourstudy, few women had the possibilityofcommunicatingwiththeirpediatricianthroughIMA.

Theconvenientavailabilityofmidwivesandthecloserelationship established through the continuity of care between them and women,seemtofacilitatetheemergenceofunexpecteddemands totheseprofessionals.Theymayreceivemessageslateatnightand duringtheweekend.Eveniftheyarebotheredbysuchdemands, theyseeitastheirdutytosortoutsituationsthatcanwaitfrom genuineemergencies.

Often,familiescontactme[lateintheevening]for[questionsthat canwait].[However],onceafathercontactedmeatteno’clockin theeveningbecausehiswifewasdepressed;hewasworriedsick.

Theyeventuallywenttothepediatricemergencyservice[thatcan hospitaliseamotherandherbabytogether].Shewasfeelingreally bad.InsuchasituationIansweredofcourse,Icalledthesenior doctor,andIdidmything.[SDI24CM]

2Detailedexamplesaboutwomen’slonelinesscanbefoundin:Perrenoud,P.

Construiredessavoirsissusdel’expérienceàl’èredel’Evidence-BasedMedicine:une enquêteanthropologiqueauprèsdesages-femmesindépendantesenSuisseromande, DoctoralThesis,FacultyofSocialandPoliticalSciences,Lausanne:Universitéde Lausanne; 2016. https://serval.unil.ch/resource/serval:BIB_A8B46DD35316.P001/

REF.

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TheuseofIMAincareisanemergentpracticeandithasnotyet been framed byprecise regulationsin Switzerland. Hence, this practice still has blurred boundaries. The professionals inter- viewedcopewithrequestsdependingonparents’situations,but alsodependingontheirownresources.Someparentswhohave littletonosocialsupport,suchasnewimmigrants,mayrelyon healthandsocialcareprofessionalswhenfacedwithdifﬁcultor even urgentsituations.IftheyspeakFrench,Englishoranother sharedlanguagewiththeircarer,theymayresorttoIMAtocontact them.Inthecaseofmidwives,requestsmaybeforhealthissues outsidethescopeoftheircompetences.

OneSaturdayafternoon,amothersentmeavideoofherbabywho washavingaseizure.Iwasnotavailable;Iwaswithmykids[atthe movies].Icouldnotdownloadthevideoimmediatelyasitwastoo big.[...]ItoldherIcouldn’twatchthevideo,butthatsheshould gotheemergencyservicesifshewasworried.[...]WhenIwas ﬁnally able to watch the video, I saw it was serious. In the meantime,shehadgonetotheemergencyservices.[...]Itendto betheﬁrstpersonforeverything,forthingsthatareoutside[of midwifery].Iamnotapaediatrician;Iwouldnotbeabletotreat seizures,apartfromadvisingtogototheemergencyservice.[SDI4 CM]

Manyparentsseemtoactasifmidwivesweretheirprimary caregiverintheSwisshealthcaresystem;agatekeepertoother services which midwives are not ofﬁcially. These practitioners cannotfunctionasaprimarycareservice24/7andinsituations thatrequireimmediatecare.

Atthebeginning,itwasdayandnight.[...]NowItellthemthey canwritemeorcallme,noproblem.Ipreferthattheycontactme insteadofremainingstressed.[...]However,Iwillnotalways answeratonce.[...]Ialsogivethemtheemergency service’s number.Theycanbereacheddayandnight,notme.[SDI16CM]

DifferencesinIMAuse

Community midwivesornurses explainthat notall women communicatethroughIMAornotonthesamescale.Somenew mothers–orfathers–sendseveralmessagesdaily.Otherparents seldom or never use IMA mediated communication withtheir carerbetweenconsultations.

ThefrequentrecoursetoIMAisseenasaclinicalcluethatsome parentsmayexperienceanxietyormayneedmoresocialsupport.

For professionals, IMA use is related to parity and parental experience.

You never hear from certain [mothers]. They don’t send any message between two consultations. [...] They are often multiparas, women who are not very anxious by nature and whomayhavemoresupportbysigniﬁcantothers.[...]Those whosendmemanymessagesareoftenmothersfortheﬁrsttime;

sometimes expatriates[whospeak English]without familyhere [and]whofeelisolated.[Mothers]whofeellonelyandsufferfrom anxiety.[SDI21CM]

According to the health care professionals who attended immigrantand non-immigrantfamiliesinourstudy,immigrant mothers whose mother tongue was not French or English communicatedlessthroughIMAwiththeircarer.

