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Revista Gaúcha de Enfermagem

versão impressa ISSN 0102-6933versão On-line ISSN 1983-1447

Rev. Gaúcha Enferm. vol.37 no.spe Porto Alegre  2016  Epub 05-Jun-2017

http://dx.doi.org/10.1590/1983-1447.2016.esp.2016-0029 

Original Papers

Pregnant teenagers’ group: contributions to prenatal care

Maria Veraci Oliveira Queiroza 

Giselle Maria Duarte Menezesa 

Thaís Jormanna Pereira Silvaa 

Eysler Gonçalves Maia Brasilb 

Raimunda Magalhães da Silvac 

a Universidade Estadual do Ceará (UECE), Departamento de Enfermagem. Fortaleza, Ceará, Brasil.

b Centro Universitário Estácio do Ceará, Departamento de Enfermagem. Fortaleza, Ceará, Brasil.

c Universidade de Fortaleza (UNIFOR), Departamento de Enfermagem. Fortaleza, Ceará, Brasil.


ABSTRACT

Objective

To describe changes in nurses’ care following the implementation of a group of pregnant teenagers in prenatal care based on the expectations and experiences of pregnant teenagers.

Method

Qualitative and descriptive study conducted from February to November 2013 at a Primary Care Unit in Fortaleza, Ceará, Brazil, through focus groups with 16 adolescents from the group of pregnant women in the second or third trimester of pregnancy. The analysis identified central ideas and units of meanings that formed the categories.

Results

The strategy of a group of pregnant teenagers, which provides a space for coexistence and the establishment of ties encourages these individuals to talk about their needs, re-signifying their ties. Educational strategies to promote self-care of pregnant teenagers and care for their babies involve the sharing of experiences, doubts and beliefs.

Conclusion

Considerations and suggestions of the adolescents contributed to guide nurses’ practice and provide a strategic space of care and support for pregnant adolescents in primary care.

Key words: Pregnancy in adolescence; Prenatal care; Primary care nursing; Health education

RESUMO

Objetivo

Descrever as mudanças no cuidado de enfermagem no pré-natal após a implementação do grupo de gestantes adolescentes norteado pelas expectativas e experiências de adolescentes grávidas.

Método

Estudo qualitativo, descritivo realizado de fevereiro a novembro de 2013 em Unidade de Atenção Primária de Fortaleza, Ceará, Brasil, através de grupos focais com 16 adolescentes do grupo de gestantes da unidade que estavam no 2º ou 3º trimestre de gravidez. Na análise, abstraíram-se ideias centrais e unidades de sentidos formando categorias.

Resultados

O grupo de gestantes adolescentes como espaço de convivência e vínculo estimulam-nas a falar suas necessidades do momento vivido ressignificando vínculos. As estratégias educativas na promoção do cuidado de si e do bebê promovem aprendizados entre adolescentes pelo compartilhamento de experiências, dúvidas e crenças.

Conclusão

As considerações e as sugestões das adolescentes contribuíram para nortear o enfermeiro no desenvolvimento do grupo e efetivá-lo como espaço estratégico de cuidados e apoio às adolescentes grávidas na atenção básica.

Palavras-Chave: Gravidez na adolescência; Cuidado pré-natal; Enfermagem de atenção primária; Educação em saúde

RESUMEN

Objetivo

Describir cambios en la práctica del enfermero después de la implementación del grupo de adolescentes embarazadas en la atención prenatal, la práctica guiada por las expectativas y experiencias de adolescentes embarazadas.

Método

Estudio descriptivo y cualitativo conducido desde febrero hasta noviembre, 2013 en la Unidad de Atención Primaria en Fortaleza, Ceará, Brasil, con 16 adolescentes del grupo de embarazadas que integran el 2º o 3º trimestre de embarazo. Del análisis se abstrajeron las ideas centrales y unidades de significados resumidas en las categorías.

Resultados

El grupo de adolescentes embarazadas como espacio de convivencia y lazos les estimulan a hablar sobre sus necesidades del momento vivido, resignificándolas. Estrategias educativas en la promoción del autocuidado y bebé promueven aprendizaje entre adolescentes, que son estimuladas por medio del intercambio de experiencias, dudas y creencias.

