SOCIAL NETWORK STRUCTURE OF PUERPERAL WOMEN WITH SUBSTANCE USE DISORDERABSTRACT
Objective: to analyze the social network structure of puerperal women with substance use disorder.
Method: this is a qualitative study based on Sanicola’s Social Network theoretical framework, conducted with 21 puerperal women who had a positive result in the screening test for marijuana and/or cocaine in the first half of 2023 in a health institution in southern Brazil. Data were collected through semi-structured interviews and by creation of a social network map.
Results: puerperal women who use substances, such as marijuana and/or cocaine, presented primary social networks of medium amplitude and strong predominantly family ties, while secondary networks were of low amplitude and density, indicating weak institutional support. Despite the presence of strong ties with health professionals in primary healthcare, especially in the form of the Nurse, the search for formal help to stop substance use was limited, revealing the need for targeted interventions to strengthen social and institutional support.
Conclusion: the importance of the social network lies in creating spaces of care/support for women that transcend the specific moment of labor/birth and that accompany them in their life process in facing social and mental health needs.
DESCRIPTORS:
Social network; Puerperium; Substance use disorders; Nursing; Mental health
RESUMO
Objetivo: analisar a estrutura da rede social de puérperas com transtorno por uso de substâncias.
Método: estudo qualitativo, fundamentado no referencial teórico de Rede Social de Sanicola, realizado com 21 puérperas que apresentavam resultado positivo no teste de rastreamento para maconha e/ou cocaína no primeiro semestre de 2023 em uma instituição de saúde no Sul do Brasil. Os dados foram coletados por entrevista semiestruturada e elaboração do mapa da rede social.
Resultados: puérperas usuárias de substâncias, como por exemplo: maconha e/ou cocaína, apresentaram redes sociais primárias de média amplitude e laços fortes predominantemente familiares, enquanto as redes secundárias foram de baixa amplitude e densidade, indicando fragilidade no apoio institucional. Apesar da presença de vínculos fortes com profissionais de saúde na atenção primária, com destaque à figura da Enfermeira, a busca por ajuda formal para cessar o uso de substâncias foi limitada, revelando a necessidade de intervenções direcionadas para fortalecer o suporte social e institucional.
Conclusão: a importância da rede social reside na criação de espaços de cuidado/apoio à mulher que transcenda o momento pontual do parto/nascimento e que a acompanhe no seu processo de vida ante as necessidades sociais e de saúde mental.
DESCRITORES:
Rede social; Puerpério; Transtornos por uso de substâncias; Enfermagem; Saúde mental
RESUMEN
Objetivo: analizar la estructura de la red social de mujeres posparto con trastorno por consumo de sustancias.
Método: estudio cualitativo, basado en el marco teórico de la Red Social de Sanicola, realizado con 21 mujeres en posparto que presentaron resultado positivo en la prueba de detección de marihuana y/o cocaína en el primer semestre de 2023 en una institución de salud el sur de Brasil. Los datos se recolectaron mediante entrevistas semiestructuradas y la creación de un mapa de redes sociales.
Resultados: las mujeres posparto que consumieron sustancias, como marihuana y/o cocaína, mostraron redes sociales primarias de mediana amplitud y fuertes lazos predominantemente familiares, mientras que las redes secundarias tenían de baja amplitud y densidad, indicando fragilidad en el apoyo institucional. A pesar de la presencia de fuertes vínculos con profesionales de la salud en la atención primaria, con énfasis en el papel de las enfermeras, la búsqueda de ayuda formal para detener el consumo de sustancias fue limitada, revelando la necesidad de intervenciones específicas para fortalecer el apoyo social e institucional.
Conclusión: la importancia de la red social radica en la creación de espacios de cuidado/apoyo a las mujeres que trasciendan el momento específico del parto/nacimiento y que las acompañen en todo su proceso de vida frente a las necesidades sociales y de salud mental.