MotherswhodonotspeakFrenchatall,whodonotreadFrench,I mean WhatsApp^TM [...] for them writing a message is complicated. [French speakers], they dare more, it’s easier for them.Theyhaveaquestion;theydo“tac-tac-tac”,easy.[SDI11 PediatricNurse(PN)]

AsIMAmediatedcommunicationisnotanofﬁcialserviceinthe Swisshealthsystem,itisnotreimbursedbytheLAMALinsurance anditremainsunpaidwork.ThefrequentsolicitationthroughIMA

was especially time consuming for community midwives.As a result,notallofthemreactedwhensomewomendidnotsendtext messagestothem,suchasimmigrantwomenwhocouldnotor barely speak French or English. In other words, French- and English-speaking mothers may receive an additional service throughIMA, that non-speakersdo not receive.However, mid- wiveswhofrequentlycareforimmigrantwomen,especiallythe ones who live under difﬁcult circumstances such as asylum seekers,tendtocompensateforthisdifferenceintheabilitytouse IMAwithseveralstrategies.

When[Immigrantmothers]callmeorhavesomeoneelsecallme,it istoaskmetocomeandseethem.BecauseItellthemifyoucallme andjustsayyourname,ifIdon’tanswerandyougetthevoicemail, justleavemeyournameonthevoicemail.[...]Iwillknowitis youandIwillcomeandseeyouthenextday.Manyofthemdon’t daretocallastheydon’tspeakFrenchorEnglish.Sometimesthey asksomeonetocallforthem.[SDI16CM]

Some of the health and social care professionals who speciﬁcallycareforimmigrantwomenandwhoalsocollaborate with interpreters, used this collaboration to engage in IMA mediated communication with women with the help of an interpreter. In our data this form of trialogue was mainly for organisationalpurposes.

Communitymidwives,nursesoreducators, mayalsoextend their usual role to countervail the social distress involving loneliness,ﬁnancialstrain,poorhousingandsometimesviolence lived by someimmigrant women. These professionals lookfor babymaterials such as nappiesor cradles,translate and write letters, help complete administrative procedures, and access services,ordirectfamilies toassociationsthat providetargeted supportsuchaslegalorsocialadvice.

When amotherreceives alettershe doesn’t understand, Iwill explaintoher[its]content.Ifamotherwantstoenrolherchildto thedaycare,whichiseasyforus[middleclassFrenchspeakers].

Youtake thecomputer, twoclicksandit’sdone.Forimmigrant families, it can be difﬁcult to enrol their child as they don’t understandthecontentofthewebsite.So,Ihelpthemsometimes.I don’tworkstrictlywithinmyprofessionalrole.[SDI11PN]

Insuchcases,IMAmediatedcommunicationsallowwomento ask for additional help provided they speak French, Englishor anotherlanguagespokenbythehealthcareprofessional.

She doesn’t feel conﬁdent enough to makethe phonecalls [in French][...].Ifshehastomakeanappointmentwithaphysical therapist,andit’stheansweringmachine,itfrightensher.Thenshe asksmeifIcanmakethecallandIsay[yes].[SDI20CM]

Mosthealthandsocialcareprofessionalsinourstudyclaimed that IMAmediated communication was time consuming. Thus, many of them had mixed feeling about the practice and complainedabouttheintrusionoftextmessagesintotheirprivate life.IfallcommunitymidwivesusedIMAintheirpractice,there werenursesorsocialworkerswhorefusedtousethemforfearof beingoverwhelmedbyrequestsfromparents.Largerinstitutions suchashospitalsandsocialservicesseemtoframeIMAmediated communicationmorestrictly.These institutionsdo notseemto allowtheirclientstosendrequeststhroughtextmessagesinthe same way that smaller institutions such as associations do.

However,theselargerinstitutions,often connectedtothestate andtopublicservices,orfoundedbythestate,useIMAmediated communicationtoforwardmessagestoclients.Thesemessages, thatseveralofthewomenandsocialcareprofessionalsshowedus are reminders of appointments or, sometimes, important announcementsregarding allowances. Theywerewritten in an impersonaladministrativestylewithouttheusualpolitegreetings xxx–xxx

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andcontainedacronyms;bothfeaturesthatmakethemdifﬁcultto understandfornon-Frenchspeakingimmigrantwomen.

Health and social care professionals found that such text messages,aswellaswrittenletters,arestressfulforimmigrant women when they come from authorities. Adult educators pointed to us that many women have literacy problems and cannotdeciphersuchmessagesalone,noruseapaperordigital calendar toremember appointments; they have to remember them byheart.One study participant hadrepeateddifﬁculties remembering the dates of her appointments with health and socialservices.Shemissedseveraloftheminvoluntarilyduring theﬁeldwork.

