QUALITATIVE

Beck
/ INTERNET
HEALTH
INTERVIEWS
RESEARCH / March 2005

10.1177/1049732304270837

Benefits of Participating in Internet

Interviews: Women Helping Women
Cheryl Tatano Beck
Advantages of face-to-face qualitative interviews for participants have been addressed in the
literature. The benefits of participating in qualitative interviews over the Internet, however,
have yet to be discussed. Based on the experiences of 40 women who made up the sample for
an Internet study on birth trauma, the author describes in this article the benefits reaped by
these mothers through their participation in qualitative e-mail interviews. She used content
analysis to identify these benefits. Seven themes emerged: experiencing caring by being listened to and acknowledged, sense of belonging, making sense of it all, letting go, being
empowered, women helping women, and providing a voice.
Keywords: Internet research; qualitative research; qualitative interviews

tatistical significance is the gold standard against which excellence in quantitative research is judged and application to clinical practice is recommended. In
comparison, qualitative research appears impotent (Morse, 2004, p. 151). Morse
has urged qualitative researchers to remain silent no longer regarding the significance of their results but instead to articulate the significance of their work. To explicate the significance of a phenomenological study on birth trauma (Beck, 2004), in
this article, I have described the benefits for women in this sample who participated
in Internet interviews. Prior to discussing these participant benefits, I will address
Internet research issues, followed by a brief description of the method used in this
birth trauma Internet study.
The benefits of participating in face-to-face qualitative interviews have begun
to be addressed in the literature. Hutchinson, Wilson, and Wilson (1994) identified
the benefits of persons participating in qualitative face-to-face interviews as selfawareness, self-acknowledgement, sense of purpose, catharsis, healing, and providing a voice for the disenfranchised. B. L. Murray (2003) shared the therapeutic
benefits for adolescents in qualitative research interviews focusing on their experience of parental alcoholism. Benefits to this vulnerable population included taking
the first step in understanding what had happened to them during their childhood,
feeling less powerless in their situations, and forming a new self from their new
perspective of their earlier experiences with parental alcoholism.
Internet research to date has been primarily quantitative, but a trend is beginning to take shape of increased interest in using the Web for qualitative research,
AUTHORS NOTE: To all the courageous women who shared their most personal and powerful stories
of birth trauma, the author is forever indebted.
QUALITATIVE HEALTH RESEARCH, Vol. 15 No. 3, March 2005 411-422
DOI: 10.1177/1049732304270837
2005 Sage Publications

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especially with sensitive topics and vulnerable/hidden populations (Binik, Mah, &
Kiesler, 1999). The benefits of participating in qualitative interviews over the
Internet have yet to be discussed. Acknowledging that using the Internet for data
collection is new to a majority of researchers, Im and Chee (2003) called for
increased discussion of issues related to Internet research. Based on the experiences
of 40 women who made up the sample for an Internet study on birth trauma (Beck,
2004), I have described in this article the benefits reaped by these women through
their participation in qualitative e-mail interviews.

