EMBARAZO EN LA ADOLESCENCIA: ESTUDIO COMPARATIVO DE LAS USUARIAS DE MATERNIDADES PÚBLICAS Y PRIVADAS

1 Enfermera Obstetra, Especialista de Laboratorio de la Escuela de Enfermería de Ribeirão Preto, de la Universidad de São Paulo, Centro Colaborador de la OMS para el desarrollo de la investigación en enfermería, Brasil, e-mail: acyntia@eerp.usp.br; 2 Enfermera Obstetra del Amparo Maternal, SP, Brasil, e-mail: zairadaud@yahoo.com.br; 3 Profesor Doctor de la Escuela de Enfermería de Ribeirão Preto, de la Universidad de São Paulo, Centro Colaborador de la OMS para el desarrollo de la investigación en enfermería, Brasil, e-mail: amalmeid@eerp.usp.br, flagomes@eerp.usp.br, nakano@eerp.usp.br Artigo Original


INTRODUCTION
The need to have social rights guaranteed by the State after the Constitution of 1988 led to profound changes in the organization of public policies in Brazil.In terms of health rights, these changes aimed to universalize the population's access to health services, in an attempt to diminish social inequalities and, consequently, poverty and underdevelopment in several regions of the country.
The health systems have undergone transformations over time towards the fulfillment of their users' needs, as well as of each country's political, social and economic interests.In developing countries, especially in Brazil, an evident demographic transition has occurred, which led to the reorganization of the health system, whose indicators (1) are: reduced rates of infant and perinatal mortality, decreased fecundity in women over 20 years old and increased life expectancy at birth.
However, the fecundity rate among adolescents has increased in the period.In 1999 (2)(3) , 23% of mothers were under 20 years old.
The fecundity rate is inversely proportional to these adolescents' income and education.In 1996 (4- 5) , the proportion of 15 year-old women who had initiated their reproductive life reached 55% among those who had no education; 19% among those who had five to eight years of schooling and less than 10% among those with 9 to 11 years of schooling.
There are also other factors (5) that contribute to the increased number of pregnant adolescents: precocious menarche and sexual life and precarious access to health services, which offer deficient family planning, since these are considered the fourth place where adolescents find reliable information on sexuality (6) .
Despite the strong biopsychosocial impact exerted by adolescent pregnancy, the biological aspect is less affected, at least from the age of 16 onwards, because its effects (7) on the adolescent's organism and obstetrical result are equivalent to those on adult women.The psychological aspect is one of the most complex, due to the peculiarities of development in this stage of life.The social aspect implies school evasion and consequent professional limitation, which can compromise their future life expectations.
Poverty and social exclusion can be seen both as a cause and consequence of early pregnancy.
There was a decrease in the proportion of liveborn infants from the less to the more economically favored areas; the highest rates of specific fecundity were observed in areas with the worst socioeconomic conditions (8) , according to a study on the intermunicipal relation between poverty and adolescent pregnancy in a city of São Paulo.Naturally, a country's capacity of generating wealth depends on the professional formation of its members (9) .
Adolescent are in the middle of this capacitation process and it is desirable that they complete their educational and professional formation, enter the job market and then collaborate in the generation of offspring who will guarantee the continuity of their social group.Because of the prevalence of lowincome adolescent mothers with professional limitations, the demand for health services to children with development and nutritional deficits and affective and psychological problems has also increased.Consequently, the social and financial costs have also grown, making the development of third world countries' (5) society and economy even more difficult.
Brazil lives a dichotomy regarding its health services: on the one side, there are the health insurance plans, usually accessible to the more favored classes and, on the other, the Single Health System -SUS -offered to all citizens, but in practice used predominantly by those of lower acquisitive power.The public and private health services are influenced by the lifestyle of their users, which determines the care model that is implemented.Thus, different profiles of users attended in the two health systems are identified, as well as significant differences in the results of these two subsystems' care delivery.
This study aimed to identify and compare the profile of adolescent mothers users of public and private health systems of a city in São Paulo, Brazil, through indexes of mortality and birth, organized by the statistical service of the Municipal Secretary of Health-MSH, available in the city's administration site (10) .It is believed that, in defining the profile of adolescent mothers, for this group of users, an analytical view can be composed of the potential differential implications in the form of care that operate in our local health system.In turn, it can provide support for the planning of actions, adequate structure and organization of services and composition of the support network, towards the so desired equity to all citizens.