Immigrantwomen’sexperienceofIMAcommunicationwith professionals

In thissubpart,wepresenthowimmigrantwomenseetheir experienceofIMAuseorabsencethereofwithhealthandsocial careprofessionals.Asmentionedabove,ourprimaryaimwasto enquire about immigrant women’spractices and needs of ICT, hencetheabsenceofSwissorFrenchwomen’sdiscoursesinthis part.Duringtheinterviews,womenwereinvitedtospeakabout the three subtopics of our research; they were usually more talkativeabouttheuseofIMAwiththeirfamilythanwithhealth careprofessionals.Inaddition,somewomendidnothaveaccessto this service. Consequently, quotes beloware less detailed than thosefromhealthandsocialcareprofessionals.

In several instances, the experience of immigrant women regardingtheuseofIMAsupportstherepresentationsofmidwives and other health and social care professionals, but women’s discoursesalsonuanceandsometimescontradictthepropositions madebytheseprofessionals.

As already noted by some of the professionals, immigrant womendidnotalluseIMAtocommunicatewiththeircarer.In threecollectiveandethnographicinterviewsinvolvingatotalof40 women led in a centre where women with limited French proﬁciencytakecourses,noneofthewomen hadhadaccessto IMAcontactwithhealthcareprofessionalsandnoneseemedto knowaboutthispossibility.

Intheindividualinterviews,severalwomenexplainedwhyit wasdifﬁcultforthemtousethisformofcommunication.First,not allthewomenwemetcouldreadanditinterferednotonlywith theircapacitytocommunicatebutalsowiththeiraccesstoservices ingeneral.

WhenImether,shetoldmethatshecannotread.Sheexplained howitisdifﬁcultforhertoorganiseappointments;shecannotplan toomanyappointmentsinadvance[becauseshehastoremember theirdateandhour].Forthetimebeingshedoesnotcommunicate throughIMAwiththehealthcareprofessionalswhofollowher.She told me that they haveher number in case of an emergency.

(Ethnographicinterview(EE),ﬁeldnotesbyCC,Englishspeaking woman,originallyfromNigeria).

Besideliteracy,theimpossibilityofunderstandingFrenchora language shared with the health care professional was also mentionedbywomenasabarriertocommunicationthroughIMA.

As I don’t speak French, it would have been difﬁcult to communicate through text messages. And I didn’t have the numberoftheinterpreter.AsIwasoftenhome,Ididn’tgoout,I waitedforthemidwife’svisit.Fromonevisittothenext.Therewas noothercommunicationpossibility.(Semi-directedinterview15 (SDI),conducted inDarithrough aninterpreter,withawoman originallyfromAfghanistan)

SeveralintervieweesusedIMAcommunicationwiththeircarer, butaslittleaspossible,astheypaidattentiontotheircareranddid notwanttointerferewiththeirprivatelife.

I’mlucky.MymidwifeisavailablethroughWhatsApp.ShetoldmeI wasverynice,becauseIdidn’tbotherherwithit.Ofcourse,Ididn’t wanttobotherher.Justonce,Icouldnotﬁnd[someinformation]

thatwasimportanttome.[...]Ihavemanyquestions,soInote them on a piece of paper and ask them during the next appointment. I can also call the midwives’ association or the maternityhospital.IknowIcancallher.Iwillnotobsessively[call hertoknowwhattodo]becausemybabycriesforhalfanhour.

[...]Iimaginetheprofessionalwhogets10,000textmessages.In the midwife’sorthe pediatrician’s position,youhaveconsulta- tions,youhavemanythings,soIwouldonlytextifit’simportant.If mybaby’spoohasadifferentcolouroneday,Iwouldwaitfortwo otherpoosamples.(SDI10,conductedinFrench,withawoman originallyfromSpain)

OtherwomenorparentstendedtocommunicatethroughIMA onlyonrareoccasionsastheydidnotfeeltheneedtoandfeltthat theirinfantwashealthy.

Ourmidwifevisitedusprettyoften,[...]sowedidnotneedto [sendpicturesorSMS]betweenthevisitsalot,becauseshewas abletoseeifeverythingwasﬁne.Butyeah,everythingwasﬁne,so it’sprobablywhywedidnotneedmuchcommunication.(SDI1, conducted in English with both parents, both originally from Russia).

TheimmigrantwomenwhohadaccesstoIMAcommunication sharedacommonlanguagewiththeircarer.Theyeitherspokeat leastabasiclevelinFrenchorEnglish.Someofthemhadhadthe possibilityofﬁndingamidwifewhospokePortugueseorSpanish.

Somewomenpreferredtosendvoicemessagesand otherstext messagesdependingontheireasewithFrench,English,speaking orwriting.WomenwhohadaccesstoIMAcommunicationwith theircarerexplainedthattheyusuallytextedmessageswithregard totheirinfant’shealth:

Oncehehadsomebloodinhissnot.Itfrightenedmebecausehe wassosmall.IwrotetomymidwifethroughWhatsAppandshe answeredmeatonce.[...]Mybabyalsohasamoleononeofhis testes.SoIsentherapicturetoaskifitisnormalandshesuggested thatIshowittothepaediatrician.[...]ThenIaskedherbecause hehadverydryskin,sheadvisedtoputsomecream.Sometimes,I sentheravoicemessage.Onenighthewaslikesnoring,reallyloud.