INTERNET RESEARCH
The use of the Internet for research has been organized into three categories:
resource locators, demographic surveys, and empirical investigations (Senior &
Smith, 1999). Empirical investigations refer to all usual kinds of research that use
the Internet as a research site or data collection method. Some advantages and disadvantages of using the Internet for data collection are starting to be addressed in
the literature. Collecting data via the Internet can be cost-efficient and also time saving (Fawcett & Buhle, 1995; Lakeman, 1997; P. J. Murray, 1995). One substantial costsaving benefit is that the data collected do not require transcription. They are
already in written format and readily available for analysis. An additional benefit is
that researchers do not have to take into account time zone differences when communicating with the study participants (P. J. Murray, 1995). Im and Chee (2003) have
termed this benefit asynchronous interaction, which permits persons on differing
schedules and/or time zones to communicate at their convenience. Eliminating the
barrier of distance is yet another advantage of Internet research (Fleitas, 1998).
International representation of participants is increased. Rapid response times are
possible regardless of the continent in which a participant lives.
The Internet can be a valuable tool for sampling hidden populations (Duffy,
2002). Nicholson, White, and Duncan (1998), for example, used the Internet to collect data from the hidden population of nonabusive, recreational users of illicit
drugs. Data collected via the Internet might be less likely to be affected by social
desirability and inhibition than face-to-face interviews or questionnaires (Joinson,
1999). Participating over the Internet might lead to participants disclosing more
intimate details about the topic being studied than they would share in face-to-face
interviews (Fawcett & Buhle, 1995). E-mail interviews also provide the participants
time to reflect on their answers to the questions without any pressure (Lakeman,
1997). Strickland et al. (2003) have warned, however, that successful qualitative
data collection over the Internet depends heavily on how well researchers are able
to use their interview skills within the confines of the Internet. Cotton (2003) has
alerted researchers of the critical need for conducting qualitative research on the
Internet that is caring, holistic, and culturally sensitive (p. 317).
Some limitations of using the Internet for data collection include limiting the
pool of participants potentially available to enter the study and a low response rate
to online surveys (Lakeman, 1997). Participant recruitment is limited to those persons with knowledge and skill in computers and physical access to the Internet
(Thomas, Stamler, LaFreniere, & Dumala, 2000). Another disadvantage is the lack of
interaction provided from face-to-face interviews. Researchers are not able to perceive changes in participants voice intonations (Fawcett & Buhle, 1995; Fleitas,

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1998). Nonverbal cues that enhance the communication of various emotions are
absent unless participants are instructed to use symbols and abbreviations, such as
tears of sadness or laughter out loud, to help convey these emotions (Lakeman,
1997).
Contrary to what was identified in the literature on Internet research, P. J.
Murray (1995) did not experience the limitation of interviews not being as in depth
or flexible as face-to-face interviews. He believed that the quality of e-mail interviews depends on the interviewer and the rapport that the interviewer establishes
with the interviewee.
Im and Chee (2001) identified the types of Internet usage by researchers: e-mail
and discussion lists, chat rooms, bulletin board systems, multiuser domains
(MUDs) and Web sites. Im and Chee put forth some challenges for researchers in
their future use of the Internet. Researchers need to be aware of the power differential between researchers and their participants. Shared authority and shared ownership of the data need to be developed. Empowerment of participants through the
research process is another challenge. Through the Internets flexibility in communication channels and social support, the empowerment of marginalized women
can be facilitated. Womens voices will be heard more easily than through other
media. At the start of the millennium, Im and Chee challenged researchers to be
active agents in using information technologies to enhance human well-being.

METHOD
The method used to conduct the original phenomenological study on birth trauma
has been reported elsewhere in depth (Beck, 2004). The research question investigated in that study was What is the essential structure of womens experiences of
birth trauma?
Birth trauma was defined as an event occurring during the labor and delivery
process that involves actual or threatened serious injury or death to the mother or
her infant. The birthing woman experiences intense fear, helplessness, loss of control, and horror (Beck, 2004, p. 28). For the purpose of this secondary analysis, a
brief synopsis of the literature review, sample, and data collection techniques are
provided as background.

Literature Review
The reported prevalence of PTSD due to childbirth ranges from 1.5% (Ayers &
Pickering, 2001) to 6% (Menage, 1993). Prior to Becks (2004) phenomenological
study, only one qualitative study had been conducted on birth trauma. In Allens
(1998) grounded theory study, she interviewed 20 mothers in the United Kingdom
10 months after they had delivered. The core variable related to birth trauma was
the womens feelings of loss of control of events or of their behavior. The women
attempted to gain control by seeking reassurance and knowledge from labor and
delivery staff and their partners. In a quantitative study out of the United Kingdom,
women diagnosed with PTSD due to birth trauma shared that during their labor
and delivery they felt powerless, were not provided information about procedures,
and perceived unsympathetic attitudes by the clinicians. Compared to women who