MATERIAL AND METHODS
This descriptive study uses information from the declaration of liveborn infants of adolescents attended at three hospitals accredited by the public health system and three private institutions in a city in the State of São Paulo, in 2000-2002.
The number of deliveries occurred in the period was taken into account for the selection of hospitals and those with the highest number of births were chosen.
The birth indicators from the MSH database, available in the city administration site (10)

RESULTS
Based on the data obtained, the adolescent mothers' profile for the study variables is presented.Table 2 shows the distribution of liveborn infants of adolescent mothers in the public and private health systems according to the mothers' age and level of education.It was found that the majority of the private health services users, between 15 and 19 years old, had eight or more years of study, that is, the expected schooling for this age range was met in 70.33% of the cases (429 mothers), while only 24.26% (148 mothers) had four to seven years of schooling.Among the mothers of liveborn infants, users of SUS in the same age range, 49.53% (2,219 mothers) had four to seven years of study, that is, the expected schooling did not follow the age range; 44.55% had eight or more years of schooling.Among the adolescent mothers of liveborn infants, SUS users between 15 to 19 years old, 194 (4.33%) had one to three years of schooling, against nine mothers (1.47%) with the same level of schooling in the private service, that is, a number almost three times higher of schooling delay than those originated from the public system.There were 45 SUS users with no schooling, which did not occur in the private system.
All mothers of liveborn infants in the 10 to 14 year-old age range in the private system had schooling compatible with their age, that is, four to seven years of study.Although the majority of mothers who were SUS users in the same age range possess schooling compatible with their age (96.8%), there were three mothers who had one to three years of study and two with no schooling at all.
Adolescent pregnancy: a comparative... Baraldi ACP, Daud ZP, Almeida AM, Gomes FA, Nakano AMS.  4 shows the distribution of liveborn infants of adolescent mothers according to the mothers' age and number of prenatal consultations attended, in the same city and period considered.The majority of adolescent mothers of liveborn infants attended seven or more prenatal consultations in both health systems, though the percentage of mothers in the public system with this number of consultations is lower than in the private system (54.46%against 89.34% respectively, if we consider the age range from 14 to 19 years old and 48.93% against 87.5% among adolescents 10 to 14 years old).None of the mothers between 10 and 14 years old who were users of the private health service performed less than six prenatal consultations, different from what occurred in the SUS: 31.38%(59 mothers) attended four to six consultations, 28 (14.9%)attended between one and three consultations, while three mothers did not attend to prenatal consultations.
Only one adolescent (0.16%), in the range from 15 to 19 years old from the private system did not perform any prenatal consultation.On the other hand, 113 (2.52%) adolescents in the public health system presented similar situations, that is, a percentage 15 times higher.In the same age range, among adolescent mothers who performed one to three prenatal consultations, 433 (9.67%) were SUS users and only five (0.82%) used the private health system.
While an expressive number of mothers performed between four and six prenatal consultations (1,363 adolescents -30.43%), in the private system, this number decreases to 46 adolescent mothers (7.54%).Table 3 shows the distribution of liveborn infants in public and private health services according to the mothers' age and type of delivery.There were 142 vaginal deliveries (75.53%) and 46 c-sections (24.47%) among mothers between 10 and 14 years old in the public health system.In the private system, only one child was born through vaginal delivery (12.5%) and seven through c-section (87.5%).Among mothers from 15 to 19 years old, this proportion was kept, with 3,275 vaginal deliveries (74.10%) and 1,204 c-sections (2.87%) in the SUS, against 103 vaginal deliveries (16.68%) and 507 c-sections (83.12%) in the private health system.mothers) had between one and three children.In the public health system, three adolescents had from four to six children, which did not occur in the private system.There was one case in which this information was given as "ignored" in the public system and 13 in the private system in the age range considered. in the same period, 17% of the adolescents had no easy access or health services available to specifically meet the young and the needs typical of their age, which was a major obstacle in the access to information and actions to protect their health, hindering their free and responsible decision making (6) .
It is known that fecundity tends to diminish with the increase in years of education and educational performance (4) .Data from literature show that early pregnancy can lead to, besides low self-esteem, giving up school, work and even leisure; among factors determining the adolescent's abandonment of school before the child's birth are embarrassment and pressure from directors, teachers, peers and friends' parents (11) .Table 2 shows the differences between schooling of adolescent mothers of liveborn infants between the two systems studied.Schooling followed the age range for the majority of mothers users of private health services, while the same is not true for the SUS users.There were differences between schooling of mothers between 10 and 14 years old: in this age range, there were no mothers with less than three years of schooling in the private health system, while there were five mothers in this situation in the public system, two of whom had no educationthe expected level in this age range is from four to five years of schooling.These data indicate the need for public policies that stimulate the insertion of these young in school life, value school as an instrument of intellectual and social ascension, and avoid the evasion of those who are already inserted in the formal education process.The Pan American Health Organization (PAHO) appoints that adolescent pregnancy is an entrance door to poverty because it leads to a decreased set of social and economic possibilities, including school access (12) .The demands of the modern, industrialized and informatized world do not absorb this disqualified and non-prepared labor, which perpetuates the situation of poverty from the young to their children.
Because adolescents spend, on the average, five hours per day at school, it could be used as an important health promotion agent, since this population is a priority in the public policies directed at sexual and reproductive rights.Research (6,13) shows that, in the period between 2001 and 2002, 94% of Brazilian adolescents between 12 and 17 years old were registered in some teaching establishment, 54% of whom were male.The intervention in these adolescents at school has the advantage of also