Washesick?Didhehaveasorethroat?Iwasafraidhecouldnot sleep.Isenttherecordedsoundtothemidwife.Shesaidthatthe soundswerenormal,thatIcouldrelax,sheadvisedmetotakedeep breaths.(SDI7,conductedinSpanish,withawomanoriginally fromCentralAmerica).

Insomecases,womenalsotextedabouttheirownhealth.

Ihadacesareansectionandthescarbecamehardwith,whatdo theycallitatthehospital?Anoedema?So,themidwifetoldmeto take pictures of my stomach and to send it to her through WhatsAppaswedidn’thaveaplannedappointment.It’stheonly timeIusedWhatsApp.(SDI9,conductedinFrench,withawoman originallyfromtheIvoryCoast)

Asprofessionalshadpointedoutabove,womenalsoconnected theirneedforacloserrelationshipwithhealthcareprofessionals andforIMAcommunicationtotheirlittleexperiencewithinfants.

IthinkthatIwasalittlebitdependentonWhatsApp.I[alsosent]

quiteanumberofpictures.HeismyﬁrstchildandIdon’tknow manythings. I’m not usedto caring fora baby.[I need] some experience.Atthebeginningwhenheissosmall,sodelicate,it’s distressing.(SDI7,conductedinSpanish,withawomanoriginally fromCentralAmerica).

Womenwhoalreadyhadchildrenmadecomparisonbetween theirconﬁdencewiththeﬁrstorsubsequentchild.Insomecases, howevernotalways,immigrant womenalsohada morestable xxx–xxx

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situationinSwitzerlandwhentheyhadtheirsecondchildwhich contributed to their better experience. Some mothers also explainedhowtheycombinedseveralsourcesofinformation.

IfIhavesomequestions,Iwillaskoneofmyfriendswhohastwo boysormysister.IfIhaveadifﬁcultquestion,thenIwillaskmy midwifeElisa³.Afterthebirth[ofmyﬁrstchild,Icommunicateda lotwithmymidwife],but[forthesecond]Iknewcertainthings,it became easier. Isometimes writeWhatsApp messagesto Elisa.

[...]Ialsotookcoursesatthemidwives’association.ImetLaura there whoisanothermidwifeand amother. Sheansweredmy questionstoo.She’samotherandhasmetsomanymothers.(SDI 20,conductedinFarsithroughaninterpreter,withawomanof Kurdishorigin).

Immigrantwomensharedacommonexperienceofloneliness duringtheirpostpartumandmanyregrettedtheabsenceoftheir closeones,especiallytheirmothers.Womenwhohadfeltthemore intenseneedtocontacttheircarertendedtomisstheirsigniﬁcant othersmoreintensely.

Mymothercametoseemeandstayedforthreeweeks.Mybabywas onemontholdwhenshearrived.Shewasanincrediblehelp.She wouldtakecareofthebabyatseveninthemorning.Shewouldtell me:“givemethebabyandsleepalittlelonger”.Iwasabletogoouta littlebitonmyowntoo.[...]Whenshewentbackto[Central America]Ifeltsobad.Sobad.Icriedalldaylong.Mybabyfeltit,that nighthecouldn’tsleep.Hefeltthathisgrandmawasgone,sosad.I’m just startingtoget used [to herabsence]. (SDI 7, conductedin Spanish, withawomanoriginallyfromCentralAmerica).

Insomecases,midwivesandafewimmigrantwomenformed WhatsApp groups to maintain a connection throughout the perinatal period. This was only possible when they shared a common language. On rare occasions, we found that some professionalshadformedWhatsAppgroupsincludinginterpreters.

Thislatteremergentpracticeseemedtoberarelyinuseandno womanwasabletocommentonit.

In general, women expressed satisfaction regarding the postpartum caretheyreceived and oftenspontaneously named thehomevisitsofmidwivesashelpful.Whentheyhadaccesstoit andfelttheneedtocommunicatethroughIMA,immigrantwomen foundthismeanconvenientandsatisfying.

MypediatriciangavemeherWhatsAppnumberearlyonsoifwe haveanyquestionswecanWhatsAppher.Ifwehaveanissue,aska questionratherthanbeingstressedaboutsomething.[...]My babyhadlikeasecretioncomingoutofhiseyeandIsenthera photo.Andshesaidtocomebytomorrowtodoaswab.Itendedit withsalineandbreastmilk;itstoppedonthenextmorning.So,I askedshouldIstillcome?Shesaidno,justkeepaneyeonit.So useful.Idon’thavetocalltomakeanappointment,gotothedoctor, payalotofmoneyforaquickquestion.[...]Reallyreassuring.