DESCRIPTORES:
Red social; Puerperio; Trastornos por consumo de sustancias; Enfermería; Salud mental
INTRODUCTION
Substance Use Disorders (SUDs) are characterized by a set of cognitive, behavioral and physiological symptoms which are responsible for the pathological and maladaptive usage pattern of a given Psychoactive Substance1. It is known that the use of these substances is considered a serious public health problem due to numerous consequences, such as cognitive impairment, which can directly affect personal relationships, in addition to causing behavioral and social harm2; as such, this problem interconnects all aspects of sustainable development, revealing interaction, transversality of the nature and dynamics of the problem at the individual, community and social levels3.
With regard to women’s lives and health, the puerperium is considered a period of greater vulnerability and complications when compared to other stages of the pregnancy-puerperal cycle4. Pregnancy is considered the period in which the woman is most fragile and exposed at a time when not only physical but also psychological changes occur, which can sometimes compromise the health of the binomial5. This causes many of these women to seek an alternative escape from reality by using illicit substances6, defined as substances which cannot be produced, sold or used, and are prohibited by law for a given territory2.
The motherhood and puerperium experienced by women who use substances make the process even more complex, considering that the use of these substances in a unique population in terms of sociodemographic aspects and gynecological-obstetric profile, given the repercussions that this has on the healthcare of the mother and newborn7.
Approximately 275 million people used some type of psychoactive substance in the world in 2021, and more than 36 million had some disorder associated with the use of these substances, making these alarming numbers which have been increasing every year8 worrying.
Moreover, the progressive increase in the use of psychoactive substances by women with regard to the pregnancy-puerperal period has become a major public health problem. According to the United States Substance Abuse and Mental Health, the UK’s largest source of information, 5.4% of women reported using illicit drugs during pregnancy in 2018, a substantial increase compared to 2010 when it was 4.4%9. A study with a sample of 104 pregnant women in Australia revealed that the most commonly used substance was cannabis (25%)10.
A study on the prevalence of illicit drug use during pregnancy in 2020 found that studies which used toxicological analyses showed a prevalence of 12.28%, meaning 7.4 times higher compared to studies that used other instruments, with 1.64%. The illicit substances most reported in the studies were marijuana (42.85%), followed by cocaine (14.29%)11. This led to health problems for newborns exposed to these substances12.
It is noteworthy that healthcare for women who use substances becomes more challenging due to the lack of intersectoral actions in public policies and the restricted social support network. These women have a fragile emotional and financial support network, and these conditions cannot be dissociated from social markers of difference such as gender, race and class, which are interrelated markers13.
Given this scenario, it is essential that women with SUDs in the puerperium have a support network during this delicate phase of their lives12. A social network can be defined as a group of people, organizations or social institutions that are connected by some type of relationship or characterized as a set of interpersonal and social relationships that are part of this network, providing the people who compose the network with: receiving help, emotional support, material support, services and information. The social network also has the function of defining a set of situations in which affective, friendship, work, economic and social relationships are evident.
This network can be divided into primary or secondary. The primary network is built by family ties, kinship, friendship and bonds focused on reciprocity and trust. In turn, the secondary network is made up of institutions, whether formal or informal, public or private, health, education, seclusion, and non-profit organizations (among others)14. The structure of a social network comprises the set of perceptible ties that are established between people and networks, causing these ties to create connections when activated which shape networks. Thus, a social network that is well structured in its scope and quality of relationships can perform support or containment functions in facing various personal and social demands14.
Understanding this reference by researchers in the health field, especially in Nursing, allows access to a relevant instrument for understanding the efficiency of their attitudes in their professional routine, aiming at a broader view of the social and family situation experienced by the individual14.
This study is justified by the need to understand the constitution of the social networks of puerperal women with SUDs through their description and structural analysis, since these relationships impact the lives and health of these women and should be valued in planning and promotion health actions. It is further justified in order to weave new reflections and perspectives of Nursing care, thus recognizing the nurse’s role as a member of this network and facilitator of care and educational actions in view of the needs and specificities of this population.
In view of the above, the guiding question of this study was: how are the social networks of women in the puerperium who use psychoactive substances configured? Therefore, the objective was to analyze the social network structure of puerperal women with substance use disorder.
