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Acta paul. enferm. vol.25 no.3 São Paulo 2012
Couple and family relationships of adolescents post-pregnancy*
Thatiana Araújo MaranhãoI; Keila Rejane Oliveira GomesII; Delvianne Costa de OliveiraIII
IGraduate student (MSc) of the Academic Master's Course in Sciences and Health , Federal University of Piaui - UFPI - Teresina (PI) Brazil
IIDoctorate in Public Health. Professor of Technical Course in Nursing, Federal University of Piaui - UFPI - Floriano (PI), Brazil; the Master's Course in Sciences and Health, Federal University of Piaui - UFPI - Teresina (PI), Brazil
IIIMaster in Sciences and Health, Federal University of Piaui - Teresina-UFPI (PI), Brazil
OBJECTIVE: To analyze the perceptions of adolescent mothers with respect to family and conjugal relationships developed post-pregnancy.
METHODS: A cross sectional study of 202 adolescents, three months after admission into one of four maternity hospitals in Teresina-PI (Brazil) that were included in the study.
RESULTS: The majority of adolescents interviewed perceived positive changes in family (60.4%) and conjugal (50.5%) relationships post-pregnancy. We observed a statistical association between the father's desire for the newborn and the willingness to care for it (p <0.01), and between changes in conjugal relations and the parental support for the child care (p <0.01).
CONCLUSIONS: Although the study has shown predominantly positive relationships between youth and their families and with a partner after pregnancy, it is expected that these results should guide health professionals so that they can stimulate an increase in bonding between the adolescent mother and people from their neighborhood during and after pregnancy.
Keywords: Adolescent; Mothers; Family relations; Family conflict
In Brazil, approximately one in four pregnant women is an adolescent, corresponding to 23% of all pregnant women (1). The impact of the unexpected arrival of a newborn in this evolutionary stage of life can generate reactions of family conflict with the superimposition of feelings of despair, joy, abandonment and acceptance of a condition that is many times inevitable (2). When there is no acceptance of the pregnancy by those living with the young woman, it is common to have intrafamily violence, not only of a physical character, but also psychological, social and emotional, which may lead to abandonment or to the imposition of an abortion (3). Thus, if a social support network is absent, it can predominate among the young women feelings of sadness, depression and even suicidal ideation (4,5). However, in cases in which pregnancy is desired, harmonious family interaction can coexist, bringing a positive meaning to the teenager (2,6).
The birth of a child causes changes of the highest proportion in the family, significantly altering everyday life and requiring a rescaling of the life of the young mother and the people around her. These people must adapt to the event, since often the adolescent is not prepared physically and emotionally to face the pregnancy and care of newborn. In this sense, the teenage pregnancy is experienced by the family as a whole, because in many cases, the young woman continues to live within the family, making it so that the costs for the child are incorporated into the home and result in more demand for attention and care (7).
Thus, the support and understanding for young mothers coming from the family are extremely important attitudes, because good relations within the family have been related to a postpartum period without major complications, and the attenuation of the anxiety of the young women (8,9).
Besides the problems associated with the family, the conflicted relationship between the adolescent and the child's father also reflects directly on her well-being. The refusal of paternity due to financial factors or the sudden appearance of unexpected responsibility can have negative repercussions, becoming an important source of stress for the adolescent. On the other hand, acceptance of the pregnancy and a good relationship between the adolescent and the father of her child mean that the mother feels accepted, independent of there being a loving relationship (10) .
In this context, it is believed that the positive interaction between the young mother and her family, as well as with the father of her child, facilitates the availability for support in their role as a mother, and in the provision of child care. This condition is indespensible for the mother to feel supported, and the neonate may develop in a calm and welcoming environment; this also encourages a better relationship within the mother-child dyad (11) .
Therefore, considering the importance of favorable relationships between the adolescent mother and the individuals belonging in her daily life, this research had as its objective to analyze the perception of adolescents about family and marital relationships after pregnancy.
This work corresponds to the second phase of the research project entitled "Self-esteem, self-efficacy and use of contraceptive methods among adolescents in Teresina, PI, Brazil."
