Biographies of pregnancy and motherhood in adolescence within rural settlements in Rio Grande do Sul

Abstracts

Buscou-se conhecer e compreender as vivências de gestação e maternidade na adolescência em assentamentos rurais. O estudo desenvolveu-se a partir de uma abordagem qualitativa, sustentando-se no método biográfico. As testemunhas foram mulheres que vivenciaram gravidez e maternidade na adolescência. A coleta de dados foi realizada em Janeiro e Fevereiro de 2009, por meio de entrevista biográfica temática. As biografias mostram trajetórias familiares de instabilidade e mudanças constantes, além de habitação e emprego precários. A aceitação da gravidez pelas famílias das adolescentes está diretamente ligada à condição do companheiro em assumir a paternidade da criança e a mãe adolescente como companheira ou esposa. As mudanças na vida pessoal decorrentes da gravidez e maternidade relatadas com mais frequência, foram perda de liberdade e aumento de responsabilidade. No plano das instituições, constata-se a ausência de políticas públicas e, consequentemente, de serviços dirigidos e adequados às especificidades de saúde nos assentamentos rurais.

Gravidez na adolescência; Assentamentos Rurais; Condições sociais; Saúde da população rural; Biografia

ORIGINAL ARTICLE

Biographies of pregnancy and motherhood in adolescence within rural settlements in Rio Grande do Sul*

Biografías de gravidez y maternidad en laadolescencia en asentamientos rurales en Rio Grande do Sul

Joannie dos Santos Fachinelli Soares^I, Marta Julia Marques Lopes^II

^IRN, Federal University of Rio Grande do Sul, School of Nursing. Member of the Studies in Collective Health Group, RS, Brazil. [e-mail]

^IIPhD in Sociology. Full Professor, Federal University of Rio Grande do Sul. Coordinator of the Studies in Collective Health Group. Porto Alegre, RS, Brazil. [e-mail]

ABSTRACT

The objective of this study was to learn about and understand pregnancy and motherhood experiences in adolescence within rural settlements. The study started from a qualitative approach supported by the biographic method. Witnesses comprised women who experienced pregnancy and motherhood in adolescence. Data collection was performed in January and February 2009, by thematic biographic interview. The biographies show family trajectories of instability and constant moves as well as of precarious housing and employment. Pregnancy acceptance by the families of the adolescents is directly conditioned to the partner taking over the parenthood of the child and the adolescent mother as partner or spouse. The most frequently reported changes in the personal life deriving from pregnancy and motherhood were loss of freedom and increase of responsibility. At institutional level, it is observed the lack of public policies and, consequently, of services addressed to and adequate to health specificities within rural settlements.

Descriptors: Pregnancy in adolescence; Rural Settlements; Social conditions; Rural health; Biography

RESUMEN

Se buscó conocer y comprender vivencias de gestación y maternidad adolescentes en asentamientos rurales. El estudio se desarrolló con abordaje cualitativo, sustentado en método biográfico. Los entrevistados fueron mujeres que experimentaron gravidez y maternidad en la adolescencia. La recolección de datos se realizó en enero y febrero de 2009, mediante entrevista biográfica temática. Las biografías muestran historias familiares inestables, con cambios constantes, además de habitación y empleo precarios. La aceptación de la gravidez por las familias de las adolescentes está directamente ligada a la condición del compañero para asumir la paternidad del niño, y a la madre adolescente como compañera o esposa. Los cambios en la vida personal derivados de la gravidez y maternidad relatados más frecuentemente fueron la pérdida de libertad y el aumento de responsabilidad. En el plano institucional, se constata ausencia de políticas públicas y de servicios adecuados a las especificidades de salud en asentamientos rurales.

Descriptores: Embarazo en adolescencia; Asentamientos Rurales; Condiciones sociales; Salud rural; Biografía

INTRODUCTION

This study is part of a larger project called "Pregnancy and Maternity during Adolescence in Small Towns and Rural Areas in the Southern Half of Rio Grande do Sul" developed by the Studies in Collective Health Group of the Nursing School at the Federal University of Rio Grande do Sul, Brazil.

