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On-line version ISSN 1982-0194
Acta paul. enferm. vol.22 no.6 São Paulo Nov./Dec. 2009
Teen pregnancy: values and reactions of family members*
Embarazo en la adolescencia: valores y reacciones de los miembors de la familia
Luiza Akiko Komura HogaI, Ana Luiza Vilela BorgesII, Rocio Elizabeth Chavez AlvarezIII
INursing Lecturer. Professor at the
Maternal-Children and Pscyhiatric Nursing Department at Escola de Enfermagem
da Universidade de São Paulo - USP- São Paulo (SP), Brazil
IINursing Ph.D. Professor at the Collective Health Nursing Department, Escola de Enfermagem da Universidade de São Paulo - USP- São Paulo (SP), Brazil
IIIPost Graduation (Doctorate) do Programa de Pós-Graduação em Enfermagem da Escola de Enfermagem da Universidade de São Paulo - USP- São Paulo (SP), Brasil. Bolsista do Programa PEC-PG/CAPES -Coordenação de Pessoal de Ensino Superior
OBJECTIVE: To describe the experience
of 19 family members regarding teen pregnancy.
METHODS: This was a qualitative study using narrative analysis approach.
RESULTS: Three categories emerged: a) family values and sexual orientations given; b) receiving the pregnancy news and arrangements made; and, c) providing support tot eh pregnant teen.
CONCLUSIONS: Teen pregnancy happened in a solid family organization context and the trajectory of teenager mothers after childbirth was characterized by family bonding and social network support. The new mother received material and psychoemotional support from her family members.
Keywords: Pregnancy in adolescence/psychology; Family/psychology; Parent-child relations; Sexual education.
OBJETIVO: describir las experiencias de
los miembros de la familia respecto al embarazo en la adolescencia.
MÉTODOS: En la investigación, desarrollada con abordaje cualitativo, se utilizó el análisis de la narración para sistematizar los datos.
RESULTADOS: Entre las narraciones de 19 entrevistados emergieron tres categorías descriptivas: a) Valores familiares y orientaciones ofrecidas; b) La recepción de la noticia y las providencias tomadas y c) El soporte ofrecido.
CONCLUSIONES: El embarazo ocurrió en un contexto de organización familiar sólida y las trayectorias de las mujeres adolescentes después del nacimiento del niño fueron marcadas por alianzas y soporte de la red social. La constitución del nuevo núcleo familiar fue caracterizada por la existencia de apoyo material y afectivo de los miembros de la familia.
Descriptores: Embarazo en adolescencia/psicología; Familia/psicología; Relaciones padres-hijo; Educación sexual.
The National Demographic and Health Survey(1), carried out in 2006, demonstrated that the percentage of first pregnancy in adolescents, at the time of the survey was 6.2% (greater in urban areas compared to rural areas). This proportion increases with age, going from 3.7% at 15 to 9.6% at 18. As for the correlation between pregnancy and the level of schooling during adolescence, the analysis showed a clear gradient, decreasing from 40.7% of pregnancies among adolescents with functional illiteracy, to zero among adolescents with 12 or more years of study. The correlation between poverty and teenage pregnancy has increased the visibility of this phenomenon and has placed it on the center of the debate on adolescent health(2).
Three adjectives have been mistakenly attributed to teen pregnancy which are not always true. The first is that it is early, that is, that there is a proper age where people are physically and emotionally maturity to have kids(3), not taking into account that in other decades this was the ideal age for having kids(2). Additionally, the same weight is given to teenage pregnancy thorough adolescence, not taking into account that more than half the pregnancies occur in adolescents over 18 years old(4). Secondly, teenage pregnancy is considered as cause and consequence of poverty since most adolescent mothers are not in school. A recent survey carried out in three Brazilian capital cities showed that, actually, adolescents in situation of social exclusion got pregnant after they left school or finished high school with no perspective of continuing education in a university(5). Third, teen pregnancy has been acknowledged as not wanted. However, several studies assessing the point of view of adolescent women demonstrate that pregnancy is not always associated with an accident or an unpleasant surprise, it can be related with the fulfillment of a project for the teenager, a type of permission to go into the adult world, getting involved with more complex dimensions that are connected with a change in the status and reassurance of projects of upward mobility(2,6).