(SDI6,conductedinEnglish,withawomanoriginallyfromNew Zealand)

TheuseofIMAinbetweenconsultationsformsanadditional service provided by some professionals, especially community midwives.Asanemergentpractice,itseemshelpfultowomenand the professionals who use it, adding to the continuity of care.

However,asexplainedabovethisserviceisnotequallydistributed among women, one oftheissues thatwill befurther discussedbelow.

Discussion

InSwitzerland,IMAmediatedcommunicationbetweenfami- lies and service providers such as midwiveshas emerged as a

bottom-uppractice since thecommercialisation and democrat- isationofmobilephonesandIMAadecadeago.Womenlargely initiateIMA mediated communicationwith theircarer, making IMA a potential component of woman-centred care [28] and continuityofcare[29]includingforwomenlivingtheirmaternity in stressful social situations [8]. As often, human innovation emerges from practice and the affordances provided by social actors’directenvironment[30];inthiscaseaffordancesconsisted oftheuser-friendlyfeaturesofIMA,whichallowrapidandlow- cost communicationbetweensocial actorssuchaswomen and midwivesornurses.Thisformofcommunicationisevensuitable forwomenonatightbudget,whocansendtextorvoicemessages, picturesand videostotheircaregivers,withoutadditionalcost, providedtheyhaveanInternetorWIFIconnection.Everymother whoparticipatedinourstudyhadamobilephoneandatleastone IMA.Onrareoccasions,midwivesnoticewomenwhoinvoluntarily lackamobilephone,andtheyseethisasanalarmingindicatorof isolationandpoverty.Insuchcases,midwiveshelpwomenobtain aphonealongsideothertypesofsocialsupport.⁴

ThefeaturesofIMAalonedonotcompletelyaccountfortheir useinpractice,fortechnologiesdonothaveagencyinthemselves;

theyaretranslatedintocommunitiesofpracticebysocialactors accordingtothecharacteristics ofeach social environment [4].

First,midwives–butnototherprofessionalsinourstudy–relate the frequent use of IMA to the risk culture that influences representationsandpracticesduringtheperinatalperiod[31].For them, the multiple ways in which health care professionals apprehendrisk mayundermine the confidence of women.The apprehension of risks concerned the postnatal period and in particularthehealthofthenewborn;acaseofriskculturethathas beenlessstudiedinmidwiferyandthesocialsciences thanthe case of pregnancy and birth. Women’s questions mirror the information distributed during prevention campaigns. For instance,aleafletcontainingpicturesofthenormalandabnormal colour of newborns’ faeces has been added to the medical handbookkeptbyparents since 2009[32]. Thisleafletaims to enablespecialiststointerveneearly inthecase of therarebut severeconditionofbiliaryatresia[32].Thepictureshavecaptured theattentionofparentsascanbeseeninthecountlesspicturesof newborns’faecessenttomidwives.Interestingly,thispreoccupa- tiondidnotshowsignificantlyinasurveydonetoevaluatethe reactionofasampleofparentstothisinformationcampaign[32].

A point that couldwarrant furtherenquiry given ourﬁndings.

Similarly,thecampaignsaimedatpreventingsuddeninfantdeath syndrome may be mirrored in mothers’ attention to their newborn’sbreathingpatterns.Inthesecases,thecontentoftext andvoicemessages questionshowpreventioncampaignsinﬂu- encethe experienceof new parents and may contributeto an augmentationofanxiety,indicatingdirectionsforfutureresearch.

Second,midwivesandnursesalsoseetextorvoicemessages sent bywomen as anexpression of the loneliness experienced duringthepostnatalperiod.Conﬁrmingthesehypotheses,studies insociologyofthefamilyhaveshownthatSwissfamiliesadopta nuclear form of organisation [33]. Intra-familial solidarity has declinedovertheyearsandfamilymembersareexpectedtobe self-reliantandtocopeindependentlywiththeirordeals[33].For immigrant families living in Switzerland, loneliness may be induced either by similar culturalfeatures or by the fact that familymembersliveabroadandcannotspendthepostnatalperiod in Switzerland [34]. Besides, the advice and the practices of women’sownmothersmaybeconsideredasout-of-datebysome women[35],makingthemreluctanttoasktheirmothersorother

3Allﬁrstnamesinthepaperarepseudonyms.

4 For a comprehensive overview of actions undertaken by midwives to countervailsocialdistress,see:(Ibid.)

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experiencedrelativesforsupportduringtheperinatalperiod[35].