Even though the topic addressed is seldom studied in rural areas, it is extremely important for the health field, especially for the nursing field, because the prenatal period and health education are important areas of action for nurses. Additionally, the identification of biographical determinants of pregnancy and maternity during adolescence can provide important information and knowledge for the planning of care actions and even preventive measures to avoid early pregnancies, specifically considering the potential of primary health care services.

Hence, the questions posed in this study are: What are the social and biographical determinants that reflect on the occurrence and experience of pregnancy and maternity during adolescence in rural areas and what are the repercussions on the adolescents' health conditions?

We start from the observation that one of the consequences accruing from transformations in socio-cultural life in recent decades is the early initiation of sexual life among adolescents, which characterizes a change in patterns of social and sexual behavior. This experience occurs in unequal conditions for adolescents and youth, evidenced by gender inequalities, different socioeconomic, cultural, and ethnic conditions, power relations among generations, and discrimination due to sexual orientation⁽¹⁾.

The main problems indicated in this context are related to female adolescents and young women. Women are culturally and socially held responsible for reproduction and for taking care of their family's health, conceptions often reinforced by health services. This role attributed to women explains why they compose the majority of patients cared for by the Brazilian Unified Health System (SUS), which is public and free of charge, including young women. This situation reflects, among other issues, inequalities of power in gender relations. Consequently, women's lack of power exposes them to unplanned pregnancies and the risk of acquiring sexually transmitted infections, in addition to different forms of violence that affect their health⁽¹⁾.

Rural areas reflect differences in health, which exist in the entire country, but certain chronic characteristics concerning access to services in their different dimensions are also aggravated in these areas. Not only is there geographically difficult access but also difficult access that results from inequalities in terms of options and care resources. It is known that rural populations are not covered by primary health care programs and depend on central urban areas that offer regional services with more advanced care levels of complexity. Hence, social factors inherent to rural areas, represent particularities expressed in increasing poverty, and difficulty accessing health care structures, among others. The situation is aggravated in rural settlements where there are poor living conditions and infrastructure services, a lack of means of production, expressive cultural diversity, and a low level of education.

As to the study's setting, the health services are located in urban areas and do not include the rural settlements in their scope. Hence, considering the economic and geographic difficulties women from rural settlements have to access health services in the prenatal period, they have to use strategies such as providing false addresses in order to be entitled to be cared for in such health units. Also, even when they are able to receive care from these services, prenatal care provided to these women has low quality compared to what is recommended by Brazilian health policies⁽²⁾.

The city Encruzilhada do Sul, RS, Brazil has a population of 24,150 inhabitants and 66.7% live in the rural area. The female population is composed of 9,933 (41.13%) women and 2,093 (21.07%) of these are adolescents. The city's general birth rate was 1.94% in 2000, above the state and national rates, 1.73% and 1.89% respectively⁽³⁾.

This context includes complex socio-cultural dynamics present in rural areas. For the topic under study, we opted to consider generation, gender and life situations, which indicate or have the potential to show multiple influences affecting pregnancy and maternity during adolescence. 'Life situations' is defined as the recognition of the existence of objective factors of vulnerability (material, immaterial and relational) and the actions of subjects as they interpret reality. Hence, life situations become instruments to understand vulnerability and, in this case in particular, events of pregnancy and maternity during adolescence⁽⁴⁾.

In such situations, inter-influences occur in which gender, defined as the social construction of sexes, is an element that structures power relationships between men and women and that supports social hierarchies that influence concrete and symbolic forms of domination⁽⁵⁾. From this perspective, this category of analysis provides elements to understand many relational experiences of adolescents and many forms of exerting or suffering pregnancy and maternity.

Hence, when hierarchy and power relations existing between genders are acknowledged, one also needs to understand that these are enhanced by the generational situation the protagonists of this study experience. Therefore, we need to analyze the contextual, historical, social and cultural conditions that influence a given social group in a given moment⁽⁶⁾. Generation and gender conjoin and show elements that intensify oppressive and violent situations for instance.

