Puerperium Online: interactions of a virtual support group

Objectives: due to the accessibility, online support groups have been used as an alternative in the constitution of a support network for women in the puerperium period. Thus, this resource is given relatively a short time of use, the present work sought to present an overview of the virtual group of puerperal women’s interactions


Introduction
The puerperium is characterized as a transitional phase in a woman's life, which makes her vulnerable to face numerous physical and biopsychosocial challenges, such as bodily and hormonal changes, concerns and insecurities. 1 At this point, a well-structured support network can be decisive to better deal with the difficulties of this period, helping to reduce mental disorders in these women and improve their health status. 2 A support network or social support can be defined as a support from the social environment, representing an important aspect of exchange between the social world and the subject, involving dimensions of comfort, assistance and information received through formal or informal social contacts. 3 These are fundamental throughout a woman's life, especially in periods of transitions and changes, such as the birth of a child. 4 Focus groups carried out with recent mothers, aiming to analyze the experiences, perceptions, thoughts, desires, challenges or problems of this stage of life, highlighted the importance of networks or structures that bring them closer, enabling of sharing experiences and the possibility of learning from each other. 1 From this perspective, online support groups, or virtual social support, can be sought as an alternative for traditional, face-to-face support groups, as they are more accessible. 5 Such online groups usually have a modus operandi that privileges interaction between users and collaborative learning. 6 Souza et al. 7 analyzed 259 users of social networks and found that 177 of them used WhatsApp, of which 112 were women (87%) and stated that this social media is one of the best forms of interaction.
For example, websites frequented by pregnant and puerperal women often have the characteristics of a common online community, in which its members voluntarily interact in response to a shared interest or need. 8 Although evidence suggests that this type of strategy has the potential in having a positive impact on the health status of puerperal women, 9 there is relatively little research on this subject, particularly in the Brazilian scenario.
Considering the potential of the virtual universe in the construction of social support and sharing motherhood experiences, based on concerns about the theme, we sought to better understand how these interactions take place in the particular context of users of Primary Health Care (PHC). Thus, this study aims to present an overview of the characteristics and interactions of a virtual group of mothers monitored at the PHC.

Methods
This is a qualitative, exploratory study of a virtual WhatsApp group, composed of women aged between 18 and 35 years, 10 users of basic health services from different Family Health Strategies (FHS) in the city of Currais Novos, Rio Grande do Norte, Brazil.
The city of Currais Novos is located in the countryside of Rio Grande do Norte and has an estimated current population of 44,905 thousand inhabitants. 11 The city has 18 Basic Health Units (BHU), 15 of which are located in the urban area and 3 in the rural area. The participants were selected from a survey on the profile of care that was provided to health professionals from the primary care teams in the aforementioned city.
The group was built starting from the premise that it should be composed of women who did not know each other previously, but who had similar life contexts, in order to increase the chances of success of the virtual interaction. The active search and the invitation to participate in the research took place in person at the BHU (while then, pregnant women carried out their prenatal consultations). Moreover, a structured questionnaire was applied to verify if the following inclusion criteria were met: performing prenatal care at the primary care network in the urban area and having consultations up to date on the pregnant woman's record card (at least one consultation in the first trimester and two in the second trimester); having a pregnancy considered to be at usual risk; being literate; being married or in a stable union; having access to the internet through a cell phone; being in the third trimester of pregnancy; and not having previously participated in social groups for pregnant women in the health unit or in reference centers; not having a history of diagnosed depression and usage of psychotropic drugs; and not being identified with common mental disorders (CMD), such as anxiety and depression, based on the application of the Self-Report Questionnaire-20 (SRQ-20) screening instrument. 12,13 Women identified with CMD were referred to psychological care in the health network in the city. .
According to Vaugh et al., 14 aiming at optimizing and deepening the dynamics of the participants, we tried to follow the orientation of 6 to 15 participants per group. Initially, about 32 women were reached, however, according to the inclusion criteria mentioned above, only 10 could be considered eligible to participate in this research. The group itself started with 10 participants, but after the first week one of them gave up participating and left the group, leaving us with only 9 participants interacting until the end of the study.
The virtual group was called "Papo de Mãe" (Mother's Chat) and consisted of pregnant women (from the 35th gestational week onwards) and, later, puerperal women, with an average age of 27 years of age. The participants of the group received prior guidance that they would be free to browse and interact without forecasting content and without a stipulated period of daily time for interaction. The researcher (a member of the group) started the conversation with a message of "welcome", reinforcing the participants' freedom regarding the content shared in the group and aiming to facilitate interaction between them, during the first week, she posted some images containing phrases about the puerperium. During the weeks that followed, the researcher was present in the group only as an observer, without any interference or interaction.
The interactions between the participants took place in a similar way to a common WhatsApp group, that is, from audios, videos, images and conversations in general regarding their daily experiences. Conversations and postings took place on a daily basis, albeit irregularly, increasing greatly in volume depending on the topic and, in general, occurred more strongly in the evening. The interactions evaluated in the present study took place between January 13 th and June 6 th , 2020, with a predominance of posts in the form of images and audios, duly transcribed/described.
After this period of 5 months, the material that gave rise to the corpus was downloaded, skimmed through, and later prepared for analysis: coding of the participants of the group to preserve their identities, reviewing and correction regarding the Portuguese language, standardization of acronyms and/or of compound words, such as the term "basic_unit_of_health" and transcription of audios, images and videos.
Then, the textual corpus was submitted to the Análise da Classificação Hierárquica Descendente (ACHD) (Analysis of Descending Hierarchical Classification) of the IRAMUTEQ software, indicated for large volumes of data, which allows the analysis of lexical roots and shows the contexts in which the classes are inserted. 15 Subsequently, the interactions were submitted to content analysis according to Bardin,16 which considers the set of characteristics in a given content fragment. Based on the ACHD results, the exploration of the material (adapted) and the treatment/interpretation of the results obtained were carried out. That said, the corpus was organized into dimensions, each of which grouped their respective interactions and contextualization.
This study followed all ethical aspects according to Resolution number 466/2012 of the Conselho Nacional de Saúde 17 (National Health Council), previously approved by the Research Ethics Committee of the Universidade Federal do Rio Grande do Norte, according to the CAAE protocol number: 20150819.8.0000.5568 and with activities started in 2019. All women participated by signing the Informed Consent Term in two printed copies.