Thisreluctancemaybefedbyprofessionalswhoentertainnegative stereotypesagainstoldergenerations’knowledge[36].Hence,ina cultural climate deemed neoliberal by social scientists [11,13], womenareexpected,andcometoexpectthemselves,toconform toaspeciﬁcmoralregime[37]:theyshouldbeautonomousand rely on themselves rather than on social support. This moral regimeofself-reliancedoesnottakeintoaccountthevulnerability thataccompaniesmanyperiodsoflife[38],suchasthepostpartum period. Neitherdoesit takeintoaccount thediversityof social situations that may impede self-reliance [11]. The numerous messages sent to midwives and other professionals further questionsthesustainabilityofsuchamoralregimeofautonomy.

Inthiscontext,itisnowonderthatwomencontactmidwivesoften andaskquestionsaboutnewborns’pimples,miliumordryskin,all benignandcommonskinfeaturesofnewborns.Hence,whensome womensendmoretextorvoicemessagesthanaverage,midwives tendtointerpretthissituationasaclinicalindicationofloneliness, anxiety and a need for more support. In this sense, they acknowledgeaneedforinterdependencethroughtheirdiscourses andpracticestocounteractthecurrentneoliberalmoralregime.

Immigrantwomeninourstudyalsohighlightedtheirexperi- enceofloneliness.Theyexplainedhowtheymissedtheirfamily, particularlytheirmotherandfemalesigniﬁcantothers.Severalof them shared that they felt insecure as they had had little opportunitytocareforinfantspriortobeingmothers;theylived their maternity withlittle to nosocial supportother than the midwife’s visits [20]. Asalso shown by other authors, women neededinformation abouttheirchild’sdevelopment and health [9,10]andsupporteitherfrompeers[9]orprofessionals[5,8,9].

Importantly,thesewomencontradictedthestereotypethatseveral midwives and nurses held aboutimmigrant womenwho were seenas“natural”andspontaneousmothers;leadingsomeofthem tounderestimateimmigrantwomen’sneeds.

Immigrantwomen’saccesstoIMAmediatedcommunication wasuneven.WomenwhowereabletowriteeitherinFrenchor Englishcouldusuallycommunicatewithmidwivesornurseswhen theyneededto.Oneof themidwives’associationsinwhich we conducted ourstudyalsoorganised for Portugueseor Spanish- speakingwomentohavetheirhomevisitsdonebyamidwifewho could speak theirlanguage, thus alsoallowing the useof IMA betweenconsultations.Despitethesearrangements,whenasked aboutdifferencesinIMAuse,midwivesconsistentlyremarkedthat immigrantwomendidcontactthemlessthroughIMAthanSwiss women,withtheexceptionofwomenconsideredtobeexpatriates who had a higher education and a relatively afﬂuent social situation.

This difference in access to IMA was conﬁrmed during the collective and ethnographic interviews that we held with immigrantwomen;manywomentendedtoignorethepossibility of reachingtheirmidwifeoranyotherhealth careprofessional with IMA, sometimes even when they spoke some English or French.Someofthemlackedtheliteracyande-literacyskillstouse IMAforcommunicationabouttheirhealthorthatoftheirbaby.

Nevertheless,immigrantwomenwhohadthepossibilityofusing IMAwiththeirmidwifeweresatisﬁedwiththatpossibility.For them,IMAmediatedcommunicationmaintainedacontinuityin the relationship with their midwife and fostered a sense of belongingintheirnewcountryastheysawmidwivesnotonlyas carers,butalsoasacquaintances.Theseelementsconﬁrmtherisk well detailed by Veinot et al. [14] that implementation of informaticsinterventionsmayworsenbothinequalaccesstocare andhealthoutcomes.

Themidwivesinterviewedreacteddifferentlytotheunevenuse ofIMAmediatedcommunicationbywomeninbetweenpostpar- tumhomevisitsasIMAisasemi-voluntarybenevolentservice.As

a result, these practitioners did not always react when some womendidnotcontactthemthroughIMA,soastoprotecttheir work-lifebalanceandhealth.Othermidwives,especiallytheones in regular contact with immigrant families and families living undersocialdistress,compensatedforthedifferenceinIMAuse.