This is a study of a quantitative, transversal, approach conducted with 202 adolescents, with ages between 14 and 19 years who, during the first phase of the original study, were hospitalized in the postpartum period in one of four maternity hospitals in Teresina-PI included in the study. Together, these institutions were responsible for approximately 90% of births registered in the city. Three of these establishments are public and one is private, and the public hospitals also provide private assistance.
The sample was selected in a random fashion and stratified proportionately to the size of the population of adolescents receiving care for completion of their pregnancy in 2004, in each maternity unit participating in the study (N = 3,612). The program, Epi Info 6.04d software (U.S. Centers for Disease Control and Prevention, Atlanta, GA) was used to calculate the minimum sample size required for the study, with a 95% confidence limit, desired accuracy of 8%, design effect (deff) of 1.4 and alpha risk of 5%. The prevalence of the dependent variable was 50%, considering that there was no prior information on the study population.
The participants of the first phase of the original study, which occurred during a trimester, were invited to participate in the second phase that occurred three months after data collection for the first phase. Upon acceptance, we asked the young woman to confirm her residential address, with possible reference points and contact phone numbers, in order to increase the chance of success in the active search for cases in the second phase. Thus, in the trimester following the first phase, the interviews were conducted at the adolescents' home, using a pre-coded and pre-tested semistructured form.
For the initiation of the second phase of data collection, we made phone contact to scheduled the best time to conduct the home interview. When this initial communication was not possible, the interviewers made their way to the home of the study participants. In the case of change of address of the adolescent reported by a community member, interviewers were directed to the new address.
Those participants who were not located were considered to be excluded when the entire strategy of location of the address was unsuccessful or when the teenager had moved to another municipality or, in only one case, with refusal to participate in the second phase of the research because of the child being very sick.
The interview was conducted in a reserved place in the home where there was no influence from fellow residents. The Terms of Free and Informed Consent was signed by the adolescents or their responsible person, as required by Resolution n º 196/96 of the National Health Council, which deals with research involving human beings. The written consent of the person responsible was solicited if the adolescent was under 18 years old.
After collection, the data were entered into two databases using Epi Info 6.04 software (U.S. Centers for Disease Control and Prevention, Atlanta, GA), by different people, so as to permit checking for typographical errors and to conduct the necessary corrections.
Descriptive statistics for univariate analysis were used. In the bivariate analysis, we used Pearson's chi-square test or Fisher's exact test, as appropriate. For the statistical analysis and inference, we used SPSS version 17.0 (SPSS Inc., Chicago, IL 60606, USA). This study was submitted to and approved by the Ethics Committee in Research of the Federal University Federal of Piauí, which received protocol number 0001/2006, and complied with the ethical and legal requirements of research involving human beings.
Study participants included 202 adolescents with a mean age of 17.5 years (SD = 1.4), with the majority in the age group of 18 to 19 years (57.4%). It was observed that three of every four young women did not attend school (77.2%) and 89.6% had schooling ranging from illiteracy to not having completed elementary school. Most adolescents lived with a partner (68.8%), did not work (91.6%) and received help in performing domestic activities (67.3%) in addition to the help of family, in caring for herself and her child (85.6%). For 57.4% of respondents, the partner wanted the newborn at this time in the couple's life. Support in caring for the child given by the father was cited by 84.2% of the young women (Table 1).
When questioned with respect to changes occurring in family relationships after the pregnancy, the adolescents reported the change was better or much better (60.4%). In relation to changes in the marital relationship after pregnancy, more than half of the young women (50.5%) cited that the relationships changed for better or much better, while 32.7% of adolescents did not observe changes in the relationship with the father of their child (Table 2).
The data in Table 3 show that there was a significant association (p <0.01) between a partner's desire to have the baby at that moment in the couple's life and the fact of helping to care for it. The data in Table 4 showed a statistically significant association (p <0.01) between changes that occurred in the marital relationship, after birth of the child, and the father's support in caring for their newborn.