OBJECTIVE

Identify and understand, through biographies, experiences of pregnancy and maternity during adolescence in two rural settlements in the city of Encruzilhada do Sul, RS, Brazil, considering aspects of the collective community of settlements, of family groups, and life and health situations reported by adolescents.

METHOD

This study has a qualitative approach based on the biographical method. This method allows reconstructing relationships that refer to society, group and individual, that is, the structural and sociological history of certain social groups for each history of life, expressed in oral reports⁽⁷⁾.

The study's setting included two Rural Settlements in Encruzilhada do Sul, RS, Brazil: Settlement Segredo Farroupilha and Settlement Quinta with 113 and 45 families respectively. These settlements are those with the largest numbers of live births for adolescent mothers between 2000 and 2006, according to state data reported in the Live Births Information System (SINASC).

The study's participants were women who experienced pregnancy and maternity during adolescence. They were identified through an active search in the field of study aided by Community Health Agents linked to local programs of the Family Health Strategy (FHS) and Community Health Agents Program in January and February 2009. The biographies were developed from the statement "tell me about your life" focusing on themes such as pregnancy and maternity, totaling 16 interviews. Content Thematic Analysis was used. It consists of discovering core meanings that compose a communication whose presence or frequency means something for the studied objective⁽⁸⁾. Data analysis was carried out through QRS NVivo version 7 and the three stages recommended for the analysis⁽⁸⁾ were followed: pre-analysis, exploration of the material, and treatment of obtained results and interpretation.

Bioethical recommendations concerning data access and analysis in research with human beings were complied with in accordance with Resolution 196 from October 10^th 1996, National Council of Health⁽⁹⁾. The Research Ethics Committee at the Public Health School, State Health Department of Rio Grande do Sul approved the project (protocol CPS-ESP nº 389/08).

In order to maintain the participants' confidentially, their testimonies were coded by the letter P following by a number, e.g. P1 (participant 1), P2 (participant 2), etc.

RESULTS AND DISCUSSION

To describe and understand the Biographies - Histories of Pregnancy and Maternity - thematic syntheses are presented and discussed:

Personal trajectories

The life histories of the 16 adolescents reveal instability and constant moves, poor living conditions and jobs. Life situations led adolescents to face hardships, experience difficulty accessing school, a lack of options, unstable jobs and difficult family life early in life. These elements contribute to reproducing experiences and difficulties experienced by the parents themselves. The marks of 'dismay' are apparent in some testimonies indicating the limited alternatives they have to construct different trajectories based on their opportunities.

Another difficulty in the case of the settlements is the sometimes inadequate school infrastructure, which is usually very distant. Similarly, the financial conditions of some families are very poor and the priorities of subsistence or even survival determine their choices or lack of them.

Most adolescent mothers initiated sexual and affective life with the father of their first child. Nine of them already lived with their partners when they became pregnant for their first time. Of these, one is separated and single and another got separated and married again. Marriage is, in some cases, considered an alternative to a life with no prospects related to school and work.

Changing status from single to married, in some groups, is a valorization of their role's attribute for women and to the relationship itself, socially consolidated and legitimated, and represents ascension within the local community. It confirms some of marriage's social functions. In some groups, women's honor is inseparable from a wife's role, who must be an efficient homemaker and devoted mother⁽¹⁰⁾.

There is also rejection of pregnant and single adolescent daughters, based on the stigma of single mother. These (cultural and, moreover, moral) arguments are based on gender inequalities in relation to sexual repression and the still current double moral standards. There is a greater control of the women's sexual behavior than that of men, which imposes on women the responsibility to prevent pregnancy. Hence, the blame is alleviated when the woman is lucky to have the father of the child to assume responsibility and marry her.

Most of the participants reported they lived well with their current partners, regardless of having married before or after their pregnancy. However, four reports of violence perpetrated by partners, show the instability and vulnerability of these young women living in what are usually imposed marriages, in addition to the lack of opportunities and alternatives for achieving a better condition for themselves and their children.

We stayed together one year and he'd beat me a lot, he'd beat me, he was very jealous (P14).