METHOD
This is an exploratory, descriptive study with a qualitative approach based on the theoretical-methodological framework of social networks by Lia Sanicola14 and guided by the guidelines of the Consolidated Criteria for Reporting Qualitative Research.
The study was developed in an Obstetric Inpatient Unit of a Teaching Hospital in Southern Brazil. The choice to conduct the study in the aforementioned hospital was due to the institutional protocol of using rapid tests which identify the use of cocaine and marijuana through a urine sample in all pregnant and puerperal women admitted since January 2021, thus providing care focused on the specificities of their needs.
The study population consisted of puerperal women who use substances and were admitted to the hospital where the study was conducted. In turn, a total of 21 puerperal women who obtained positive results in one or both screening tests were intentionally invited; all agreed to participate in the study.
The first phase of the study included women in the immediate postpartum period with a positive result in the screening test for cocaine and/or marijuana who were attended in the Obstetric Inpatient Unit during the data collection period; then, the second phase included the same participants in the late postpartum period (between the 10th and 45th day after delivery). The exclusion criteria were women with a negative result in the screening test for cocaine and/or marijuana and those who had a diagnosis of postpartum depression. The study was conducted in two phases, as described in the data collection phase. There was no loss of participants between the first and second study phases.
Data were collected after participants accepted and signed the Informed Consent Form, which was obtained in writing. The collection was conducted by the main researcher, an obstetric nurse working in the Obstetric Inpatient Unit and a master’s student. Semi-structured interviews were conducted in the first half of 2023 during hospitalization and after positive tests for psychoactive substances. The second phase (between the 10th and 45th day after delivery) was conducted by telephone contact with the puerperal women, aiming to analyze their social network structure according to the specific care needs of motherhood and the puerperium. The interview script contained information about the characterization of the participants, questions about the description of the social network and the following guiding question: how are the social networks of women in the puerperium who use psychoactive substances configured?
Creating a network map enabled graphically visualizing its structural dimension, using geometric figures to illustrate the network elements in different colors, and representing the types of bonds established as: normal, strong, fragile, conflicting, broken, interrupted, discontinuous or ambivalent. These bonds are symbolized by lines with different shapes and thicknesses, following the proposed theoretical-methodological framework14.
Identifying the social network occurred in two steps: a list of people who could provide help or support in the situation presented was initially drawn up, which could be obtained from the person’s daily life, representing them graphically to facilitate analysis and intervention in relationships. Next, the types of bonds, connections and strengths between the members of the network were described, analyzing the ties established between the different types of networks and each person present, and in turn representing them on the maps using the Figure 1 14. Thus, construction of the social network maps occurred during the first stage of the interviews in collaboration with the participants.
Consolidated map of the social networks of 21 puerperal women who use marijuana and/or cocaine. Porto Alegre, RS, Brazil, 2024.
Next, specific questions were asked to help in creating the map to understand the interactions of the puerperal women with their primary and secondary social networks. The questions addressed the people present or related to the lives of the participants (relatives, friends, neighbors, colleagues, associations, institutions), the degree of closeness or distance, the types of bonds established, the relationship forms, the types of help received (material, emotional, informational) and how these interactions are structured in the social network. Finally, the map was presented to the participants, providing insight into the active elements in their social network and the different forms of support available to meet their care needs.
The maps were initially drawn manually on A4 paper using colored pencils, based on the model adapted by Soares15. All the maps of the 21 participants were subsequently digitized by the lead researcher using Draw.io® software, a free online diagram editor. A consolidated map was then constructed based on the data analysis and interpretation, representing the individual social networks in an integrated manner.
The interviews were conducted exclusively by the lead researcher with the participants, without the presence of companions or other professionals. Invitations were intentionally directed at making the interviews feasible, and the interviews took place outside the lead researcher’s working hours, adapting to the available opportunities. The interviews were recorded and transcribed by the main researcher, ensuring anonymity of the participants using Arabic numbers, just as the other members mentioned in the network map design were identified according to the degree of kinship or their social relationship with the interviewee.