It is emphasized that the results showed the perceptions of respondents with respect to variables studied.
We observed a significant number adolescents who did not attend school, confirming that the pregnancy and the birth of a child are important causes of isolation and difficulty in studies among adolescents (12).
The high proportion of adolescents with education ranging from illiteracy to not completing elementary school, demonstrates the reduced level of instruction prevalent across the young women surveyed. Studies indicate that low educational level is directly related to higher fertility, probably because the higher the education level of the adolescent the greater the chances of using contraception during sexual intercourse (13-15).
After pregnancy, the majority of the adolescents did not work. The fact that mothers needed to assume new responsibilities associated with the creation of the child, complicated or prevented them from entering or returning to the labor market. Another determining factor for this result was the low professional qualifications of the participants due to early interruption of studies. So, with little education and without a profession, they are limited to the possibilities of entering the competitive labor market, with a chance to perpetuate themselves and their financial dependency, thus establishing a continuous cycle of poverty, poor professional qualifications, and submissiveness to the people on whom she depends (12,16,17).
Adolescents who lived with a partner were in the majority, a result consistent with other studies (12,18,19). Research conducted with pregnant adolescents in the city of Teresina showed that, among young women who lived with a partner, 30.7% remained financially dependent on parents or other persons (12,13). Thus, the early marriages may place the young people in a more difficult socio-economic situation, especially when the partner is also an adolescent and/or unemployed, making them more vulnerable to other conditions of social risk. Moreover, the early occurrence of marriages may limit the adolescent only to the functions of mother and housewife, leaving school and paid work outside the home in the background (20).
A substantial number of adolescent mothers reported the presence of family support in the execution of household chores and care of themselves and their child. This can be fundamental, because many young people feel unprepared to care for a child at this time of life, with the aggravating factor of financial instability further contributing to feelings of fear and insecurity (11).
Evidence suggested that changes occurred for better or much better in the relationship between the young mother and her family after the pregnancy. This result corroborates research demonstrating that, from the perspective of adolescent mothers, family relationships are more favorably established after the birth of the child, with the improvement of care provided to the teenager and greater acceptance of the newborn (2,18,20). In research about the family relationships of low-income adolescent mothers, this improvement in care was explained by the necessity that family members had to unite to assist the child, thus increasing the interaction and improving relationships (18).
Positive relationships between the young mother and her family are fundamental, both for her emotional support, as well as the financial status and child care. Furthermore, the well-being fostered by these good relations prevent the adolescent from developing depressive episodes (5) . In this sense, family support facilitates the adaptation of the adolescent to her maternal role, and decreases anxiety during the care of the newborn (8).
Research that analyzed the relationships between adolescent mothers and their fathers, two years after birth, showed that when the good relationships were maintained within the family , the young women had a higher chance of staying in school and achieving higher education, thus demonstrating the importance of favorable family support as a factor that positively influences future education (21).
In the perception of the majority of the current study's adolescents, the partner wanted the child in that moment of the couple's life; however, the perception of the young women does not always agree with the statements of the partners in studies that consider their opinion about the pregnancy of their teenager partner. In research regarding adolescence and reproduction in Brazil (22), there was evidence of a high number of partners who did not intend to become a father at that time. In another study, the majority of young people interviewed considered that the pregnancy of the partner had occurred at an inopportune time, nevertheless, the acceptance of paternity was perceived as very positive, and there was an absence of regrets associated with the new status of father (13).
As for the changes observed by the teenager in her relationship with her partner, after completion of the pregnancy, a little more than half cited changes for better or much better. The support from the partner is essential to the well-being of the young mother, since there is considerable risk for the onset and chronicity of postpartum depression when it is present or established within troubled marital relations (23). Moreover, it has been shown that children of women who were not effectively supported by the partner had a higher chance of dying in the postneonatal period (24). On the other hand, it is notable that many times the spouses of young mothers are also adolescents. In this sense, besides the negative socioeconomic factors, a marital union among adolescents is characterized by emotional immaturity, which limits the capacity to resolve differences and exacerbates marital conflicts, making the relationships unstable (25).