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had not experienced birth trauma, the PTSD mothers had experienced significantly
more invasive procedures (Menage, 1993).
In Sweden, factors related to mothers PTSD due to childbirth included a history of psychiatric problems, a negative perception of the past delivery, nulliparity,
and negative interactions with the delivery staff (Wijma, Soderquist, & Wijma,
1997). Creedy, Shocket, and Horsfall (2000) in Australia reported the stressful birth
events of women with PTSD due to childbirth were extreme pain, fear for their own
lives or those of their infants, and perceived lack of obstetrical care.
One study in the United States examined predictors of birth trauma (Soet,
Brack, & Dilorio, 2003). Cesearean delivery, high level of medical intervention,
painful labor, inadequate information, feeling powerless, negative interactions
with labor and delivery personnel, and differences between expectations of childbirth and the actual events were the significant predictors. Czarnocka and Slade
(2000) investigated predictors of traumatic births in the United Kingdom and found
these to be low levels of perceived support from both partners and from clinicians
and lack of control during labor.

Sample and Procedure

Forty women from around the globe made up the sample for this qualitative
Internet research. These women were from the New Zealand, the United States,
Australia, and the United Kingdom. Women were recruited for the study primarily
through Trauma and Birth Stress (TABS), a charitable trust located in New Zealand
(Web site www.tabs.org.nz; e-mail ptsdtabs@ihug.co.nz). TABS is a self-help organization that provides support for women who have experienced birth trauma. The
chairperson of TABS informed the members about the study and about me and provided them with my e-mail address. I had personally met the TABS chairperson at a
conference in New Zealand, and we had established a rapport. Consequently, the
chairperson could personally vouch for me, which helped mothers feel safe in making the initial contact. Another invaluable benefit of having the chairperson make
the initial invitation to the study was that as the intermediary person she was a nonmedical person and was viewed as a person on the side of the mothers. If women
were interested in participating in this study over the Internet, they e-mailed me. I
then sent any interested mothers the informed consent and directions for the study
as attachments.
In my initial e-mail message to the mothers, my primary concern was to
develop a rapport and begin a trusting relationship with prospective participants. I
shared my professional background and my purpose in conducting this study with
the women. In this first e-mail, I promised to honor the mothers words to the best of
my ability to educate health care providers about birth trauma and its resulting
posttraumatic stress disorder, which can wreak havoc in the lives of women.
Women electronically signed the informed consents and returned them as
attachments. Each woman was asked to describe her birth trauma experience in as
much detail as she wished to share with me. Thirty-eight women sent their birth
trauma stories to me over the Internet as attachments. Two mothers sent their handwritten stories by regular postal mail. Examples of the birth traumas described by

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these women included infant death/stillbirth, emergency cesarean delivery, inadequate medical care, fear of epidurals, inadequate pain relief, postpartum hemorrhage, forceps/vacuum extraction, degrading experience, and premature birth.
Mothers waited until they had completed writing their birth trauma stories to
send them to me. They did not submit several paragraphs intermittently over a
series of weeks or months. The length of the mothers birth trauma stories varied
from as short as 1 typed page to as long as 38 typed pages. One woman mailed me
two boxes filled with her diaries, journals, medical records of her labor and delivery,
and her formal complaint to the hospital regarding her traumatic birth. Another
mother handwrote her traumatic birth story, and it was 69 pages long.
No matter whether a woman typed her birth trauma story on the computer or
wrote it by hand, all the women shared that they had to write their stories in segments mainly for two reasons. First, it was difficult and exhausting for the women
to dwell on the details of their traumatic births. Second, the mothers had infants and
older children to care for, so they did not have the luxury of long, uninterrupted
periods to work on their stories. As one mother shared, The hurdle will just be for
me to find the time given that I am caring for a newborn.
Data collection occurred over an 18-month period. Participants varied in the
length of time it took them from the time they returned their electronically signed
informed consent to the time they sent me their completed birth trauma story. The
shortest turnaround time was 1 week, and the longest was 12 months.

