Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 14 nº 3 - Jul/Sep - 2017

Original Article Imprimir 

Páginas 54 a 62


Difficulties and challenges of prenatal care under pregnant adolescents' perspective

Dificultades y desafíos del pre-natal bajo la perspectiva de las adolescentes embarazadas

Dificuldades e desafios do pré-natal sob a perspectiva das adolescentes grávidas

Autores: Magali Motta1; Melissa Paiva de Jesus2; Flávia Regina de Moraes3

1. Specialty in Obstetric Nursing and Social Obstetrics, São Paulo Federal University (Unifesp). São Paulo, São Paulo State, Brazil. Lecturer and Welfare Nurse, ABC Medical School (FMABC). Santo André, São Paulo State, Brazil
2. Graduand in Nursing, ABC Medical School (FMABC). Santo André, São Paulo State, Brazil
3. Graduand in Nursing, ABC Medical School (FMABC). Santo André, São Paulo State, Brazil

Melissa Paiva de Jesus
Rua Fascinação, 278, bloco 04, Apt. 43, José Bonifácio
Itaquera, SP, Brasil. CEP: 08257-080
melissapaivaj@hotmail.com

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How to cite this article

Keywords: Pregnancy, pregnancy in adolescence, prenatal care.
Palabra Clave: Embarazo, embarazo en la adolescencia, cuidado pre-natal.
Descritores: Gravidez, gravidez na adolescência, cuidado pré-natal.

Abstract:
OBJECTIVE: Characterize the pregnant adolescents attended in prenatal Teen Clinic, and analyze compliance of pregnant teenagers to prenatal care in a health facility at ABC Paulista region.
METHODS: This is a quantitative exploratory research. Data were obtained by means of a structured questionnaire containing 19 questions. Teenagers attended voluntarily by signing the consent form. Data were tabulated by Epi Info version 3.5.1 software and for data illustration it was used Excel 2013.
RESULTS: Regarding adolescent compliance to prenatal care, 81.5% haven't missed the appointments, initiated it in the first quarter of pregnancy (66.6%) and reported the distance as a major complicating agent (33.3%). The average of age was 16.1 years old, predominantly single (66.7%) and had more than 8 years of study (70.4%). Gestational profile of teenagers showed that 96.3% were in the first pregnancy.
CONCLUSION: The low rates of absence can highlight the positive acceptance of a specialized service, as it offers a more directed care to the difficulties faced during this period.

Resumen:
OBJETIVO: Caracterizar a las adolescentes embarazadas atendidas en el Ambulatorio de prenatal de Adolescentes y analizar la adhesión de las adolescentes embarazadas al prenatal en un servicio de salud de la región del Grande ABC Paulista.
MÉTODOS: Consiste en un estudio cuantitativo, mediante la técnica exploratoria. Los datos fueron captados a través de un formulario estructurado conteniendo 19 preguntas. Las adolescentes participaron de espontánea voluntad a través de la firma del término de consentimiento, los datos obtenidos fueron tabulados a través del software Epi Info versión 3.5.1, para ilustración de los datos se utilizó Excel 2013.
RESULTADOS: Con relación a la adhesión de la adolescente al prenatal, 81,5% no faltaron a las consultas, iniciaron el mismo inclusive en el primer trimestre de gestación (66,6%) y relataron la distancia como principal factor de dificultad (33,3%). El promedio de edad fue de 16,1 años, predominantemente solteras (66,7%) y poseían más de 8 años de estudio (70,4%). El perfil gestacional de las adolescentes mostró que el 96,3% eran primerizas.
CONCLUSIÓN: Los bajos índices de falta pueden dejar en evidencia la aceptación positiva de un servicio especializado, por ofrecer un servicio más dirigido a las dificultades enfrentadas en ese período.

Resumo:
OBJETIVO: Caracterizar as adolescentes grávidas atendidas no Ambulatório de pré-natal de Adolescentes e analisar a adesão das adolescentes grávidas ao pré-natal em um serviço de saúde da região do Grande ABC Paulista.
MÉTODOS: Consiste em um estudo quantitativo, mediante a técnica exploratória. Os dados foram captados através de um formulário estruturado contendo 19 questões. As adolescentes participaram de espontânea vontade através da assinatura do termo de consentimento, os dados obtidos foram tabulados através do software Epi Info versão 3.5.1, para ilustração dos dados utilizou-se Excel 2013.
RESULTADOS: Em relação à adesão da adolescente ao pré-natal 81,5% não faltaram as consultas, iniciaram o mesmo ainda no primeiro trimestre gestação (66,6%) e relataram a distância como principal dificultador (33,3%). A média de idade foi de 16,1 anos, predominantemente solteiras (66,7%) e possuíam mais de 8 anos de estudo (70,4%). O perfil gestacional das adolescentes mostrou que 96,3% eram primigestas.
CONCLUSÃO: Os baixos índices de falta podem evidenciar a aceitação positiva de um serviço especializado, por oferecer um atendimento mais direcionado as dificuldades enfrentadas nesse período.