It's because I'm humiliated at home. He calls me names. Everyday he wakes up upset, doesn't even talk. Sometimes, I've already thought many times to go to the city and denounce him, but he'd kill me, there's no chance. I said to him: 'the day you beat me again, I don't care if my son comes in the way, who comes in the way, I'll get a knife and will shred you all'. Then he said: I kill you if you touch me, I'll punch your mother and kill your sisters with a knife (T13).

These situations of extreme violence are coupled with a lack of alternatives. Women living in rural areas are susceptible to severe social vulnerability associated with the lack of information and poor access to public services, which intensifies gender asymmetries in affective relationships between women and men. In this context, the daily routine of many women is marked not only by violence and subjection but also by the need to cope with situations without support. In relation to domestic violence, women experience situations often considered normal, e.g. couples' arguments, and consequently not acknowledged as a punishable crime⁽¹¹⁾.

This cultural invisibility and consequent loneliness in coping with domestic violence is experienced by many women, which confirms an asymmetry of power and lack of public policies addressing these dimensions by aiding women to cope with their situations. The government is also absent in relation to material conditions such as housing, work, income, etc. These women have poor living conditions, which make them even more vulnerable, especially young women.

A pregnancy during adolescence

In some cases, especially among the already married adolescents, the pregnancy was reported as something expected and planned. However, in most cases, the pregnancy happened without any planning. If, on the one hand, an unplanned pregnancy during adolescence is often considered an obstacle and maybe a deviation from life projects, on the other hand, especially in cases where adolescents were already married, the child becomes their life project. They consider themselves to have fulfilled their social role when they become housewives and mothers. Some of the women, who had more than one pregnancy during adolescence, became pregnant again with their second or even third child without any planning.

The fact that the subsequent pregnancies were not planned either, is evidence that the experience of maternity does not necessarily lead to changes in contraceptive strategies. This fact may be related to irregular school experience and an absence of professional perspectives⁽¹²⁾. This last argument may be related to the small universe of perspectives available in rural settlements. It may be also related to problems of access to health services and contraceptive methods as well as a lack of information.

The adolescents' reactions when they learned about the pregnancy were diverse, passing through happiness, concern, fear and guilt. No relation of acceptance to the whether the pregnancy was planned or was not identified.

In many cases, a pregnancy during adolescence is faced with difficulty because the adolescent lives in a situation characterized by conflict in the abrupt transition from being a woman in development to becoming a woman and mother. They are often not physically, psychologically, socially and economically prepared to play the maternal role⁽¹³⁾.

In a society that sees marriage as a prior condition to forming a family, the marriage of the adolescent to the child's father contributes to representing the early pregnancy as a natural and desired event⁽¹⁴⁾. However, in the cases in which there is no marriage, the young women are rejected by their families and by the social network in which they find themselves. The close relationship between the family's acceptance and the man assuming his paternal responsibility by marrying the pregnant adolescent is apparent.

Moral blame is still persistent when women exercise their sexuality out of marriage or out of stable relationships. This argument is based on Catholic morality, which determines that sex without the purpose of procreation and out of relationships legitimated by society such as civil and religious unions is a sin. The Catholic Church has an essential and historical role in maintaining the female model. These arguments reaffirm the double moral standard that attributes to women the responsibility (blame) for transgressions (sins) and consequences of pregnancy.

Adolescents were supported by their partners (or boyfriends) in almost all situations.

But actually I didn't want the baby because I was too young and wanted to abort it. Then, we talked, he and I, and he convinced me to not do it, that we'd raise the baby together (P5).

He became very happy, he said that I should not take any tea (abortive tea), that we'd raise the baby together (P8).

There were adverse reactions in two cases of adolescents who were single and were not supported by the boyfriends.

Ah, they got really mad, really angry, you know? (P1).

Then she [mother] threatened to kill herself, she said she'd hang herself because she'd rather see me dead than pregnant (P14).

