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Our Internet/social media analysis of perinatal health promotion by a multijurisdictional sample of Canadian governmental/NGO agencies reflected the emergence of COVID-19, impacts on health services and acknowledgement of considerable stress and uncertainty. Although it is well established that infectious respiratory diseases such as SARS, MERS and influenza are associated with increased disease severity and pregnancy complications including preterm birth and spontaneous abortion, [16] Canadian governmental agencies generally missed opportunities to disseminate COVID-19-associated perinatal health information via websites and social media platform-Facebook. Social media posts were regionally-relevant, included local COVID-19 restrictions, reports of outbreaks and evolving hospital/clinic access policies. Breastfeeding, infant care, labor/delivery, parenting support and healthy pregnancy were among the major perinatal themes promoted by governmental Facebook posts. NGO Facebook posts reflected the values and perspectives of host organizations, with Dad Central emphasizing fatherhood and Native Womens Association of Canada describing cultural and traditional practices associated with pregnancy.

Perinatal health promotion may be addressed in secondary school sexual education, prenatal classes, targeted interventions for communities marginalized by poverty, racism, xenophobia and other structural inequities, and generalized public health messaging. Generalized public health messaging is a cost-effective strategy that can work in concert with individualized counseling, targeted interventions and community-based programs to mitigate modifiable pregnancy risk factors. Such health communication campaigns typically increase uptake of desired health behavior by about 5% [21]. In the context of perinatal health promotion, online public health messaging may reinforce mass media campaigns and social norms about health-risk behaviors such as smoking, drug and alcohol use, and obesity/sedentary behavior, [21, 22] however only two municipal and one provincial government hosted-Facebook posts addressed lifestyle risk factors for perinatal health. As lifestyle risk behaviors are often concordant within couples/families, [23] generalized health promotion targeted to all household members would mitigate pregnancy risks, and increase likelihood of behavior modification.

Major Facebook perinatal-themed posts were positive in tone- emphasizing pregnancy/birth, breastfeeding and parenting. Although all organizations included in our sample promoted perinatal health, their use of Facebook was varied in terms of breadth of topics posted. Breastfeeding was promoted by municipal/regional health both actively (e.g. description of benefits, subject of classes/presentations) and passively (e.g. job titles for profiled staff members, resources). Several organizations used World Breastfeeding Week as a basis to promote breastfeeding, services and staff profiles, previously described as an example of social breastfeeding campaigns [24]. Such promotion campaigns translate to about 18% increase in breastfeeding, proving to be quite effective [21].

Social media is fairly ubiquitous among commercial organizations, with government agencies slower to capitalize on the benefits of established and emerging media platforms for health promotion[11, 25]. As perinatal health promotion is encompassed within a broader public health mandate by Canadian governments included in our sample, we were unable to assess the general use of social media by these organizations. It was evident that perinatal-themed post frequency varied considerably across jurisdictions, perhaps reflecting only limited use by some agencies. Conceptually, social media health promotion falls within the evolving promise of e-government to best use information technologies to enhance activities [26]. The universal reach of Internet- and social media communications in industrialized countries serves to democratize government messaging by widespread accessibility [25, 26]. Governmental public health agencies use of social media is primarily unidirectional, used to ensure transparency and accountability through dissemination of organizational updates, health promotion and health policy news [25]. Although we can confirm that Canadian government Facebook posts provided promotion and updates related to perinatal health, we did not assess public response to these posts. Similar to mass media campaigns, [22] Facebook followers (Table 2) receive updated posts with further study required to evaluate awareness, uptake and resulting behavior changes from these perinatal-themed posts.

Social medias public reach and timeliness make these platforms ideal for emergency communications [27]. Prior to the emergence of COVID-19, government agencies have used social media for emergency communications related to H1N1, [28] Ebola,[29] Zika virus [30] and a broad spectrum of localized natural disasters and emergencies [27]. As with the Zika outbreak, COVID-19 has serious implications for pregnancy, necessitating perinatal-specific public health guidance [30, 31]. Pregnancy emerged gradually as a risk factor for severe COVID-19 illness [32]. COVID-19 vaccine roll-out across much of the Western world began in late 2020, including Canada, however this was complicated by the initial recommendation by the National Advisory Committee on Immunization (NACI) and other agencies, to withhold COVID-19 vaccination from pregnant people pending further evidence [33]. As our social media analysis was restricted to 2020, we did not capture public health government-Facebook promotion of COVID-19 vaccines, however our review of Canadian government health website content into early 2021 did yield updated NACI-messaging regarding vaccine safety during pregnancy and breastfeeding [34]. Whereas a limited number of government websites addressed COVID-19 risks of pregnancy complications/disease severity, Facebook posts predominantly focussed on disruptions to health services and related visitor restrictions/need for infection control masks, physical distancing at healthcare centers.

Government agencies can respond to trending myths or barriers to health behaviors through amplification of evidence-based directives that specifically address rumors and misinformation [27]. Although adverse pregnancy outcomes are now well-established sequelae of COVID-19 [35, 36], throughout 2020, often contradictory public health guidance and misinformation regarding COVID-19 and risks to pregnancy appeared on social media [31]. COVID-19-themed perinatal Facebook posts peaked in the second quarter (AprilJune) of 2020, with only municipal/regional health authorities exhibiting a modest rebound of activity in the final quarter, indicating missed opportunities by public health agencies to reinforce messaging. Pre-emptive risk communication about COVID-19 vaccines and pregnancy by these public health agencies was warranted, as rumors and misinformation related to infertility, menstrual cycle irregularities and miscarriages accompanied COVID-19 vaccination programs and the eventual prioritization of pregnant people in 2021 [35,36,37]. Social media provides the opportunity for public health agencies to monitor real-time responses to emergency management and related intervention, but also to curtail the spread of misinformation.