For adolescents living in a low income community in the city of São Paulo, pregnancy meant a real chance for getting away from the problems faced at home, especially those related with lack of freedom and violence(7). A balance made by adolescents on maternity led to the conclusion that this condition produced more gains than losses, even if the role has been experienced in inappropriate circumstances, such as the need to face obstacles related with survival and lack of positive perspectives for personal and family future(7).
We do not want to deny that teenage pregnancy and maternity are complex phenomena, especially for adolescents in situations of social exclusion. Pregnancy definitely affects their life path, greatly increasing social vulnerability(6). However, we must consider that it is not always seen as a problem, either by adolescents or their families or social group.
This occurs partially because of the transmission of sociocultural values in the family context which have to do with the social role of women which is still connected with marriage and reproduction, especially in low-income families. Even though maternity is a highly valued event by families, when it occurs during adolescence, it can lead to ambivalent reactions, and many feelings and attitudes are involved with the need of an internal reorganization(3).
The family perspective in teen pregnancy has been little described. To know the experiences of families facing adolescent pregnancy is essential to align the care provided by health workers and the needs of adolescents and their families. Correspondence between professional perspectives and that of users of services is a central element of a socially relevant work(8).
The present study was carried out to know the perspective of the families of pregnant adolescents in order to achieve this alignment. The objective is to describe the experiences of family members concerning teenage pregnancy.
The study, carried out using a qualitative approach because of the naturalistic feature of the research, used the method of the narrative analyses for data systematization(9). The essence of this method is to access primary experience as represented by the person experiencing it. The five stages of the method were developed by the authors of this article.
The first stage was to propose the study to access the experience of people who had experienced pregnancy and maternity of an adolescent in the family. In the second stage, we contacted family members so that they could report the experience. The family was the context studied because it has a significant influence in the experience(10). The inclusion criteria for the present study were: being a family member, having a blood relationship with the adolescent and having lived with her during pregnancy and maternity.
The first participant was a person known by one of the researchers. He lives in the outskirts of a big city located in the state of São Paulo, which is in the Southeast of Brazil. The majority of people living in this place are low-income families. To obtain an intentional sample, at the end of the interview each participant was asked to introduce a neighbor or acquaintance. A similar measure was adopted until the inclusion of the last participant. This measure was adopted to include people who had similar socioeconomic conditions. All of them have been informed on the objective of the study and have been asked to take part in it, there were no refusals.
We have interviewed people with different family roles. This diversity was important to obtain different point of views and to picture the family system which is part of other broader systems(10).
The following question has been made: "Tell me about your view and experience concerning pregnancy of a teenager from your family". Further questions have been made when there was the need to go deeper into the subject. The point of view of participants was essential in the analysis of the narrative(9).
Personal data, those related with the family structure and the marital status of teenagers were obtained in a room of participants' houses(15) or in the workplace(4), between November 2005 and January 2007. Each interview lasted from 20 to 60 minutes. The criterion to stop including new participants was continuous repetition of data. This repetition started to occur in the 15th interview however, to ensure theoretical saturation of data(11), 19 participants have been included.
The third stage, transcribing the experience, was performed through transcribing oral interviews, fully recorded into written discourse. Individual characteristics of expression have been preserved and the grammar mistakes have been corrected in this stage. The fourth stage, assessing the experience, has been developed in an interpretative and inductive fashion(11). Careful initial reading of the narrative allowed for a general idea of the individual experience. In the other readings, the focus was on the constant meanings of the narratives.
The fifth stage, reading the experience, identified the recurrence of ideas so that descriptive categories could be designed. These categories show the representation of participants regarding teen pregnancy and maternity in the family context. Small excerpts from the narratives have been used to exemplify the meanings of the categories. They have been separated by dots (...) indicating that each part has been taken from one identified participant. The strongest example has been used to represent the other, similar examples. These resources have been vital for a realistic description of the experience and to preserve the personal perspective which is an essential point of qualitative research(11), especially for the method of narrative analysis(9).