Conclusión

Consideraciones y sugerencias de las adolescentes contribuyeron para orientar la práctica de las enfermeras y brindar un espacio estratégico de atención y apoyo a las adolescentes embarazadas en atención primaria.

Palabras-clave: Embarazo en adolescencia; Atención prenatal; Enfermería de atención primaria; Educación en salud

INTRODUCTION

Adolescent pregnancy has been considered a worldwide public health problem for more than four decades due to its biological, psychological, economic, educational and family consequences that impact the socioeconomic and health indicators of a country1 In fact, teenage pregnancy was one of the factors that contributed to Brazil’s failure to achieve the fifth Millennium Goal that recommends reduction of global maternal mortality by 70%. The goal is now included among the Sustainable Development Goals and the world health officials have reinforced the need to improve health care practices for this population2.

Assistance to pregnant teenagers is usually provided at the Primary Health Care Units (UAPS), through prenatal appointments with nurses and physicians. Follow-up activities include guidance on specific aspects of gestation, self-care of pregnant teenagers and care for the infants aimed to reduce the risk of complications during pregnancy and delivery3 On the other hand, studies carried out in different Brazilian regions showed that prenatal care for teenagers still falls far short of what is recommended, especially with regard to guidance, to the ability to attract the target audience to the groups of pregnant teenagers at an early stage, and to the delivery of permanent care. Guidance/education activities are neglected because of the large number of tasks performed by health professionals and the limited time available for prenatal consultations4-5

Nevertheless, individual care in prenatal consultations may strengthen the link between health professionals and pregnant teenagers, focusing on their particular needs. However, prenatal consultations do not provide an opportunity for these young mothers to interact with their peers and learn from their experiences6 Although the group of pregnant women is considered a strategy that provides a space for health education, the traditional lecture-based instruction method, which is mainly a one-way method of communication is still prevalent6-7 Therefore, educational activities that stimulate the empowerment of pregnant women, through a mutual process of teaching and learning that encourages interaction and promotes the exchange of experiences among the peers is recommended3, 6 7

In the setting of the present study, activities related to guidance/ and education on self-care of pregnant women and care for their, pregnancy risks, breastfeeding and sexuality were frequently held for groups of pregnant women that involved women of all ages. However, teenagers did not actively participate in these meetings. Moreover, the UAPS where this study was carried out comprised a large number of pregnant teenagers, and despite the efforts of nurses and community health agents to attract them for prenatal visits on a timely basis and to convince them to participate in groups of pregnant women, attendance rates were low, and these young mothers often did not take the recommended prenatal tests, which increases their risks of complications during pregnancy.

During the individual consultations one of the researchers of the UAPS asked the pregnant teenagers to explain their low levels of attendance to the group activities. The reasons included lack of interest in the topics discussed and embarrassment of sharing their doubts and difficulties with the others. In view of the aforementioned, the following guiding question was proposed: Does insertion of pregnant teenagers in the process of implementation of these groups contribute to changes in the daily practice of nurses in prenatal care, minimizing gaps in the care provided to these young women?

It should be stressed that the topic teenage pregnancy and its coping strategies is one of the top priority research themes in health and nursing in Brazil 8 Thus, we hope that the sharing of the results obtained may guide other teams in the improvement of prenatal care practices, especially of nurses, in the construction of a “special” and customized care for pregnant teenagers.

Thus, the following objective was formulated: to describe changes in nursing care after the implementation of pregnant teenager’s group sessions in prenatal care, a strategy based on the expectations and experiences of pregnant teenagers that participate in educational activities.

METHODOLOGY

Qualitative descriptive study conducted in a Primary Health Care Unit (UAPS) in the city of Fortaleza, Ceará. In the referred unit, the pregnant women’s group approach, for women of all ages, was implemented in 2010. The group sessions were mediated by nurses.

Given the importance of addressing the needs of pregnant teenagers and the interest of the researchers in developing a study with this population, the study began in February 2013, and the groups were divided as follows: pregnant women’s group for women over 20 years of age and pregnant teenagers’ group. The sessions were monthly held for both groups, but on different days.