Risk perception is decreased by privilege and social status [38]- such that racialized women- most likely to experience severe COVID-19-related pregnancy outcomes [31]- are also likely to perceive COVID-19 as a high health hazard. In response to the heterogeneous public framing of any health risk issue, influenced by gender, race/ethnicity, emotions and experience, risk communication is most effective if the agency/spokesperson inspires trust [39]. Trust in government agencies may be gained by transparency, credibility, and acknowledgement of scientific uncertainty in the face of evolving information, [27, 39] however countering this trust is social medias contributions to the increasingly political polarization of science and the recognition of societys structural racism which contributes to inequities [40]. Performance indicators identified for Canadian public health emergency preparedness included credible, culturally-competent emergency leaders with bilateral crisis communication skills, community engagement, and redundant in emergency communication channels including social media [41]. Ottawa Public Healths creation of a distinct Parenting in Ottawa Facebook page with 100 perinatal-themed posts in 2020 suggests this agency has fully embraced social media and opportunities of community engagement. Ottawa Public Health consistently attributed authorship of perinatal health Facebook posts to named healthcare professionals with credentials (e.g. registered nurses, lactation consultants, nutritionists)- thereby imbuing their posts with expertise, credibility and authority. Beyond perinatal health, Ottawa Public Health emerged as the most followed local public health unit in North America on Twitter, entertaining and informing over 130,000 followers in 2021 with empathy, honesty, nuance, humor and celebrity endorsements to promote COVID-19 and other public health messaging. Although most public health social media applications emphasize community engagement, social media may also provide platforms for health professionals to network, collaborate and exchange emerging science and practices [42].

We included NGO websites and Facebook pages in our analysis, recognizing the diverse landscape of online perinatal health information. NGO content reflected the mission, values and philosophies of each organization, and unlike the governmental organizations in the sample, NGO topic areas were exclusively women, fatherhood and perinatal health. NGO websites more consistently provided COVID-19-themed perinatal health promotion, including content related to disease severity, vertical transmission, breastfeeding and pregnancy outcomes. Similarly, NGO Facebook posts more frequently mentioned infection control, breastfeeding and emotional health, in the context of COVID-19. Two NGOs profile important aspects of perinatal health that are often overlooked- fatherhood and the realities facing Indigenous pregnant people in Canada. Cohabitating fathers and non-biological partners, contribute to both the physical and psychosocial environments of pregnant people. The impact of the non-pregnant partner on pregnancy outcomes has been largely studied heteronormatively, using marriage status among the determinants of concordant health behaviors [43]. Bringing attention to fathers, and non-biological partners recognizes their contributions to modifiable risks to pregnancy such as smoking, exposure to second-hand smoke, physical activity [23] and intimate partner violence and social support [44]. Perhaps due to social support and relationship integrity, fathers involvement in pregnancy is associated with better pregnancy outcomes and improved maternal health behaviors [45]. Influenza vaccination exhibits spousal concordance, with female partners generally influenced by positive health behaviors exhibited by male partners, [46] suggesting similar dynamics may occur with COVID-19 protective behaviors, although this remains to be studied.

Indigenous peoples face environmental, economic and health disparities due to colonialism and Canadas legacy of cultural genocide [47]. Pregnancy outcomes are similarly affected, challenged by limited prenatal and birthing care in rural and remote communities [48]. Recognized as priority communities for public health engagement during emergencies, [41, 49] Indigenous peoples were identified as key populations to receive early COVID-19 vaccinations [50]. Indigenous traditions and stories along with stark depictions of medical abuse/racism comprised the Native Womens Association of Canada (NWAC)s perinatal-themed Facebook posts. The tone of NWACs Facebook posts reveals a devastating portrayal of the experience of pregnancy and motherhood in the context of Missing and Murdered Indigenous Women and Girls, and the lasting trauma of forced removal of Indigenous children from their families, first by nationally-run residential schools and now through the child welfare system. Social media and the Internet are useful tools for pregnancy and parenting support, particularly as these modalities enable anonymous information seeking and sharing, thereby reducing discriminatory and stereotyping treatment, and addressing rural and remote barriers to healthcare [51]. Culturally-safe perinatal care, both in-person and through public health Internet and social media messaging, developed collaboratively with Indigenous stakeholders, improves pregnancy and neonatal outcomes [52].

We acknowledge that both government and NGO groups included in our sample provide services and resources addressing a breadth of topics, in addition to the perinatal-themed social media and online content evaluated here. As data collection was completed in early 2021, we also recognize that these organizations may have deleted or modified relevant posts, and may have since updated perinatal promotion messaging with possibly increased or different emphasis. We did not ascertain the public reach of online/social media messaging, nor did we measure Facebook interactions such as post comments, likes or shares. Facebook followers for each page appear in Table 2, which provides a crude estimate of the number of people who viewed each post on their respective Facebook newsfeeds.

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Public health perinatal promotion during COVID-19 pandemic: a social media analysis - BMC Public Health - BMC Public Health