The assumptions of Resolution 196/1996 of the National Health Council(12) have been respected and the research project has been approved by Verdict 384/2004, by a dully accredited Committee. All participants gave their written consent.
Personal characteristics of participants and their families
Family roles performed were mothers(12), fathers(3) sisters(4) of pregnant adolescents, identified by letters "m", "f" and "s" and their respective numbers. They were between 23 and 56 years old, schooling was complete elementary school or less and two of them had zero years of study. Predominant religion was Catholic(12) and Evangelical(7) and the family genogram was nuclear(10) and extensive(9). Teenagers' age at the time they got pregnant ranged from 14 to 18 years old, 15 got married and four remained single. Among those who got married, 8 continued to live with parents, five lived with their husbands' families, and two had their own houses. Among those that remained single, all of them continued to live with their parents.
Family values and guidelines provided
Single parenting was feared because it was against the prevalent moral principles with a negative effect on the concept of family in their social group. Sexual intercourse which is seen as part of dating, however, as a "modern" habit should be accompanied by birth control. Advice to avoid pregnancy was continuously given because pregnancy was seen as an embarrassment to the family, representing a concrete sign of disrespect to the family and social values. This reality made mothers resort to prayers in an attempt to avoid pregnancy.
"I used to tell her not to get pregnant single so as not to embarass the family (m1,3, 5, 8, 10) ... I prayed I asked the lord for my daughter not to get pregnant, people would talk about it (m1,3, 5, 10, p 3)... today, everything is very modern, people have sex before getting married, but we must avoid pregnancy to keep the family moral .... (m1,3, 5, 8, 10, p 3, 4).
Several guidelines were given on the proper behavior in relationships with men. Mothers take up the responsibility to direct and supervise the behavior of teenagers. The emphasis was on the care that should be taken so as not to "fall for men's talk". There was the idea that men only wanted to have sex. The idea that women were responsible for falling or not for men's appeal was rooted. Adolescents received guidelines so as not to give in promptly to men's attempts. Intimate relationship should only be started when they were certain about the good intentions of men, which assumed a commitment and a bond. Being a virgin was clearly valued.
"I explained to her how men were, I told her not to fall for their talks, because they get sex and then they disappear (m3, 5, 7, 8, i1, 3) I told her to hug, to kiss but not to give in to sex...this is just when they have good intentions... (m3, 7, p 3, 4) men value virgins (m3, 4, 8)".
Dialogues on sexuality and birth control did not occur in some families because they believed adolescents already had this kind of knowledge. Furthermore, to these families, these issues were available at school and in the media. To be ashamed to talk about that with their daughters and to have no idea daughters had sexual intercourse were also explanations given for not providing guidelines.
"I have never talked to them because they know more than we do, the school and the television teach; they got pregnant because they wanted to, because they knew everything... (m2, 6, 9)... I did not talk because I was embarrassed to talk about this"; "I have never talked because I though she did not have sex with anyone (m4)".
Finding out about pregnancy and the actions taken
Pregnancy news was given by several people of the family and social circle of adolescents, among them, sisters, friends, the boyfriend or fiancée or their parents. The way the news was given was also different, and regardless of the strategy adopted, these moments have been accompanied by fear, which was more intensive in the cases where there was no clear bond between adolescents and the children's father. Pregnancy occurring in these situations led to greater concern because it was a clear proof of not following the guidelines repeatedly given. In some families pregnancy was hidden up to the limit because there was the fear of being punished. Some adolescents ran away from home which made family members suspicious of a pregnancy.
"She hid for as long as she could, I found out late in the pregnancy... (m4); I got suspicious and I asked and she would say: no, no...She ran away, desperate, we found about the pregnancy only later (m4, 9,3)".
When mothers were the ones receiving the news first, they were the ones responsible to give the news to the other family members and to intermediate the family conflict. This was a hard work because there was the possibility of a hard punishment and harsh actions, including sending adolescents away from home. In other families, the mother was the most feared person and, in these cases, fathers performed the role of moderators in the family conflict.
"My husband said he would throw her out of the house... I told him: easy, let's see how we can handle this" (m3, 5,9).. "My mother received the news and my father had to step in to deal with the problem... (s1, 4)".