Results
The ACHD showed a convergence of characteristics around three themes, being The Class 1 -"Puerperium Itineraries", the main theme, representing 56.1% of the elementary context units (ECU) of the total corpus (the object of interest of the present study). The dimensions identified and described from Class 1, by content analysis, are shown in Figure 1. Dimensions identified by the content analysis of the class "Puerperium Itineraries", obtained from the ACHD. Brazil, 2020.
The last gestational weeks (beginning of the collection period) were marked, especially, by the retrospective on the discovery and experience of living the pregnancy (especially those that had not been planned -seven out of a total of nine pregnant women) and by the feelings of anxiety for the birth of the baby. The "sleep" dimension was the most frequent in the analyzed class.
The women use their own experiences about motherhood in order to help other women, in order to create a support network (socially and emotionally), especially for primiparous women, providing information, encouragement and empathy. Table 1 shows some interactions between women during the collection period.

Discussion
The main objective of this work was to present an overview of the interactions of a virtual group of mothers accompanied in primary health care (PHC). Motherhood is often seen as a fairy tale phase, in which every woman is born to be a mother with a vocation for it. But that is not necessarily true. A woman is not born a mother, she becomes a mother throughout the process of motherhood, a process that, in addition to happiness, involves many challenges, suffering, insecurities, fears, pain and difficulties (starting from the very moment of the discovery). 18 This was the reality found Table 1 Transcription between the participants' interactions, based on the dimensions identified in the class "Puerperium Itineraries" obtained from the ACHD. Brazil, 2020.

Feel/Want
"At first when I found out I was pregnant, the feeling was of fear, but then it was wonderful to know that there was a little being growing inside of me" (participant 8) "I was desperate because I have a 2-year-old baby, but as the days went by, things started to fall into place and today I thank God for the grace of being a mother once again" (participant 7) "When I found out I was pregnant I was desperate, I cried a lot because it wasn't planned. It took me a long time to get used to the idea of being a mother again. " (participant 9) "I was very surprised when I found out I was pregnant (...), but thank God it was the best news" (participant 6) "I always think like this: everything passes, it's not easy (...) each one with its particularities, but soon they will grow and we will miss them. I spent six years trying to get pregnant. " (participant 7) "Thank you for the opportunity to learn more from you, it is a pity that we cannot meet right now" (participant 5) "I don't know about you, but I'm really enjoying this group of ours because I have a lot of doubts. I'll ask you guys and we'll learn with each other, right?!" (participant 1)

Support
"When someone in my family does something for me I feel more loved, it feels so good" (participant 8) "The best part is getting pampered, I feel loved" (participant 7) "My husband helps me a lot" (participant 1) "Today I managed to wash my hair, because the father was at home and he stayed with the baby" (participant 8) "I'm tired, really tired (...) I've been at home alone with her since she was born, I don't have anyone here helping me, my husband helps as he can, because he needs to work" (participant 5)