The family accepting the adolescent's pregnancy is conditioned on the child's father assuming responsibility for the child. The adolescent accepting her own condition is conditioned on everyone accepting her: family and partner. It seems an obvious consequence since this context shows hostility and exclusion, weakening the adolescent and introducing feelings of revulsion and blame. From this perspective, a lack of social support (especially from the family and partner) or conflicting support is considered an important source of stress⁽¹⁵⁾.

Hence, authors investigating pregnancy and maternity in lower classes contribute reflections concerning the meaning of these events in different contexts of class^(10,16). These meanings are evidently constituted from gender conceptions that are configured with class categories and institute positions and hierarchies in society. Maternity is valued in lower classes where becoming a mother is equivalent to achieving a new social status, that of being a woman. Pregnancy is the access to femininity. Through a child, the adolescents feel like mothers and women. The female social function is related to maternity, that is, being a woman for these adolescents is equivalent to being a mother. The desire to have a child is a rite of passage, a substantial change from the status of being a girl to being a woman^(10,16).

Experience of maternity

This analysis is embodied in the expressions/reactions of the participants' biography from the triggering element What was it like for you to become an adolescent mother? Hence, the following analysis is based on excerpts of testimonies.

Maternity is...

It's a little difficult but it's good (P1).

Nowadays? I feel I'm a different person. My kids taught me a lot of things and I value them a lot (P9).

I feel good because it's our destiny, who wants to have a family, it's fate [...]having a family is better (P11).

It was very good to have a child early on, because if you have a child when you're young, it changes you a lot (P12).

This idealization of maternity brings with it many contradictions, such as: you can't say it's not good. This positive representation and social (moral, cultural, religious, etc) legitimacy necessarily leads to acceptance even though is some cases, it assumes the nature of sublimation. Positive feelings linked to maternity overlap other roles such as worker, for instance. And maternity as 'fate' (or ideology) is imposed on the life of these adolescents as the only possible option.

In some cases, the adolescent mothers reported that one of the advantages of having kids is that they did not feel alone because of having their company. It also reaffirms a lack of prospects. The child distracts them since they do not have many alternatives.

Because sometimes we're alone at home and have them only and they distract you. When they leave, then it's really difficult, it seems there is no fun at home. Because I like to play with them and sometimes I leave my obligations and stay to play with them (P1).

I don't stay alone anymore, when my husband leaves I have him [son] (P7).

Maternity is particularly idealized in situations in which the adolescents are married, not very young and can assume the economic consequences of having children. In settlements, assuming the consequences is more visible and the collective may demand it from them given the physical proximity and knowledge of the poor living conditions of some of the community members. Again, women are in situation of greater vulnerability and distress and often times with no family structure, no income and a lack of social support.

In regard to the care provided to children, the interviewed adolescents reported some difficulties faced when the child was still a baby. There were fewer difficulties for those who had someone around to teach them and for those who had some experience with other children in the family.

Most of them reported they currently care for their children by themselves. They report they can count on their family, especially the women (mother, mother-in-law, sister, cousin, sister-in-law). Some said that their partners also help to take of their children.

The adolescents' mothers are the main elements in the support network, followed by other female relatives⁽¹⁷⁾. This fact reaffirms that the care networks, even in rural areas, are predominantly composed of women, whether from the family or neighborhood. Other information transmitted among women includes the first care actions provided to children such as hygiene and feeding, as well as health care, such as the identification of diseases and home remedies to deal with them.

Among the changes that occurred with pregnancy and maternity, the most cited were loss of freedom and increased responsibility. It shows that the condition of being a mother represents a point of rupture between adolescence and adult life. Hence, having responsibility, becoming a woman, changes in their bodies, individualistic behavior, and thinking about a profession or job, interfere in the adolescents' conduct within their experience of maternity.

Many of the interviewees acknowledged the project most harmed by pregnancy was studying. A pregnancy interrupts life with no responsibility and impedes the necessary mobility to attend school. Being out of the school and work universes constitutes a symptom of female internality, a tendency sharpened when one considers that leisure is significantly compromised by a child's birth.

