The likelihood of finding preconception care recommendations consistent with AJOG on the Internet was low, using search strings selected either by health professionals or by women of childbearing age.
This study shows that current approaches for searching preconception information on the web do not result in finding a complete and accurate set of recommendations, although we found no websites reporting totally incorrect preconception information. The obtained result is helpful to estimate the level of consistency of information found on the web considering the increasing use of the Internet for seeking health information by women and health care professional, and the importance of the web as a helpful instrument for health professionals for rapidly improving their knowledge and communicating with patients [11–22].
The recommendation on folic acid supplementation was, overall, the most frequently found on the Internet; moreover, it was significantly easier to find a correct recommendation on this subject for a health professional than for a woman of childbearing age. This result may be explained by the observation that a specific string search on this topic was provided by health professionals and not by women. However other specific search strings, as those on lifestyle and on preconceptional visit, were evenly distributed between the search groups and did not result in any difference on correct recommendation. On the other hand the high frequency of correct recommendations on folic acid supplementation may be favored by a recent campaign conducted in Italy on folic acid supplementation [29–31].
Since physicians may be influenced in their clinical decisions by information found through Google searches, they should be warned on the frequent inconsistency of data retrieved by this means. Information obtained from general search engines should always be integrated with recommendations obtained from specific medical databases. This observation seems particularly relevant, as Google is planning to release utilities such as Google symptoms , that may be used by physicians in the near future.
Information on diet if overweight or obesity were correctly reported only in 1/4 of the reviewed websites. The insufficient presence of this recommendation, in particular on websites found by women of childbearing age, parallels the results from other studies that show a poor quality of nutritional information on the Internet for patients with specific medical conditions [33–35].
As for recommendations regarding vaccinations, rubella immunization is the second most frequently found item consistent with international recommendations, with no significant difference by search group (health professionals vs women of childbearing age). This result can be explained by the fact that rubella is a widely known risk factor for fetal disease. Rubella infection still presents a worrying incidence , and vaccination against rubella is included in an international eradication program . Moreover, Italy has adopted a national plan for preconception health care promoting medical check-ups including blood tests to verify immunity against rubella . Therefore, health professionals and women in childbearing age are widely informed on rubella’s risks for pregnancy and on measures for its prevention.
On the contrary, the recommendation regarding pertussis immunization is one of the less represented. This finding reflects the fact that pertussis is not sufficiently recognized as a threat for newborns. In several outbreaks the maternal-newborn transmission has been observed as one of the main transmission patterns .
Regarding web page categories, Communities and blogs were more frequently retrieved by women, while Medical/Public Agencies were the most frequently found by health professionals. This is strongly related to the source of the search strings used for the search (respectively, women and health professional). Communities and blogs represents overall the most represented category. This is an interesting result, as it shows a general interest among Internet users for the preconception care topic. Although, it is also the website category that reports less information consistent with international guidelines. This result suggests that preconception care specialists should consider an active use of blogs, forums and other social networks as powerful media for providing women of childbearing age with correct preconception information.
Presence of commercial links in a web page was associated with a higher quality of preconception information. This result shows that industries are actually implementing promotion of health care on the web as a part of their marketing strategy. Among the websites that were reviewed, few were disclosed as property of pharmaceutical industries. We cannot exclude that other websites were driven by other companies.
Strengths and limitations of the study
The main strength of our study concerns the methodology: we investigated preconception information available on the Internet through a formal approach that helps avoiding the biases originating from arbitrary choices of keywords by study researchers. Several authors investigated quality of information found on the Internet regarding specific health topics, including cystic fibrosis , pediatric cancer , rheumatologic diseases , Mediterranean diet . The search keywords used in these studies were chosen by the authors themselves, either simulating a search by a random user, or simulating a patient’s experience . Weighing suggestions from a group of users against the frequency of Google searches should increase the likelihood to perform simulations closer to real life. We recommend this methodology for the evaluation of quality of medical information on the Internet.
The main limitation of our study is that it has a cross sectional design, and it analyses a static situation at the moment when the survey has been conducted. Presence of information on the Internet, on the contrary, is intrinsically dynamic. A periodic survey of the web would constitute a precious, alternative source of information on specific public health issues.
The analysis has been conducted using only Italian search strings, therefore the results may not be generalizable to other countries. Finally, we investigated presence of specific web information using generic search strings. This may have led to an underestimation of the presence of consistent recommendations on the web. Nevertheless, we can assume that this approach reflects the average search strategy most frequently chosen by the users.