Several actions were taken and they depended on the prevalent values and beliefs. In some families, pregnancy was well accepted and was a reason for joy and happiness, even though it was accompanied by accepting the situation.
"I was happy although she is very young ... ( 5, 8); it was the best thing in the world (m2)...it was too early, but what can we do... (m1, 5, 8); I thought, my dream is coming true... (m2); I was surprised, but happy at the same time ..I suffered but I accepted it... I was sad but I supported her, what to do? (m3, 7)".
The measures taken depended on the characteristics of the bond between adolescents and their partners. When the relationship was not stable, negative reactions were predominant and the event caused intense suffering, because it was seen as a confrontation to the family. There was concern for the negative criticism that would come from relatives, neighbors and friends. The fear was greater in cases where pregnancy occurred in the beginning of the couples' relationship.
"I was shocked; shaken, sad; desperate; unresigned, I fell apart because she barely knew the boy...they had just started dating ... it was as if I had been stabbed ... (m2, 3, 6); I thought about what people would say because she had just met the boy (m4, p3)".
Worries were lower when the couple was in a steady relationship and there were already marriage plans. Regardless of the connection between couples and the circumstances involved, pregnancy led to frustration because it implied the need to stop or change the family project.
"I was not sad because she was already with her partner ...It was not that bad because she was about to get married (m2, 6)...the study was the most important thing (m4, 5, 7, 9, p1, 3) the dream of a good education ended there (m4, 5, 9, 10, p3, 4)".
When the stage to adjust to the new reality was overcome, the main worries were with structuring teenagers' family and financial stability. Decisions were taken regarding continuing or dropping school and if teenagers would start or restart working. Quick measures to establish a formal relationship between couples, through legalizing the union have been adopted. Although most context of alliances and support from the social network and, in most cases, by the formation of a new family nucleus with material and affective support from their families.
"The marriage was within the law ... and we were more relaxed (m5, 10, p2, 3, 4)... I told her: We have to decide now, make things clear between the two and the children... (m2, 5, 9, 10, p2, 4); it would be better to get married but if you think it is not going to work, it is best to remain single (m5, 7, 10, p2, 3) "My mother wanted to make me get married, but my father told me I did not have to get married (i1, 3)".
All families provided some type of support for adolescents. This occurred in several ways, either by having the adolescents that remained single and their children in their own house, or by financial support and help in upbringing the children.
"I built another bedroom and I help when it is needed... (m1,2, 3, 4, 5, 8, 10, p4) it is the most important time, I give support ... (i1, 3); I raise my grandchildren (m3, 6, 9, p1, 4)".
In some families, support was conditioned to the fulfillment of some requirements, such as adjusting the behavior to the role of mothers. This demanded changes in the life style, dedication to studies or work, with discipline and greater intensity and consequently, restriction to leisure activities and decrease or interruption in night life. In the families where support was not given, this occurred because they did not notice this type of demands.
"If it is to work or study, I take care of the children, but if it is to party, I don't... (m1, 3, 8, 10); I told her I would help as long as she behaved herself (m4, 6, 9, i2, 3.. she takes care of the child herself, the other grandmother helps ... (m1, 3, 6, 10)".
The concern with teenage pregnancy was related with fear of being judged by the social group they are inserted in, because this showed there was sexual intercourse before marriage, a behavior that is considered inadequate since it involved the moral integrity of families. The sequence dating, marriage and pregnancy is the rule in family moral and should be followed by teenagers, it is widely present in the discourse of the domestic context.
To follow these social rules, women should not fall for men's talk(13-14). Thus, pregnancy was seen as a weakness of adolescents that "fell for" men's lines, that is, they did not follow the families' recommendations. Making adolescents responsible for their pregnancy shows an idea that is also rooted in the actions of the health area, that adolescents are solely responsible for their reproductive health, not taking into account the role of partners and that contraception is a relational and subjective process, rather than rational, that is learnt and acquired with time(15). It is widely known that when a relationship gets steady and the typical steady relationship of adolescence is dating there is a tendency to be more relaxed regarding the practices to regulate fertility(16), this aspect has to be considered both by families and health workers to avoid pregnancy occurring during adolescence.