It could be partially attributed to lack of support during pregnancy and social demands. Even though society highlights maternity as an attribute of femininity and the most important social role of women, in situations when these occur outside of social conventions, abandonment by family and the partner is frequent. Another element is lack of social and family support for the adolescents to maintain studies and work as essential elements for them to achieve personal realization and ensure better living conditions for themselves and their families. The lack of public daycare, facilitated access to school and options for jobs are the basic difficulties these women face and what impedes their experience of social re-insertion.

Current Life and Projects for the Future

The remaining adolescents did not explicitly say it was bad but let their dissatisfaction be apparent when complaints predominated in the narratives about their lives. Even considering this classification (good or bad), half of the interviewees reported their current life is better than their previous lives.

Even though most of them overcame initial difficulties, they were not happy with the family's financial conditions and responsibilities; home chores increased and reflect their female responsibility in serving the family⁽¹⁸⁾. These responsibilities seem to be even more exclusively female chores from being in a rural area.

About life in the settlement, some report they like the atmosphere of conviviality and security gained with the land on which they could live and cultivate as well as the socio-communitarian activities. Some complain of lack of resources and paid jobs, especially for women. Hence, for many of them there is the family to help with care and home chores. With children to raise and a low level of schooling, their opportunities are reduced to non-paid activities and providing some help in agriculture, which is often not acknowledged. It limits their individual and family perspectives, since they have few official financing programs and adolescents do not manage to compete for the few jobs in the cities for a lack of qualification, aggravated by lack of time and family structure.

In regard to relationships with people in the settlement, the participants report there is good coexistence and mutual support. It is to be expected that the very situation of solidarity that emerges from common goals and struggle for the land and conquest of a plot develop feelings of togetherness and mutual support. In situations of pregnancy and maternity, this interaction sometimes means exchange of experiences and support during hardships.

Thus, social support networks are mainly composed of people from the family (mother-in-law, sister-in-law, mother) but also of neighbors and friends. The rural activities developed by the women in the settlements are varied; normally they care for the animals and perform softer chores in agriculture. These practices are usually performed concomitantly with care provided to children and house chores and are considered some help.

In regard to plans for the future, most of the interviewees mentioned the desire to have a house or acquire their own goods, in addition to improving their housing conditions. Among their plans to improve material conditions is the motivation to be independent and make their own contribution to the family. The family is in the center of their concerns and projects for the future.

Another perspective is related to the idea of progressing in life by going back to school. Five of them stated their desire to go back to school. However, studies are a dream that has to be postponed for most of them and are conditioned on the need to raise the children and ensure the family's stability.

The desire to have a paid job was also manifested by most of the interviewees. This dream is related to the expectation of becoming independent and accessing a better life from a material point of view. Being a worker and getting a job is in their plans even if it is also conditioned on the priorities of their families and roles as mothers.

The difficulties in this sphere are related to a low level of education and lack of professionalization among adolescent mothers, which hinders their inclusion in the competitive job market and, therefore implies low paid jobs⁽¹³⁾. It is further aggravated if there is a lack of opportunities such as in the rural areas and in particularly in settlements, where paid jobs are mainly directed to men.

This reality shows that maternity during adolescence introduces an important differential in the school and professional paths of women from lower classes: it takes these mothers from the public space and confines them to the household. Hence, maternity is opposite to what occurs with young fathers; it does not include women in the job market, instead it makes them dependent on others to ensure their subsistence⁽¹¹⁾.

There were narratives concerning what they though would be different in their lives if they had not become pregnant during adolescence. Seven of them answered they would not be married, five would be working and five would still be studying.

And if were not the children...

Everything would be different. It could be I'd be single yet, could go out, take care of my mom, because my mom is alone, my father died two years ago and I could be with her. Everything would be different, I'd enjoyed more my youth, my adolescence. I guess it'd be much better.(P5)

It'd be different, because it'd something else, I certainly wouldn't be here, would be working, rule my life, know other people, it'd certainly be different. (P9)

The reports try not to curse early maternity (using a word they used themselves); they do not manifest anything bad or disaffection when they talk about their children. However, in the case of unplanned pregnancies, they were unanimous in stating that everything would be different. And this difference corresponds to personal investments in study, work and family of origin, care and help for parents to achieve a better life.