CONTENT ANALYSIS
In this secondary analysis, content analysis was used to identify the repetitive
themes regarding benefits of participating in a birth trauma study over the Internet
(Beck, 2004). I did not ask the participants in the birth trauma study whether they
perceived any benefits from participating in this research over the Internet. Thirtyone of the 40 women (78%), however, took the initiative to share with me what they
felt were the benefits they had reaped by participating in the study. Only one participant e-mailed a problematic response. She wrote, I felt a bit reluctant about sending such personal information through cyberspace to someone I dont know.
I performed all the content analysis. Krippendorff (2004) has defined content
analysis as a research technique for making replicable and valid inferences from
texts (or other meaningful matter) to the contexts of their use (p. 18). Three of
Berelsons (1952) list of 17 uses of content analysis were pertinent to this analysis:
(a) to discover patterns in communication content, (b) to reveal attitudes and interests of a population, and (c) to identify attitudinal responses to communications.
The unit of analysis was thematic units (Krippendorff, 2004). The thematic units
were defined as segments of the mothers birth trauma stories that pertained to the
benefits of participating in the e-mail interviews. I employed Krippendorffs analytical technique of clustering to identify data that could be grouped or lumped
together by sharing some quality. I used dendrograms, which are treelike diagrams,
to illustrate how the data were collapsed into clusters. In Figure 1, I have presented
the merging of data for one of the patterns or themes revealed in the content
analysis.

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FIGURE 1:

Partial Dendrogram Resulting From Clustering Benefits of Participating in Qualitative

Research Over the Internet

PARTICIPANT BENEFITS OF E-MAIL INTERVIEWS

Content analysis revealed eight patterns, or themes. Overall, when trying to capture
the essence of the benefits of participating in this qualitative research study on birth
trauma via the Internet, the following quote from one of the mothers from New Zealand says it best: I think I will always remember the day I received your first e-mail
reply and I felt as though Id been thrown a lifeline.

Experienced Caring by Being

Listened to and Acknowledged
The women experienced caring from me and, in turn, repeatedly expressed their
gratitude. They were thankful to me for caring enough about the womens plight to

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conduct this Internet study on birth trauma. The mothers were grateful for a health
care professional who cared by wanting to listen to their experiences of traumatic
births. Women expressed thanks for acknowledging that birth trauma exists and
acknowledging that their birth experiences were, in fact, traumatic. As a mother
from New Zealand explained,
I think part of the stress that is suffered comes out by the lack of being heard or
acknowledged (and the sense of alienation that comes as a consequence of this and
the expectation to just carry on leading a normal life after such an event). Being
asked to write down my experience without being deflected (because people dont
know how to react) helps acknowledge the tough time that it was.

Participants who experienced caring from me were so grateful to feel the

warmth of this emotion. As one participant from the United States shared,
Thank you so much for your caring response to my story. It is a very personal story
and only a very few know parts of it, let alone all of it, as you now know. It feels so
good to be able to tell the story to someone who cares, understands, and wants to do
something to educate health care professionals.

Another mother from Australia wrote,

You thanked me for everything in your e-mail, I want to THANK YOU for caring.
For me, it means a lot that you have taken an interest in this subject and are taking
the time and effort to find out more about PTSD. For someone to even acknowledge
this condition means a lot for someone who has suffered from it.

Sense of Belonging
Women suffering from birth trauma felt isolated and alone. Participating in the
Web-based qualitative study helped mothers not feel so alone. As one mother from
the United Kingdom shared, Knowing that other people feel the same way I do
helps me feel less isolated. A woman from New Zealand explained,
The mere fact that this is being studied, and there is more than just me in your sample gives me some sense of belonging in that there are actually other women out
there that have been through some kind of birth trauma themselves.

Mothers drew comfort from knowing they were not alone and that women around
the world had been through similar experiences. As one woman from New Zealand
put it, We gain strength in numbers.

Making Sense of It All

Writing down their birth trauma stories on the computer resulted in the benefit of
helping the women sort out the details of what had happened to them during their
labor and delivery. It provided a clearer understanding and facilitated their making
sense of it all. Lots of things that happened to them during their birth traumas were
consolidated. A quote from a mother in the United States illustrates this benefit.

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It gave me a clearer picture of my experience than just talking about it. So many
things went wrong with my labor. I had been trying to summon the presence of
mind to summarize it. My story I have just written for your study comes the closest
and is the most effective vehicle.

Another mother from the United States explained,

It has taken me months to start to piece it all together so I can understand what happened to me. This is one reason that I have decided to try and write down my memories for this study because I hope that writing things down in some logical order of
events will help me to find reasons for my random thoughts and feelings over this.
It is a good record of events for me.