During the study, the pregnant teenagers’ group had six sessions. Initially, the needs of the young women were identified and the following themes were defined: common complaints of pregnant teenagers, healthy eating, type of delivery, signs of labor, breastfeeding and care of newborns. The technique of Focus Groups (FG) was selected to provide knowledge on the experiences of the participants and information for the research, as it favors interaction and encourages dialogue, facilitating the verbalization of doubts, taboos and prejudices, and the search for solutions to common problems 9

The sessions of the Focus Groups were held in October and November 2013, at the auditorium of the UAP, which is reserved for educational activities, with 16 teenagers At that time, 26 pregnant teenagers used to participate in the groups, and 22 of them met the selection criteria: gestational age between the second or third quarter and had participated in at least one meeting of the group until the day of information collection. However, six participants were excluded because they did not attend the sessions for the development of the focus group.

We held three meetings with an average duration of one hour and thirty minutes. The meetings were attended by a moderator (researcher), an observer (UPAS nurse who had not participated in the group sessions) and the participants, who were asked to talk according to the thematic guide, as follows: contributions of the pregnant women’s group for mother and baby care; motivation to participate in the group and suggestions for improvement. The information was recorded through voice and image recording and the corpus was thoroughly read, transcribed and the coded data was grouped into subcategories and categories in the results of the research 10

Formal consent was given by the participants and legal guardians 11 The study began after approval by the Research Ethics Committee of Universidade Estadual do Ceará, according to statement no 501.683. The subjects were invited to participate in the study and informed about the objectives of the study, participation, risks, benefits and on the guarantee of anonymity and freedom to accept or refuse to participate in the study. At the end of the presentation of the free and informed consent form, participants and/or guardians (for the minors) gave their consent. To ensure the anonymity of the respondents, their names were replaced by letter A (of adolescent), followed by an ordinal number from 1 to 16 and preceded by their age (Ex. A1, 19 years old).

RESULTS AND DISCUSSIONS

Participants were aged 14-19 years, seven of whom were single, five were married and four lived in a stable union with their partners. Ten teenagers were primiparous, three were expecting their second child, two were expecting their third child, and one was expecting her fourth child. Six of them had children and three had aborted in previous pregnancies. All participants had attended the minimum number of prenatal consultations recommended for their gestational age (3). Thirteen had more than six appointments, and three had attended fewer than five appointments, either in the second trimester or in the beginning of the third trimester.

The following categories contemplate the analysis of the formation of the group of adolescent pregnant women and part of their experiences and suggestions, incorporated in the practice of nursing care, particularly in the group of pregnant teenagers.

The pregnant women’s group approach as a space for coexistence and establishment of ties

The respondents described their experiences of participating in the pregnant teenagers’ group, perceived as a space for coexistence that brought them closer to the nurses and other pregnant teenagers. Sharing their experiences with peers make them feel safer and more comfortable to interact and express their feelings, expectations and doubts. In these groups, these youngsters feel encouraged to talk about their views, complaints and needs, as follows:

In the groups we talk to each other [...] we feel at ease, we let off steam and ask for the opinions of the others [...] I don’t feel embarrassed to express my views (A2, 14 years old).

I enjoyed talking to the nurses [...] they were very attentive and caring (A8, 15 years old).

Dialogue is essential in these groups where teenagers are supposed to interact among themselves and with the health professionals. Thus, health professionals must be able to listen to the reports of these young mothers and guide the discussion in an unbiased way12 Therefore, it is through attentive listening to the reports of these pregnant teenagers that a bond is established as well as collaboration to help these youngsters and their families cope with the issues of teenage pregnancy 7

The possible ways in which nurses may improve prenatal care include their availability and responsibilities towards the target population in basic care, which should favor a closer interaction and the establishment of bonds with pregnant teenagers7 Moreover, the expertise of nurses encourages the delivery of humanized and comprehensive care through care and educational practices that promote the health of pregnant women and the prevention of obstetric and neonatal disorders 13

Another report shows that teenagers find it difficult to establish a dialogue with health professionals during the prenatal visit, and the groups may facilitate this dialogue.

Most medical consultations are very short ... [...] so we often forget to clarify some doubts ... In the groups we can express all our doubts (A15, 16 years old).