A sensitivity test was conducted (semi-structured interview) to validate the questions in the data collection instrument, in which the researcher applied it to two participants who were not eligible for the study, aiming at adapting and improving the instrument, but there were no changes16. In the end, a total of 21 puerperal women were interviewed who met the criterion of theoretical data saturation17.
The results were interpreted in light of the theoretical methodological framework of Sanicola’s Social Network, following the indicators for detailing the network structure. Then, each drawing created during the interviews was digitized, enabling to identify the types of bonds established between the participant and the members mentioned by them. In addition, it was possible to characterize the breadth of the participants’ relationship network during the data collection period as being small (up to 9 people), medium (10 to 30) or large (with more than 30 members). The analysis of the maps highlighted the source of support provided by the network members14.
The main researcher subsequently described the social network map, explaining the amplitude, density, intensity, physical proximity and frequency of each one in order to understand the meaning of each of the statements made by the puerperal women when answering the questions during elaboration of the social network map. Furthermore, the main researcher transcribed the interviews and later performed an exhaustive and repetitive reading of each of the statements, which made it possible to identify the network member who assumed the role of network operator who acts in problem-solving. This contributed to establishing problem-solving interventions and promoting alternatives to support puerperal women14.
The study was approved by the Research Ethics Committee and the provisions present in Resolutions No. 466/2012 and No. 510/2016 of the National Health Council of the Ministry of Health were considered.
RESULTS
The sociodemographic and obstetric description of the participants was made using self-declared variables: age, race/color, education, woman’s income (in minimum monthly salaries), marital relationship, number of children, prenatal consultation, delivery route and breastfeeding.
Regarding the use of psychoactive substances, 12 tested positive for marijuana, 4 for cocaine, 5 for both marijuana and cocaine, and 17 reported being smokers and drinking alcohol. Another important piece of information concerns breastfeeding, in which 13 puerperal women continued to breastfeed their babies after discharge and 8 puerperal women did not breastfeed. Of these, 3 because they reported having discovered HIV in previous pregnancies, and the other 5 because they reported difficulties with breastfeeding, for example, reporting having little colostrum. In addition, 18 puerperal women reported that they continued to use illicit substances and had not sought help to stop, and only 3 puerperal women sought help. Moreover, 15 participants said they were not referred to other postpartum networks according to Table 1.
The analysis of individual primary network maps showed that they were configured with medium amplitude (11 to 24 members). The most frequent density indicator of primary networks was average, being identified in 16 networks. Meanwhile, the secondary social network was considered as small amplitude (up to 6 members), as well as of low density due to few interconnections between the people who are part of the network. It was also possible to verify fragility of the puerperal women in relation to their secondary networks.
A construction of strong bonds with family members (mother, father, husband, partner, children, siblings and grandparents) stands out in the primary network, in addition to relatives (in-laws and aunt/uncle). Thus, the normal bond with family members (partner, mother, child, brother/sisters and grandparents) predominated in the primary network, and the strong bonds were motivated and established by situations of greater coexistence and/or assistance in needs, in addition to greater physical and emotional closeness. Therefore, the social network of puerperal women with SUDs is composed of family members and relatives.
Among the institutions of the formal secondary health network, primary healthcare was mentioned in all 21 individual networks, predominantly characterized by normal bonds, and mainly highlighting professional nurses. The bond was characterized as a strong bond, and the bonds in some individual networks were represented as normal and fragile. However, it is noteworthy that support house services also appear as strong and normal bonds in these networks, and some networks as interrupted, with the professional social worker mentioned as the main strong bond of support reported by the puerperal women.
Taking into account that there was diversity of actors/sectors and bonds in representing the social networks of puerperal women with SUDs, Figure 1 presents the consolidated map of the social networks of the 21 puerperal women, at which time all the social relationships presented in the individual maps of the participants were considered, including all the members mentioned in the primary networks, as well as all the institutions comprising the secondary network.
DISCUSSION
When analyzing the amplitude and density indicators of the primary networks of women with SUDs, it is revealed that the bonds established between members in these networks do not indicate intensity in the relationships, but are referred to as bonds of family and social coexistence as the main support in the lives of these women during the entire puerperal period during hospitalization and continuing until after hospital discharge.