Letting Go
By writing down their birth trauma stories, women experienced an unexpected
benefit. Now that all the details of their traumatic births were written down on
paper, women felt as if they could finally let go of all these details. As a mother from
New Zealand revealed, I felt the need to record everything so as to validate my
experience to myself and to get rid of ALL the little things that kept coming to
mind. Another mother from New Zealand shared,
I feel by writing about it my story is outside me and not inside filling me up with
anxiety. It has taken a couple of months to get my story out but its been a very therapeutic exercise doing so.

A segment from a womans story from Australia provides another illustration of

this benefit. Writing about my birth trauma experience has said to part of my memory forget about some of the details for awhile, have a restits all written down if
you want to come back to it.

Being Empowered
As a result of participating in this qualitative study online, women were empowered. For example, one mother living in New Zealand described that Writing this
birth trauma story has been a cathartic experience and has given me the push
needed to write it out and finally make a formal complaint to the hospital about my
treatment.
From the United States, a woman wrote,
It is no wonder that it has taken so long for the story of birth trauma to be told.
Trauma victims are so dis-empowered by the results of events. It was my desire to
own my story that did drive me on because it really meant nothing to those who
held the facts. I didnt feel I had a choice in writing my own story. It was something I had to do, I wanted to empower myself.

Another example of the empowerment of these trauma survivors comes from a

mother in New Zealand, who was now pregnant again after experiencing birth
trauma with her first delivery. She wrote, I have given a copy of my birth story that

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I had written for your study to my new midwife and her trainee to help them understand how stressful the experience was last time for me.
The best illustration of this blossoming empowerment comes from the United
States. This mother revealed,
I now have a new goal in life!! When this lawsuit is over, be it settlement, or my
choiceby trial, I very, very, very much want to establish some sort of trust or
fund for women to be able to get the help that they desperately need, but cant
afford!

Women Helping Women

Providing a sense of purpose was another benefit the women experienced by participating in this Internet research on birth trauma. Women helping women was a benefit that the mothers treasured. Usually, the mothers began their stories with
phrases such as If I can help someone not feel this way, I would love to help, or, as
a mother from New Zealand shared,
I had an almost desperate fear that this would happen to another woman. I was
especially concerned that it would happen to a very young woman who wouldnt
be able to cope. I became filled with a wish to protect others.

As one mother from the United States expressed,

It is my heartfelt desire that by sharing my experience(s) I can in some way help to
prevent any other woman from ever having to experience the horrors that not only I,
but my family, have had to endure. It GREATLY saddens me to know so many other
women have had to go through this nightmare. We must all work together to bring
an end to these events. The day your baby [babies!] is/are born, should be the happiest day of a womans life!

Another woman from the United States explained, I want other mothers to know
that they are not alone and that there is a light at the end of (sometimes a very long)
tunnel.
Mothers also benefited from their hope of increasing health care professionals
awareness of birth trauma and its resulting PTSD. One mother in the United States
explained,
I share with you my birth story because I want so dearly for a much better awareness
and understanding amongst the health care profession of the incredible effects a
negative birth experience can have on mothers mental health.

Another woman from the United States stated, I must share my story so that health
care providers are aware and informed of what can happen to a woman and her
family after a traumatic birth.
Knowing that they could possibly help improve care given to women during
labor and delivery was yet another benefit women received from their participation
in this qualitative study via the Internet. From New Zealand, a woman e-mailed, If
my participating in your research can bring about some positive changes in

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maternity care then this will be wonderful and I feel that writing my story is all the
more worthwhile.
Although from the United Kingdom, a mother e-mailed that through her writing her birth trauma story for the research, she hopes it will lead to improvements
in training that will minimize the occurrence of this largely preventable disorder.