Other studies also report the persistence of the biomedical paradigm in prenatal care practices, with the implementation of traditional lecture-based educational activities merely aimed to convey information and make recommendations that are not consistent with the reality and do not meet the specific needs of the target population5-6 The lack of a space for active communication and interaction between health professionals and pregnant women creates obstacles to the development of appropriate prenatal care 7 Some authors claim that the bonds established in prenatal care may provide sufficient confidence to maintain the care cycle during child-care consultations 13 Therefore, the importance of ensuring the pregnant women’s groups in the UAPS was perceived as a strategic tool for approaching and caring for pregnant teenagers.

The experience of early pregnancy/mothering usually has greater impact on young women who do not count on the support of their families/or companions and facing the judgments made by the others12 Poor coping skills may lead teenagers to neglect self-care and the care for their babies, refusing to attend prenatal care appointments and, thus, contributing to biopsychological and social vulnerabilities14

A study with 430 pregnant teenagers found that one in three pregnant teenagers experienced psychological distress associated with low social class, school repetition, poor relationship with their mothers, non-acceptance of the pregnancy by the partner, and lack of family support, which reinforces the need for strategies aimed to address the emotional aspects of pregnant teenagers to prevent possible damage to the young mothers and their babies 15

A blinded randomized controlled trial with 106 North American primiparous pregnant teenagers revealed that interventions performed during prenatal care may reduce the risk of postpartum depression. In the therapeutic approach of these youngsters, the REACH (Relaxation, Encouragement, Appreciation, Communication, Helpfulness) program was used. Its content is focused on the development of effective communication, skills to manage relationship conflicts before and after the baby’s birth, expectations about maternity, stress management, development of a healthy support and relationship system, establishment of goals and psychosocial resources for mothers 16

A recent theoretical model constructed by specialists in early pregnancy/mothering showed that this is a difficult experience even for teenagers who count on social, family and financial support, and stressed that health services should also operate as support networks 17

I loved the group sessions... The nurses were very attentive and devoted to us [...] invitations, snacks [...] they were committed to clarify all our doubts during (A13, 18 years old).

My mother has already accepted my pregnancy, but she does not talk much with me. I rarely see my classmates. Here I feel comfortable to talk about myself ... share my experiences, because other girls have already gone through this and help us face the situation (A14, 16 years old).

When health professionals take into consideration the social and cultural context of these young patients, they are more likely to recognize health services as a reference network of support 15 In the present study, this was expressed in the statement of a young woman who recognized the importance of maintaining the pregnant women’s groups. The referred teenager highlighted the role of the group on her support network, since the meetings helped her express her feelings and needs, motivating her to care for herself and for her infant.

The group should be maintained, especially for those pregnant women in their first gestation [...] I would have enjoyed participating in this pregnant women’s group when I was expecting my first child (A3, 18 years old).

The results obtained with the use of Focal Groups were presented to the coordination staff and all the employees of the UAPS, and they recognized the importance of this strategy to pregnant teenagers. There is now greater integration between the members of the multidisciplinary team, with emphasis to nurses, physicians and dentists who are in direct contact with the teenagers. Over the past three years, the group strategy has grown and is the sessions are permanently held as part of the monthly UAPS’s prenatal care monitoring plan, on the last Wednesday of every month, at the auditorium of the unit.

Consistently with the recommendation of the Ministry of Health (3) that health services should develop their own mechanisms to attract pregnant teenagers to prenatal counseling services at an early basis, a prenatal monitoring and incentive system was implemented through the use of cards: each medical consultation, exam or educational activity attended by these patients would earn points and make her eligible to win a baby outfit. The prizes were delivered monthly during the sessions of the group. This strategy has increased attendance to prenatal consultations and stimulated voluntary participation in the group’s activities.

Educational strategies for self-care and care for the babies

Primiparous women usually face more challenges related to physical, psychosocial and newborn care, especially in the immediate postpartum period. Thus, the authors emphasize the importance of the use of educational technologies by health professionals to help these women adapt themselves to the new role 18

The pregnant teenagers said they felt insecure and unable to provide appropriate care for their infants. Therefore, they wanted to guidance on how to bathe, change diapers, clean the umbilical stump and breastfeed. Discussing these themes in educational activities seemed to reduce anxiety and prepare them for the challenge of caring, since most of them are expecting their first child.

I think I am now more able to take care of my baby on my own [...] participating in the group made me feel more confident ... before these sessions I did not know how to breastfeed or hold the baby (A11, 19 years).