Thesepractitionersmayoffermorefrequentorlongerhomevisits andtaketheinitiativetocontactwomenwhenworriedabouttheir situation.Ina previous anthropologicalfieldworkthatenquired about the experiential knowledge-making of community midwives,⁵thesepractitionersalsoshowedhowtheirintentionwasto find a balance between intervention and respect for women’s agency;allowingsometimetopassbeforecontactingwomenthey were worried about, tolet these women takethe initiative of makingcontact asmuch as possible.Thesame sub-segmentof midwives were also more prone toexpand the scopeof their practicebyrunningerrandsandhelpingwomenwithadministra- tivetasksorbyentertaininglongtermrelationshipswithwomen invulnerablesituationsincludingcasesofgenderbasedviolence [20]. In addition, one of these midwives created postpartum meetings for immigrant women in a poorer neighbourhood to prolongtheaccesstoservices,careandpositiverelationshipsafter thehomevisits[39].Thewomenwhobenefitedfromsuchtailored careexpressedtheirgratitudeduringourfieldwork.Oneof the participantssaid,forinstance,thatthesemeetingsprovidedasafe spacewhereshedidnotneedtofeelafraid,contrarytomanyother instancesinherlife.Theseexamplesshowthatwoman-centred caremayneedmidwives’socialengagementandcreativitytomeet women’sactualneeds.Theyalsohighlightthatifthecontinuityof care(r) from theonset of pregnancy tothe postnatal period is seldom guaranteed in Switzerland, it is ensured during the postnatalperiod.

InSwitzerland,asinotherhigh-incomecountries,immigrant womenandinfantssufferfromahighermorbidityandmortality rate[40,41],andpoorermentalhealth[42,43].Studiesconducted inneighbouringcountriesandabroad,indicatethatthesediffer- encesinoutcomearepartlyduetodifferencesincare[44].IMA mediatedcommunicationmayseematrivialformoftelemedicine, howeveritwasconsideredusefulbytheimmigrantwomenwho hadaccesstoitaswellasbythehealthcareprofessionals.Thus,the apparent difference in IMA mediated communication between Swiss,expatriateand non-FrenchorEnglishspeakingorpoorer immigrantwomenformsanotherlayerofInverseCareLaw[45];

IMAmediated communication is provided less towomen who need more care. This is worth the attention of professional associationsandotherpolicymakersastheroleoftelemedicine mayincreaseinthefuture[14]andwillalsoconcernreproductive andmidwiferycare,particularlyduringandintheaftermathofthe COVID19crisis.

SomeinstitutionsdiscouragedtheuseofIMAbetweenhealth andsocialcareprofessionalstoaddresswomen’sneeds.Paradoxi- cally,theseinstitutionsweremorepronetouseIMAtoconvey messages to women such as appointment reminders and, surprisingly, ofﬁcial decisions regarding allowances. For non- Frenchspeaking women, especially women withliteracy problems,writtenreminderssentthroughIMAinacrypticformatmay notbeanidealmeanofcommunication.Suchemergentpractices mayreassureprofessionalsandinstitutionsthattheyhavedone theirsharetoensurethat womencome totheirappointments.

However, our study suggests that such impressions may be misleading.Imposingdigitalinsteadofdirectcommunicationhas beenapreoccupyingandemergentfeatureofcontemporaryhealth and social care systems since the inception of telemedicine

5 See:(Ibid.,p.251 252).

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technologies[46,47].Therecoursetodigitalrelationshipsbetween usersandhealthcareprofessionalsappearstobeaby-productof the centralisation of hospitals and services, implemented to contain costs by limiting access todirect contacts[47]. In the situation described in this article, the imposition of digital communication remained limited, nevertheless it was deemed stressful by allactors interviewed.Asmissed consultationsare signiﬁcantindicatorsforaugmentedmorbidityandmortality[48], these new practices demand closer attention in practice and research. Women in vulnerable situations such as non-French speakingimmigrantwomenneedtailoredinformationtoensure thattheyreceivethecaretheyneed.

Studies that have examined the use of IMA by health care professionalsalsoreﬂectupondatasecurity[8].Untilrecentlythe verypopularWhatsApp^TMwasconsideredsafeasthedatawere encrypted[8].AsshownbytherecentchangeinthisIMApolicy, encryption and data protection may be lifted under diverse circumstances,suchasthedecision ofacompany orthelawof individual countries. The Swiss Federation of Midwives had expressed preoccupations regarding the temporary guarantee offered by companies that commercialise IMA such as What- App’s^TM and had advised against its use betweenwomen and midwives apart from organisation purposes. As IMA mediated communicationtendstobewanted[24]andinitiatedbywomen, thisobjectivemaybedifﬁculttoachieve.Inaddition,andasour article shows, IMA mediated communication seems to satisfy women and discardingitsuse doesnot seem tobe a woman- centred option. Nevertheless, data security remains one of the concerns regarding IMA use between health and social care professionals.Thefeasibilityofmigratingthesecommunicationsto saferIMAshouldbeexplored.