DISCUSSION
In the municipality and period under study, a number of adolescent mothers eight times higher was computed in the maternities of the public health system.The UNICEF report shows that 62% of the Brazilian adolescents belonged to class C and only 2.5% to class A, between 2001 and 2002 (6) .This fact leads to a potential disparity regarding the access to health services, determining a higher number of adolescent mothers in the public service.In addition, Adolescent pregnancy: a comparative... Baraldi ACP, Daud ZP, Almeida AM, Gomes FA, Nakano AMS.
educating boys on contraceptive methods and reproductive rights, since health service actions for boys in this age are practically non-existent.The increase of education in the country, the incentive for Brazilians to follow formal education beyond the primary level present some immediate reflexes on the reproductive health of the whole population (4) .There are differences not only in these mothers' profiles, but also in the professionals' conduct and in the institutions' health policies.The type of birth to which the adolescents were submitted clearly shows this dichotomy.Studies (14)(15) show a high rate of c-sections in Brazil, mainly due to inadequate medical care, pregnant women's precarious education, causes of economic nature, among others.
This increase is progressive and exaggerated, and occurs especially among the socioeconomic favored classes, who attend private clinics and/or have health plans, while these indexes are lower among the economically less favored classes, whose deliveries mainly occur in public hospitals or teaching hospitals (14) .Table 3  of vaginal deliveries and 83.12% of c-sections.This proportion was also found for the deliveries of mothers between 10 and 14 years old.
It is important to appoint that the index of csections tolerated by the Ministry of Health is 15 to 20%, and that the current high rate of c-sections constitutes a public health problem, since it has led to higher rates of maternal and perinatal morbidity and mortality (16) .
The Ministry of Health recommends as ideal a minimum of six prenatal consultations, and stresses that the adherence of women to prenatal care is related with the quality of care delivered by the service and by the health professionals, which ends up being essential for the reduction of the elevated rates of maternal and perinatal mortality in Brazil (17)   .
We can note in table 4 that, although a majority of adolescent mothers attended seven or more prenatal consultations in both health systems, the percentage of mothers with a reduced number of consultation is higher among SUS users: there was no adolescent with less than six prenatal consultations in the group from 10 to 14 years old in the private system.In the public system, 28 of them (14.9%)attended between one and three consultations, and there were three mothers who did not attend any prenatal consultation.
Among mothers from 15 to 19 years old, a percentage 15 times higher did not attend prenatal consultations in the public health system (0.16% against 2.52%); 9.67% of SUS users in the same age range attended between one and three consultations, against 0.82% in the private health system.
Besides the young age in the first pregnancy, we can also note that some of these mothers go through more than one pregnancy during adolescence.In both systems, the majority of adolescents did not have previous children.However, there was a higher percentage of adolescents who

CONCLUSION
In both health systems, the adolescent users of the public system attend to less prenatal consultations, with less education and higher parity, normal deliveries are more frequent while, in the private system, the numbers of prenatal consultations, schooling, primiparity and c-section are higher.
already had children among public health service' users.It is remarkable that four adolescents between 10 and 14 years old in the public service, had from one to three children and mothers from 15 to 19 years old had from four to six previous children.These data confirm issues already discussed earlier, related to the direct proportional relation between poverty, low schooling, low adherence to prenatal care and early pregnancy, besides precocious menarche, very early sexual initiation, lack of resources and information regarding sexual life, reproductive rights, family planning and unprepared professionals and services to deal with a different clientele.

Table 1
(11.7%) occurred in private hospitals and 4,668 (88.3%) in public hospitals.The occurrence of eight liveborn infants (1.3%) was observed among 10 to 14 year-old mothers in private hospitals, against 188 (4.03%) in the public system.In the 14 to 19 yearold range, 4,480 (95.97%) births occurred in public hospitals and 610 (98.7%) in private hospitals.It is important to appoint that the percentage of births, in the 10 to 14 year-old range, is three times higher between SUS users.

Table 2 -
Distribution of liveborn infants of adolescent mothers in the public and private health systems according to the mothers' age and level of education, in a city in São Paulo State, between

Table 5 -
Distribution of liveborn infants of adolescent mothers in the public and private health systems according to the mothers' age and number of previous liveborn children, in a city in São Paulo State, between 2000 and 2002.
pregnancy: a comparative... Baraldi ACP, Daud ZP, Almeida AM, Gomes FA, Nakano AMS.Rev Latino-am Enfermagem 2007 setembro-outubro; 15(número especial):799-805 www.eerp.usp.br/rlaeIn addition, the State needs to exert a regulatory role in private initiative, so as to guarantee private health system users obstetrical care based on the principles of humanization and encouragement of normal delivery, in order to improve maternal and perinatal morbidity and mortality indexes.
training, so that they can provide adequate access to information, family planning, sexual health and reproductive rights, besides teams especially trained for this group's particularities, thus guaranteeing immediate reflections on the reproductive health of the entire population.Adolescent