Providing a Voice
This benefit from participating in qualitative Internet research is best stated by one
mother: A number of New Zealand secondary schools have a motto something like
lumen et emcipe pertiwhich means carry the light or pass the knowledge to othersthanks for doing this for me. Another woman, this time from Australia,
shared the following with the researcher: Thank you so much for giving us a voice
that we so desperately need. Im so glad the material finally has a voice.
After a mother from the United Kingdom had read the prepublication version
of the manuscript that I had sent her, she responded with the following e-mail
message:
Thank you from the bottom of my heart for giving us a voice. I read through the article and I am humbled and extremely grateful for the way you have listened and
shown empathy to the stories of the women in the study. I was moved to a flood of
tears which is something I am virtually incapable of doing . . . not for the stories but
the hope that this study will/may prevent someone else from suffering like we
do.

Another woman from the United Kingdom wrote,

To suggest childbirth is ever anything other than a joyful rewarding experience is to
challenge an orthodoxy routed in centuries of folklore, religion, and mysticism. We
women in your study are not just participating in it but are helping to write a piece
of social history!

DISCUSSION
The content analysis of the mothers birth trauma stories sent online mirrored the
benefits of participating in face-to-face qualitative interviews identified by Hutchinson et al. (1994): healing, empowerment, catharsis, sense of purpose, self-awareness, self-acknowledgement, and providing a voice for the disenfranchised. Some
of the themes from the birth trauma Internet interviews are similar but have been
labeled differently. For example, letting go was certainly part of the healing process for women who experienced birth trauma. Making sense of it all helped the
mothers self-awareness. The women definitely had a sense of purpose, which
came out loud and clear in the theme women helping women. Even though the
interviews were not conducted face-to-face, unlike those reported by Hutchinson
and colleagues (1994), the Internet interviews yielded similar benefits for the participants. Two additional benefits of Internet qualitative interviews emerged from the
birth trauma study: feeling cared for and a sense of belonging. Even though the
women who participated in the study only e-mailed me and did not communicate
among themselves (only I knew the identities and e-mail addresses of the partici-

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pants), the comforting feeling of not being isolated and alone was experienced. The
mothers felt a much-needed sense of belonging with the other mothers from around
the globe who too had participated in the study. I would share with the women how
many mothers, to date, had participated in the study and from which countries,
such as New Zealand, Australia, the United Kingdom, and the United States.
The birth trauma Internet interviews also confirmed the therapeutic benefits
described in B. L. Murrays (2003) qualitative research on the adolescents experience of parental alcoholism. Murray shared that by telling their stories in face-toface interviews, the adolescents took the first step in making sense of what had happened to them. They felt less powerless in their situations, and they started to let go
of the past and start healing. Participation in qualitative interviews, be they face-toface or over the Internet, can be a beneficial and powerful experience.
Not only the participants but also I benefited both professionally and personally from conducting this Internet study. This was the first time I had conducted
research over the Internet. Getting to know these incredibly strong and unselfish
women who had suffered traumatic births was an inspiring experience. At times, I
grieved with mothers when they shared their most private photos of their infants
burial with me. At other times, I rejoiced with women as they e-mailed me updates
to share that they had become pregnant again and this time had a labor and delivery
that was a healing experience for them.
The thought I would like to end with is the acknowledgement of the powerful
effect qualitative researchers can have on their participants, even though they are
conducting Internet interviews. Despite the fact that researchers and participants
are not physically present with each other and there are no faces to put to names,
researchers still have the challenging responsibility to convey caring and respect to
their participants. Your e-mails to your participants should be crafted carefully to
allow your caring and authentic presence and listening to come out loud and clear.
When you are conducting research on sensitive topics, your e-mails can provide a
comforting blanket to wrap around vulnerable participants. One cautionary note,
however, is that I do not meant to suggest that Internet research is a type of therapy
through e-mail exchange.
Miller and Crabtree (2003) have called for a clinical research space to be created
where the patient, clinicians, and researchers meet and hold a conversation, where
the walls meet clinical reality, and where these walls separate patient from clinician
and qualitative researcher from quantitative researcher. Creating this clinical
research space involves bringing these various groups outside their walls and seeking out common ground. As evidenced by the qualitative birth trauma study, the
Internet can help facilitate the movement of these groups to a common ground
where conversations at the walls in cyberspace can be held.

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Cheryl Tatano Beck, D.N.Sc., C.N.M., F.A.A.N., is a professor of nursing at the University of Connecticut, Storrs.