The dynamics of family relationships are the main landmark in the network structure of women with SUDs, since it is in the family that the first experience of deep relationships is built, being considered the first and most important link in the networks. The family constitutes the central node of the primary networks, since it is in this network that we learn to live in relationships, being recognized as the first human and social capital of the person14.
The presence of strong friendship bonds in the primary network of women with SUDs stands out in this study. Friendships are formed by criteria based on emotional closeness, and when activated constitute important sources of help to meet the needs and provide healthcare for these puerperal women. Studies show that friends, family members and especially partners are extremely important in social support, with their help during emotional instability and in adapting the puerperal woman to her new social role being considered a strong impact, sharing the care and tasks with the newborn and reaffirming affective and emotional bonds18.
Corroborating the research findings, another study conceives the family as a primary network of social interaction and provider of support and support, being essential in maintaining the physical and psychological integrity of each individual19-20. In this context, it is essential to establish a support network for these puerperal women, considering that they need help from people and institutions to care for the newborn, but also in situations and needs of their daily lives, such as accompaniment during consultations, qualified listening and sharing household tasks, which are essential elements in this very delicate moment in the life of each of them21.
Therefore, social networks constitute a significant resource in healthcare and can be characterized as a set of interpersonal relationships between family members, friends and institutions. Thus, the individual maintains their social identity, receives support, and has the possibility of developing other social relationships14.
Primary networks are capable of causing subtle movements resulting from the relationships between their members, according to daily needs. Some positive or negative situations (considered critical events) can impact the network, resulting in changes in relationships, strengthening or weakening the established bonds14. Postpartum women who use psychoactive substances without qualified prenatal and pregnancy monitoring may have marked this as a negative critical event in their social network, as this event can sometimes generate distance in relationships, unfavorable perinatal outcomes and results, compromising the health of the binomial22-23.
Although the participants mentioned the presence of a nurse and a social worker regarding the relationships established with members of the secondary network, weak bonds with health professionals were identified. This fragility can interfere with adherence to postpartum consultations and the care of women who often begin using psychoactive substances before or during pregnancy24.
In this sense, the gestational phase represents the most appropriate period to address the use of marijuana and cocaine, since many pregnant women stop using them, fearing for the health of their newborn. Rapid tests are essential for detecting substances during prenatal care, enabling appropriate care for pregnant women and improving perinatal outcomes25.
It was observed that a minority of the puerperal women interviewed expressed a desire to stop using psychoactive substances, while the majority reported weakened support networks and financial difficulties in accessing aid institutions, resulting in only a few of them being able to seek assistance or support. The importance of strengthening support networks in establishing strategies for reducing and/or abstaining from substances is highlighted, especially during pregnancy and the postpartum period, considering the uniqueness and period of life experienced25.
A study conducted with puerperal women indicated that marijuana, cocaine and crack were the most common used substances among these women during the pregnancy-puerperal period, and that they had difficulty abstaining, which would probably continue to occur during lactation. Furthermore, it revealed that those who breastfed their children continued to use Exclusive Breastfeeding (EBF)26. This finding corroborates this study, in which the vast majority of puerperal women continued to breastfeed their children and did not stop or reduce the use of psychoactive substances.
The American Society of Pediatrics recommends that EBF be contraindicated in puerperal women who use psychoactive substances; the discontinuation time may vary depending on the substance consumed. The World Health Organization does not recommend EBF in these women, but recommends that these substances not be used27. It is difficult to find official publications on the discontinuation of breastfeeding when using psychoactive substances in Brazil. According to the guidelines of the Ministry of Health, it is recommended that nursing mothers do not use such substances. If this is not feasible, they should discontinue breastfeeding, express milk, and discard the milk for 24 to 36 hours after use28.
It is essential that health professionals are prepared to care for these puerperal women. The transition of care in Brazil is still under construction, while Canada, Portugal, and Spain have already made progress in studies and strategies for the work of nurses in this area through multicenter research29. The findings of this study indicate that strengthening/qualifying the care transition for puerperal women with the specificity of a psychosocial approach would enable better perinatal outcomes. This context provides improvements to the health of women who live with issues of substance use prior to pregnancy, affecting their mental health and generating specific social needs30.