Lastly,IMAmediatedcommunicationdoesnotpertaintothe services recognised in the Swiss insurance system for self- employedmidwivesornursesandresultsinunpaidworktogether withtheerrandsthattheseprofessionalsfeelcompelledtorunfor womenwholiveinsocialdistress[20,23].Inourstudy,midwives consideredIMAmediated communicationtobestressful atthe beginning of their self-employed career; and tended to find it manageablelaterintheirworkingexperiencebyusinganarrayof strategies.Nevertheless,addedtoanalreadybusyschedule,tothe alsounpaidadministrativeworknecessarytotheorganisationof interprofessionalcollaboration[23],thisadditionalunpaidwork shouldnotbeunderestimated.Theproportionofmidwiveswho sufferfromprofessionalburnout isquiteimportant,evenifthis proportionisdifficulttomeasure[49].Theworkload,thecarefor families in complex situations and insufficient pay are all consideredasfactorsthatcancontributetoprofessionalburnout asarecentscopingreviewshowed[49].Thecontinuityofcarer, highly valued by the self-employed midwives in our sample, constituteshoweveraprotectivefactor[49].

Limitsofourstudyandfurtherdevelopments

Our study hasseveral limits thatprevent a comprehensive analysisofIMAmediatedcommunicationbetweenwomenand theircaregiversduringtheperinatalperiod.First,asthefocusof our socio-anthropological study was immigrant (expectant) mothers’ relation to ICT, our data do not include interviews with Swiss women. Further exploration of IMA mediated communication between caregivers and (expectant) mothers are thereforeneededtoappreciate howthisemergentform of careintervenesintheexperienceofSwisswomen.However,the experience of immigrant women should not be considered essentiallydifferentfromSwisswomenasthedeconstructionof culturalism in anthropology has shown [26,27]. For instance, immigrant women share about their uncertainties regarding

their experience as ﬁrst-time mothers. Second, some of the immigrant women were recruited through their caregivers, a methodthatmayputunduepressureonwomenifnotusedwith utmostcaution.Ourresearchteamcarefullyexplainedwomen’s rightsnottoparticipateinthestudy,withoutconsequencesfor them, and paid careful attention to women’s reactions and comfort. Third, as the timeframe for our study was short, a circumstanceinherenttothecallforprojectswerespondedto, wedidnotplantocollectquantitativedatatocomplementour qualitative researchplan.Futurestudiesabout the useof IMA mediatedcommunicationshouldcollectdataaboutthenumber ofmessages, thefrequency ofspeciﬁccontents andthediffer- encesbetween frequentandinfrequent usersof IMAmediated messagesin-betweenconsultations.Itwouldalsoberelevantto explore the use of IMA mediated messages in other area of medicineandcareaswellasinothercountries.

Conclusions

IMAmediatedcommunicationbetweenwomen,midwivesand otherhealthandsocialcareprofessionals,appearsasapromising emergentpracticethat couldcontributetowoman-centredcare andcontinuityofcare,especiallyaswomenwish[24],appreciate [5,8] and often initiate this communication themselves. As an emergentpractice,IMAmediatedcommunicationhasnotyetbeen framed by comprehensive recommendations from professional associationsandotherpolicymakers[50];thescopeofitspractice isthuspractitionerandinstitutiondependent.IMAishencenot officiallypartoftheservicesprovidedbycommunitymidwivesor nursesinSwitzerland;therefore,itisnotreimbursedwithinthe compulsoryinsuranceschemeLAMALandremainsunpaidworkto theday.ThissituationmaycontributetounequalaccesstoIMA services by women during the postpartum period, as the professionals do not always react to some women’s lack of engagementwithIMAmediatedcommunication.Quantitativeand mixed methods studies are needed in order to measure the differences in use of IMA mediated communication between subgroups of women, as well as the countervailing measures undertaken by midwives and other health or social care professionals.A complementaryqualitativeresearchwithSwiss including French-, German-, Italian- and Grischun-speaking women–theofficialSwisslanguages–wouldalsobeneededto enquire about these women’s experience of IMA mediated communication with their carer. Last, midwives adopted IMA mediated communication as a complement to the face-to-face visits they made with women. As IMA and other forms of telemedicine have been increasingly used since the COVID19 pandemic,thisstanceisimportanttokeepinmindwhenreflecting onpolicyduringandintheaftermathofthepandemic.

Authors’contributions

PPdesignedthestudy,CKperformedtheliteraturereviewprior to the study, PP, CC and CK produced and analysed the data, includingtherevisionanddiscussionofthecoding.PPwrotethe ﬁrstversionofthemanuscript;PP,CC&CKeditedthemanuscript.

Allauthorshavereadandapprovedthearticlepriortosubmission.

Ethicsapprovalandconsentforparticipation

Theresearchprotocolwasgrantedapprovalbythecompetent ethicalcommissionsinSwitzerland(Project2018-02081CER-VD LausanneSwitzerlandandCCER-GEGenevaSwitzerland).Partic- ipants wereinformed of the objectives and procedures of the study, when necessary, with translated documents and an interpreter,andgavetheirconsenttoparticipation.

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