Domestic activities
"I'm also trying to handle all the daily activities in the house, with a little skill I think it's working, I managed to put her to sleep in her crib" (participant 5) "I'm feeling very worn out with so much pressure, it's a lot of responsibility for me and I can't handle it" (participant 4) Breastfeeding "I want to stay on exclusive breastfeeding until at least six months, while I'm producing milk, that's the only thing I'll give him, God willing" (participant 5) "Has any of you ever felt guilty for not being able to exclusively breastfeed? I would very much like to breastfeed exclusively, but today I had no other option, I had to give formula in the bottle. I think that due to the stress of everyday life my breast is no longer producing breast milk (...) I'm feeling tired, it's very exhausting" (participant 4) "Stay calm, don't feel guilty, the important thing is that your baby is fine" (practitioner 5) "Don't feel sad, our babies' well-being must come first. You are super moms, regardless of whether you are on exclusive breastfeeding or not. " (participant 7) "I feel like giving the formula just to see if she sleeps earlier, because of my tiredness (...) It is necessary to have patience to wait for this phase to pass, my eyes are burning from not sleeping" (participant 5) "My chest is hurting a lot, so I bought food formula" (participant 4) "I have already started feeding the baby formula because I have noticed that my breasts are not producing enough breast milk" (participant 2) "I didn't want to give formula either, but I'm going back to work, so I'll have to start, I'm already imagining it with a heavy heart" (participant 3) "They're so small and so dependent on us, aren't they? Being able to breastfeed is the best feeling in the world, I will miss that feeling" (participant 5) "It's a feeling we're going to miss until we have another baby, isn't it?" (participant 1)