The framework of the Sanicola Social Network allows us to reflect on the importance of a professional network operator who works in articulating, connecting and monitoring this population between the primary and secondary networks. It is thus clear that the nurse has the potential to act in this care transition and articulation with the points of the network, since they compose the secondary network of these women at the primary and tertiary levels of the health sector.
It was difficult to access women in the second stage of the interview by telephone or social networks due to the particularities of the postpartum period and the interview method via telephone contact and mobile application. Despite these limitations, they did not result in loss of participants in the second stage.
In using Sanicola’s framework and mapping the network structure of women with SUDs, the research results are revealed as a robust tool capable of contributing to broadening the vision and raising awareness among health professionals in the healthcare of this population. They can particularly constitute an important instrument for nurses for understanding the relationship, support and support that these women have in their primary networks, so that network operators can assume their roles, improving healthcare. This contributes to strengthening the networks and the primary health system in issues related to the study population. Furthermore, the study findings have the potential to broaden the approach to this specific population in teaching, care and among managers in these areas to consider new interventions and the construction of internal protocols guided by the Ministry of Health and the World Health Organization guidelines to promote humanized care based on evidence that can meet the real needs of this population.
FINAL CONSIDERATIONS
The map construction enabled understanding the social network of puerperal women with SUDs through the ties and bonds formed by the members of the primary and secondary networks. The primary networks of these puerperal women are structurally composed of varied bonds determined by affective and social coexistence, with the family as the central node. The secondary network presented a varied composition, with stronger ties with Primary Healthcare, some specialized institutions and other health establishments, with the role of the nurse and the social worker being essential during monitoring and treatment of these puerperal women.
It is important to recognize the importance of the secondary social network in creating spaces of care/support for women that transcend the specific moment of institutionalization for birth. In addition, it accompanies them in their life process in view of the social and health needs of this segment which has important specificities interfaced in the field of women’s health and mental health.
The use of this theoretical-methodological framework constituted an easy-to-apply tool that should be incorporated as a technology to ensure sustainable development and interprofessional care aimed at people who use psychoactive substances. This powerful tool has the potential to guide professionals in planning interventions and coordinating efforts that encompass the domains of health, social aspects and specific demands. This enables an in-depth understanding of the dynamics of primary and secondary networks, as well as healthcare for this population. Furthermore, it plays a crucial role in this scenario, encouraging formulation of regulations and ordinances through managers that direct additional investments towards improving Primary Health systems. This includes initiatives such as the promotion of breastfeeding and the prevention and reduction of harm related to the use of psychoactive substances.
It is suggested that this reference be used to conduct new research in the health field, especially in relation to women’s health, and also in clinical practice, favoring the search for better results and outcomes for the continuity of healthcare.
DATA AVAILABILITY
The data supporting the findings of this study are available upon reasonable request to the corresponding author, Valéria Lindner Silva (e-mail: val.lindner@hotmail.com). The dataset is not publicly available due to the presence of sensitive information that could compromise participants' privacy and anonymity. The study involved individuals in situations of vulnerability, including users of psychoactive substances and individuals under judicial measures, which requires additional confidentiality safeguards in accordance with ethical guidelines for research involving human subjects. Data sharing, when requested, will be evaluated based on ethical criteria and may require the signing of a confidentiality agreement.
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NOTES
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ORIGIN OF THE ARTICLE
Extracted from the dissertation - “A rede social de puérperas que fazem uso de substâncias ilícitas: contribuições para o cuidado em saúde”, presented to the Postgraduate Nursing Program of the School of Nursing and Public Health of the Universidade Federal do Rio Grande do Sul, in 2023.
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APPROVAL OF ETHICS COMMITTEE IN RESEARCH
Approved by the Ethics Committee in Research of the Hospital de Clínicas de Porto Alegre/RS, opinion no. 65461722.5.0000.5327. Certificate of Presentation for Ethical Assessment 5.846.038.
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TRANSLATED BY
Christopher J. Quinn