Girls who are expecting their first babies should attend these groups to learn how to care for them (A15, 19 years old).

The group was considered a space for discovery and learning even by the teenagers who had children because they received guidance, clarified their doubts and some beliefs and taboos were demystified.

I did not breastfeed my first child. I did not have any help ... my nipples were sore, and so I had to give up breastfeeding. However, I learned that this is caused by incorrect positioning during breastfeeding. Now it will work, and I want to breastfeed (A6, 17 years old).

The exchange of experiences between individuals who face a common situation empowers he subjects through the mutual process of teaching and learning7,9,12. This strategy has been incorporated into the activities of the pregnant women’s groups and was well received by the participants. On the other hand, it is known that these pregnant teenagers are strongly influenced by their family culture15, 18 Thus, participation in activities mediated by trained health professionals who can stimulate debate and reflection on cultural issues may provide these youngsters with a greater ability to make sound decisions and promote self-care and care for their babies.

According to the teenagers, the nurses were effective mediators and stimulated debate and reflection on the participants’ experiences and on their current situation. Those who had children shared their experiences with the primiparous women, helping them clarifying some doubts. The implementation of interactive activities that promote contact between pregnant teenagers seems to be an excellent strategy for identifying the needs and demands of this population. For some authors, this dynamics operates as a production network, which must be stimulated by health professionals in their routine practices 19

Therefore, the exchange of knowledge and experiences was welcome by the participants and ensured group dynamism, facilitating learning. The incorporation of this result into the practice of nurses at the UAPS where the study was conducted contributed to change the logic of the traditional pedagogy, characterized by the traditional one-way communication method of transferring information to women during pregnancy and the postpartum period6

Raising young women’s awareness about the importance of their role as caregivers is an important educational initiative promoted by health professionals at the UAPS aimed to help pregnant teenagers develop the necessary skills to provide care for their infants13

I really enjoyed the video about breastfeeding because it made it easier to understand the procedure (A9, 18 years old).

I liked the video because they used a doll to explain to us how to hold the baby and change the diaper (A11, 19 years old).

The results of the Focal Groups also indicated the need for investment in educational activities targeted to teenagers’ self-care. The use of audiovisual resources and the technique of dramatization were incorporated into the activities developed at the pregnant women’s groups to convey information on pregnancy, healthy life habits and the recognition of signs of labor or complications during pregnancy.

Participating in the group was the most effective way to cope with my pregnancy .. I am now aware of the importance of self-care and on the need to eat healthy foods... I am more able to control my weight (A13, 18 years old).

A frank and open dialogue is expected among the teenagers and the nurse professionals during the group sessions to encourage these young women to exchange their experiences, and sometimes, a more customized support is necessary 14

The considerations and suggestions provided by the participants were essential for the planning of the educational practices targeted to this population, which involve the use of technology strategies.

After these group sessions the health professionals became aware of the importance of using interactive activities to transfer information to the pregnant teenagers, rather than the traditional lecture-based instruction method. In turn, the teenagers showed greater interest and commitment with prenatal care activities.

Unfortunately, although peer-group activities is widely used throughout the world with pregnant adolescents, there is no high-level of evidence to support that this strategy effectively improves the parental skills of teenagers 20 Based on a practical evaluation, the group strategy apparently encourages awareness of the maternal role among pregnant teenagers and, of the responsibilities involved. However, further studies on the efficacy of these pregnant women’s groups are needed.

FINAL CONSIDERATIONS

The group dynamics with pregnant teenagers in the space destined to prenatal care favored greater interaction between health professionals and these young mothers, which resulted in suggestions that guided the planning and the implementation of the pregnant teenagers’ group of at the UAPS.

One limitation of the study is that its findings suggest the need for longitudinal studies on the impact of group activities on obstetric and neonatal outcomes. However, the important contribution of this study is the sharing of experiences in a strategic space of care and support for pregnant teenagers in prenatal care, which associates the theoretical and practical knowledge of nurses with the experiences, needs and suggestions of the teenagers.

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Received: December 10, 2016; Accepted: April 04, 2017

Corresponding author: Thaís Jormanna Pereira Silva. E-mail: thaisjormanna@hotmail.com

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