Say/Guidance
"I was taught to pass the baby's comb from the areola of the breast towards the nipple to relieve the pain" (participant 7) "I am eating a lot of sweets, some family members taught me that, for those who are breastfeeding, eating a lot of sweets is very good to increase breast milk production" (participant 1) "My breast hurt at the beginning of breastfeeding, I was not able to breastfeed, but I started passing the breast milk through the nipple, wetting it, and I started sunbathing" (participant 4) "The nurse advised me to massage the breasts and keep squeezing until a significant amount of breast milk comes out before putting the baby on the breast, because she said that when the breast is very full, it becomes very hard" (participant 8) in the evaluation of the material produced from the group's participants' interactions. Palmén and Kouri 19 observed in their study with seven mothers of babies, with an average of 26.9 years of age, that the most appreciated internet services were those of social media that allowed them to get to know each other and form a closed group in which friendship becomes possible, in this way they can share experiences related to their daily routine, including those related to health and well-being. From the increase in connectivity and bonding between mothers, virtual support can contribute in reducing the risk of depression and improving quality of life, since it is capable of influencing stress levels from this period. 20 From this perspective, a factor that was widely discussed by mothers, as a stressor, was the issue of sleeping. The "sleeping" dimension grouped the largest number of ECUs in the analyzed class. With the birth of the baby, sleep tends to change due to new activities and the child's sleeping routine, which consequently determines the mother's routine. Coutinho et al. 21 consider sleep and the state of rest as one of the basic needs most strongly influenced by pregnancy and puerperium.
As reported by the participants, sleep fluctuations resulting from this physiological moment end up having a negative impact on productiveness/willingness to perform activities of daily living, which was the main focus of the "Domestic Activities" dimension. According to the mothers, the accumulation of these activities is especially aggravated by the lack of support from third parties to perform these tasks (in most of the reported cases), resulting in an increase in the physical and emotional inherent to the puerperal period, which largely permeates interactions in the "Feel/Want" dimension in a mother's life. Support strategies should provide women, in addition to the fragility of the figure of being a mother, the understanding of their insertion in a social, historical and cultural context, understanding breastfeeding as a phase of re-signification of their femininity. 22 According to Wennberg et al. 23 this sharing of experiences about breastfeeding in groups provides, in addition to the feeling of security in the face of the difficulties encountered, an identification and understanding of the process, strengthening, mainly, self-confidence in the ability to breastfeed. Parental support, for example, which was mentioned several times in the interactions between the participants (included in the "Support" dimension), in addition to monetary provisionis understood as fundamental due to emotional influence, participation in carrying out household activities, family planning and development of a healthy puerperium period, in general, and can also positively influence the success of breastfeeding and the reduction of the risks of postpartum depression. 24 A father involved in pregnancy and puerperium is able to encourage the woman and reassure her about the changes in her body and daily life, because, although pregnancy and childbirth are activities performed exclusively by women, men are also affected by the arrival of the baby. 25 However, there seems to be a persistent idea that the father's participation in the caring of the house and the baby is considered as a "help", with the mother being the main responsible for these activities. [21][22][23][24] The breastfeeding process, in fact, involves physical, psychological and emotional aspects, and it is natural that there are challenges that promote the mother's insecurity, 22 as identified in the dimension of "Breastfeeding". Some of the members of "Papo de Mãe" (Mother's Chat) faced difficulties in the success of the long-awaited Exclusive Breastfeeding (EBF), surrounding this experience with anguish, triggered mainly by the daily overload that, in some way, interfered with milk production. There were many interactions aimed at exchanging experiences on breastfeeding, which reflect the reality behind the romanticized view of breastfeeding, which does not consider the possible limitations and difficulties of this process, which can lead women to feel guilty and feel as a failure as a mother.
A challenge faced by some puerperal women, which was the subject of many interactions, was the need to early offer food formula before the baby was six months old (age recommended by the Ministry of Health 26 for EBF), motivated by different factors that end up interfering with the decision and duration of the procedure of breastfeeding, which can be positively or negatively influenced by the ways of coping.
In this sense, the support network and the practice of health education that these women receive can directly influence the confrontation of this problem, preventing a discontinuation of breastfeeding. 23 It is necessary to strengthen support for breastfeeding, especially on the part of PHC, since, both during pregnancy and in the immediate postpartum period, there are many doubts, anxieties and concerns that, due to the lack of reception in the health services, end up leaving the woman at the mercy of the guidelines that can lead to the shortening of EBF.
Considering that all these mothers underwent prenatal care in PHC, as well as puerperal follow-up, these reports encourage reflections on the need to implement new strategies to be able to provide specific and continued support on issues related to breastfeeding. Cabral et al., 22 when evaluating the virtual support for the breastfeeding support network with 11 women, highlighted that this scenario becomes a company for women, especially during the breastfeeding period and during the immediate postpartum period.
Social support, especially family's support, directly reflects on coping with pregnancy and puerperal difficulties, either negatively or positively. From a romanticized perspective, the main role of the family is to offer a network of protection, affection and companionship, especially in the sharing of daily routine activities. 25 However, weakened relationships are commonly associated with a high risk for psychological diseases, such as postpartum depression, which may reflect on physiological aspects, such as the decrease in breast milk production, due to the stress, fatigue and sadness involved. 27 In this sense, considering that partners and family members need to continue their work routines and these women stay for long periods of time alone with their babies, the relationships and approximations of people who have similar experiences are expanded, corroborating the reality found in the present study.
The use of technologies has shown great effectiveness when it comes to the coverage of health services, and is even recommended to increase the reach of service offerings related to comprehensive healthcare, for example, in the use of teleservice, 28 taking into account the possibility of creating virtual bonds, which strengthen the bonds between service and user, thus increasing the chances of broadening care. 29 The subjects that make up the social networks assume positions of support to needs or difficulties faced. Therefore, the WhatsApp app can be recognized as a social support network, where bonds awaken feelings of friendship, trust and solidarity among participants. [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27]28 Brazilian public health policies establish guidelines and guide the FHS on actions for puerperal care aimed, especially, at primary care, visualizing that this is the fundamental level of care for comprehensive care for women and children. 30 However, there is evidence that postpartum care in PHC needs improvements related to its physical structure and also human and material resources, strengthening professional qualification, humanization and care centered on women, thus overcoming technical care, [25][26][27][28][29] referring to the dimension "Say/Guidance".
The present study presented a unique view on topics and discussions of interest to mothers during the end of the pregnancy and throughout the first four months of the baby's life. Specifically, it was possible to perceive how social support positively impacts in facing difficulties and challenges resulting from the puerperium, even if the experiences are unique for each woman. This support can be seen in the exchange of knowledge that took place between the participants on different subjects, such as, for example, the best cost-benefits in choosing diapers, how to choose a good pediatrician, marital issues, experiences with medicines and alternative therapies of popular knowledge (such as the use of teas and aromatic herbs).
In fact, the participants established a relationship of confidants, advising each other on difficult and challenging issues, such as financial difficulties and the fatigue caused by motherhood, sharing their daily experiences in the virtual group, something that would have been impossible to happen otherwise, given the geographical distance between them.
Finally, it was possible to perceive that the group "Papo de Mãe" (Mother's Chat) was configured as a space of exchange, it was alive and interactive, helping its participants in the journey of motherhood, promoting safety and protagonism. Positively, these groups create a bond between people with similar experiences, doubts and challenges, regardless of their social contexts and geographic borders.  Furthermore, it is considered that more studies are needed to explore this type of experience, creating and systematizing parameters and strategies for the best use of this type of tool within the repertoire of primary health care.