Even though there have been changes in the social rules that establish relationships between teenagers currently, with greater parental tolerance and sexual intercourse occurring before marriage, this does not mean that there are no moral classifications on women's behavior regarding sexuality(15). Thus, to announce teenage pregnancy is a source of moral concern, not necessarily of sadness or family disappointment(17).
For that reason, the immediate actions taken by family members to get their daughters married are justified. However, some families let adolescents remain single. In the idea of these families, marriage in adverse conditions led to more harms than benefits, especially regarding the marital future.
The discourses also showed that in some families there were no talks on pregnancy prevention between parents and children. Although the issue sexuality and their possible consequences is a great concern for families, the talks in this sense did not go beyond the barriers of "concerns, warns and reprimands"(15), in the greater intention of shaping the behavior of daughters to preserve their moral rather than preparing them for safe sex. A survey conducted in the Brazilian context showed that only 20% of the teenagers had this type of conversation with their families, and the mother was usually the reference(18). This may be partially explained because parents find it hard to approach issue related with sex and contraception, leaving to the school and health services this responsibility, demonstrating that they need qualified care for sex and reproductive health(19).
All families taking part in the study mentioned they offered some kind of support to adolescents regarding pregnancy, with a greater or lower intensity. Mobilization of family members around the pregnant teenager and the establishment of a real support network have already been described(20). This support was effective and, in many cases, it occurred through the adoption of a new behavior by adolescents, who should definitively take up the responsibilities of the adult world, restricting the night life and parties.
Welcoming pregnant teenagers after the first stage of intensive anguish and family crises, contradicts the usual discourse that teenage pregnancy is not only the fruit but also a determiner of a family disrupt. In the case of interviewed families, pregnancy occurred in a context of a solid family organization and the path of teenage women after children's birth was marked by a family context of alliances and support from the social network and, in most cases, by the formation of a new family nucleus with material and affective support from their families.
Support from the family and social network was the emphasis made in the narrative of family members. Family values and the social moral, repeatedly mentioned in the family context did not hinder the appearance of pregnancy in the family who faced huge dilemmas during the adjustment to the new reality. On the other hand, the affective and relational ties were reinforced among family members and adolescents contributing to an environment with affection and material support.
Health professionals working in primary health care must disseminate the results of the present study. They provide important signs on family organization and the social network involving teenage maternity especially in low-income groups. This knowledge will enable proper planning of nursing care. It should encompass the needs of adolescents, men and women that are strongly influenced by beliefs and cultural values that are predominant in the family and social environment, including socialization to perform the traditional roles men and women are subjected to since birth. From this information, there is the need to carry out further studies also encompassing adolescent fatherhood and the perspective of their families.
Providing support and giving relevance to the support network available to teenagers before, during and after pregnancy imply an integrated work of professionals. They should develop activities in health education with organization taking into account cultural and social aspects involving the families and the social network. This study is essential to improve maternal and children morbidity and mortality rates among low-income families that are already affected by several socioeconomic and political factors. Despite facing complex problems deriving from this reality, low-income teenagers can also benefit from education actions. They should be appropriate to individual, family and sociocultural singularities since this care is essential to promote female's empowerment, which is also built in the relationship with the other, either the partner, the family or the network of social relations. This may occur through raising awareness of teenagers to their sexual and reproductive rights.
To the National Council for Scientific and Technological Development CNPq, by the support granted.
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Corresponding author: Received article 25/11/2008 and accepted 19/02/2009 * Study carried out by participants
of the Research Group "Núcleo de Assistência para o Autocuidado
da Mulher - NAAM" (Center for Women's Self Care) connected with the Escola
de Enfermagem da Universidade de São Paulo USP São Paulo (SP),
Luiza Akiko Komura Hoga
Av. Dr. Enéas de Carvalho Aguiar, 419
São Paulo (SP), Brazil. CEP. 05403-000
Received article 25/11/2008 and accepted 19/02/2009
* Study carried out by participants of the Research Group "Núcleo de Assistência para o Autocuidado da Mulher - NAAM" (Center for Women's Self Care) connected with the Escola de Enfermagem da Universidade de São Paulo USP São Paulo (SP), Brazil.