Another aggravating element is that adolescence is a stage of life when reaching the age of majority has not been accomplished, qualification and schooling are not complete yet, which impedes getting a formal job and being included in the job market with social guarantees and institutional support. Only informal jobs and unstable work relations are available. Studies confirm such arguments when they reveal that young individuals with a low level of schooling have a lower chance in the increasingly competitive job market and even when they manage to get a position they are low paid. What ensures their survival is usually their family members or partners⁽¹⁹⁾.

Health Situations

When the analysis is focused on the health situation, the participants confirm their fragilities and lack of preparedness to cope with circumstances that demand preventive actions and information. This fact is aggravated in the exercise of sexuality, difficulties negotiating with a partner regarding safe measures to prevent sexually transmitted diseases and pregnancy.

Hence, the adolescents reported they were aware of the risk of becoming pregnant though some thought it would not happen to them.

Then, the first time was ok, we had sex and nothing happened, no condoms or anything. Then, the second time, again no condoms. Only that I thought that I'd never become pregnant (P5)

I didn't take any pills, and he didn't use condoms, nothing. Only that we thought it would never happen (P3).

Health services are frequently far away and usually inaccessible. Nonetheless, all the participants attended prenatal care in local public services. Most of them felt they received good care.

It is thought that appropriate medical follow-up during pregnancy (which is currently observed in Brazil) is a compensatory health policy to minimize the effects of socio-economic inequalities. However, a pregnancy is a valuable opportunity for health services to promote women's health and that should not be limited to this period of life⁽²⁾.

A study carried out in a rural settlement in the metropolitan region of Belém, PA, Brazil indicates that the implementation of SUS has produced few perceptible results concerning access to and integration of health care. In relation to the role of nursing, a need to revise health activities, paradigms, work tools, and qualification of human resources to value the subjective dimension of health is observed. These issues need to be considered when planning the type of intervention and individual and collective health practices. Hence, health is a big challenge for nurses because it expresses inequalities in society⁽²⁰⁾.

Even with difficult geographic access to health services, the interviewees considered prenatal care was important. The main means of transportation from settlements to the health services located in the cities is buses. The greatest difficulties faced referred to the distance from their houses to the bus stop and time spent during the trip and the waiting time at the health unit. However, their commitment to their pregnancy and the need to ensure the health of their children always motivated them to face the difficulties.

CONCLUSION

This study allowed unveiling in rural contexts what is unknown and little discussed within the scope of public policies implementation, in social and specifically in health terms. There are similarities with motivations of adolescents from lower classes living in urban contexts in which the social roles and greater prestige in the adult world motivate pregnancy and maternity. In these similar contexts, these motivations are coupled with a lack of prospective socio-professional ascension and rare opportunities of paid jobs limiting the adolescents' future projects. Hence, pregnancy and maternity are considered life changes, which lead adolescents to acknowledge the losses accruing from the responsibilities of the new role they assume.

The adolescents and mothers in this study with their generational and gender fragilities develop coping strategies and raise their children responsibly, sharing care with their families and community. However, they are unanimous in stating that their lives could be different.

There are many possible perspectives and ways of looking at this reality. We highlight that this is a qualitative study that contemplates the reality of the studied rural settlements. The contributions of this study will be presented to representatives of public agencies and local health services so that health and nursing practices become suitably updated and influence, through the knowledge produced, the construction of viable and new possibilities in public policies that consider distinct situations of life and health, distinct contexts and particular vulnerabilities of different subjects to improve their practices. In relation to public policies from the perspective of SUS and its strategies of action, access (as a right) and accessibility (location, transportation, specificities, proximity) are weak points to be overcome in order to ensure inclusion and bonds.

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Correspondence adressed to:

Publication Dates

• Publication in this collection
  25 Nov 2011
• Date of issue
  Aug 2011

History

• Received
  06 Jan 2001
• Accepted
  15 Oct 2010