The fact that the father desired this newborn in that particular moment of the couple's life was significantly associated with paternal support dispensed during child care. These findings suggest that the acceptance of the child by the father figure is a determining factor, so hethen acquires a greater predisposition for assuming the responsibilities related to child care. The paternal presence is particularly important when considering the benefits obtained of good emotional, behavioral, social and educational development of children who maintain permanent contact with the parent, even if he does not reside with them (26). From this perspective, we reiterate the necessity of further actions in order to encourage responsible parenthood, especially among adolescents, as well as the provision of satisfactory conditions so there is better interaction of the mother-father-child triad (6).
The presence of paternal support during the care of the newborn was also significantly associated with changes perceived by the adolescent in the marital relationship after the birth of the child. These results show that when the changes that occurred in the marital relationship were for better or much better, there was a greater predisposition for paternal care. Conversely, when the modifications suffered by marital relations were for the worse or much worse, there was an increased frequency of adolescents' perception that the partner had the tendency to neglect child care. The findings of this study corroborate the research into parental involvement in the care of infants; the statistical significance was confirmed of the association between problematic marital relationships and the absence of paternal involvement in child care (27).
In addition, the literature has shown that the absence of social support and the presence of unfavorable relationships between the adolescent mother and her family and/or partner are not only directly related to depressive symptoms, but also to rejection of the child. Thus, when young mothers are isolated from a network of emotional support, there will be elevated chances of experiencing negative interaction between mother and child and major risks of rejection of the child by the mother (28). From this perspective, the study of social support among adolescent mothers showed that from the perception of these young people, both the close relatives, especially her mother and spouse, are considered the most important sources of support. These, in turn, contribute significantly to the reduction of stress and anxiety in the young women, as well as to the best maternal behavior (5).
The young need social support as a restructuring factor for emotional relationships and for emotional strength, so they can experience a positive pregnancy and motherhood, because the feeling of security and protection promotes ideal conditions for maternal care (29). Thus, we perceive that family support and participation in the life of young people who experience a teenage pregnancy are fundamental, so they can exercise the maternal role with responsibly and security, with the perspective of a better future for both mother and child. To this end, health professionals, in particular those in nursing, should seek to establish trusting relationships with adolescents and the people around them by providing an open channel of communication so that everyone can externalize his/her fears, worries, anxieties and feelings that are preventing healthy relationships within families.
Even with the contributions so far observed in this study, there are some limitations that do not preclude the results, but must be cited so that they can be avoided by other studies. Thus, we must include in other studies data about the age group of the baby's father, for better comparison with other research, since perceptions of adolescent and adult fathers in relation to acceptance of paternity may differ (30); likewise, we should include the actual response of the partner with respect to his desire for the child at that moment of their lives, and not just the perception of the adolescent mother.
Significant favorable changes in family relationships and, to a lesser extent, in their marital relations of post-pregnancy adolescent mothers were noted. In spite of positive findings, it is necessary that these results subsidize health policies geared to the demands of reproductive health in adolescence. These policies should be accomplished through actions of health professionals, especially nurses, during the approach to families, to encourage an increase of the bond between the adolescent and the people who live with her and with the father of the child, both during and after pregnancy. Thus, by implementing these actions, we hope to contribute to a greater predisposition to accept the child, with positive representations of the maternal role, and decreased stress for the young woman.
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Corresponding Author: Received article 08/02/2011 and accepted 04/10/2011 * Study extracted from the Scientific Initiation Work entitled "Family relationships and marriage of adolescents after pregnancy" - presented to the University Federal do Piauí - UFPI - Teresina (PI), Brazil.
Thatiana Araújo Maranhão
Av. Frei Serafim, 2280, Centro
Teresina-Piauí - Brasil CEP: 64001-020
Received article 08/02/2011 and accepted 04/10/2011
* Study extracted from the Scientific Initiation Work entitled "Family relationships and marriage of adolescents after pregnancy" - presented to the University Federal do Piauí - UFPI - Teresina (PI), Brazil.