INTRODUCTION

Brazil´s Ministry of Health follows the World Health Organization definition of adolescence as the period between 10 and 19 years of age. This is a stage of human development characterized by physical, mental and social alterations1, as the time between childhood, while still not yet being adult. We may thus say that adolescence conveys the idea of transformation, ushering in a life process that contributes to autonomy and responsibility2. As this is a very special period for the construction of individuals and their insertion into society, it must also be viewed as a time of risk and vulnerability3.

The attitudes, habits and behaviors that shape the lives of adolescents and young people are still being formed and shaped. The values and behaviors of friends become increasingly important, as youngsters move naturally away from their parents towards greater independence, paving the way for exploring new experiences that may include drugs, alcohol, sexual initiation and teen pregnancy1-4.

Becoming sexually active is accompanied by doubts and curiosity and, although there is plenty of information available, youngsters do not always feel comfortable about seeking out details. The search for information is often channeled through peers who are already sexually active, sharing their experiences, creating "theories" and mystifying sexual intercourse with "truths" built up empirically5,6. Early sexual initiation without proper knowledge carries risks of sexually transmitted diseases and unwanted pregnancies. There are many reasons for pregnancy before reaching twenty years of age; some girls become pregnant due to a lack of knowledge or poor contraception, which may be understood as a function of the specific characteristics of this time of exploring their sexuality, involving gender-related negotiations, in addition to difficulties in coping properly with contraceptive methods. Added to this is widespread ignorance of the physiology of reprodution6.

Pregnant girls are rated as high-risk, not only at the medical level, but also due to biological factors related to immaturity, age, non-existent or poor prenatal care and diseases linked to low economic status, together with social and cultural factors4.

For the Brazilian Ministry of Health, the phenomenon of teen pregnancy is rated as high-risk due biological and social complications and social factors looming over these young mothers and their babies. Girls under 14 years of age are subject to a higher risk of death during pregnancy, while their babies are often pre-term and low-weight1.

Oversight is essential for maternal and fetal health in any pregnancy. To do so, prenatal care is required, which consists of monitoring by physicians and nurses during pregnancy, in order to avoid problems for mother and child during this time, as well as during birth7,8.

Healthcare practitioners play an important role in listening to their needs, and should allow them to express the feelings emerging from their experiences of pregnancy in ways that underpin relationships of trust. This avoids prenatal care becoming an exchange of multiple fragmented information and demands, as one of the purposes of healthcare for this group is to pave the way for constructing favorable conditions that make these girls feel welcome and comfortable for coping with the experiences of pregnancy, birth and motherhood in ways that buttress their own health and that of their babies (Bahia, Bahia State Health Bureau, apud Melo and Coelho 2011)7.

During prenatal care, at least six appointments are required, preferably one during the first trimester, two during the second trimester and three during the final trimester. Routine tests must be run, including hemogram, fasting blood sugar, type I urine, serology for toxoplasmosis, German measles, hepatitis B and Human Immunodeficiency Virus (HIV), as well as Rh isoimmunization and obstetric ultrasound examinations. Except for the obstetric ultrasound examinations, all the other tests must be run during the first prenatal appointment and at the 30th week of pregnancy. More frequent visits as pregnancy draws to a close are intended to assess perinatal risk and the clinical and obstetric occurrences that are more common during this trimester, such as early labor, pre-eclampsia and eclampsia, preterm pre-labor amniorrhexis and fetal death 7,8.

Signing up for prenatal care is often delayed, as much of this population lives in poverty-stricken outlying urban areas that are home to low-income families with little schooling, where confirmations of teen pregnancies trigger a broad range of reactions: acceptance by partners, families and friends; changes in routines and habits; self-care responsibilities that must be accepted, as well as for the fetus, with massive psychological and physical impacts. The explanations most frequently given by pregnant girls for avoiding prenatal care include rejection of their pregnancies and fear of the social consequences of being pregnant9. Compliance with prenatal care is often patchy as well: skipping visits and resisting new routines are attitudes that have been noted4. Healthcare facilities must be strategically available and well prepared to welcome and accept these pregnant youngsters8.

Teen pregnancy gained a high profile as a public health problem from the 1970s onwards, as fertility rates rose proportionally among girls up to 19 years of age or less8. The specific fertility rate of youngsters between 15 and 19 years of age rose by 25% between 1991 and 2001 in Brazil, and then began to drop from the year 2000 onwards. The contribution to the total fertility rate made by the specific fertility rate for women between 15 and 24 years old (throughout all the childbearing years) rose from 34% in 1980 to 53% in 2006. This upsurge was due mainly to an upsurge in the relative share of the fertility rate for girls between 15 and 19 years of age, which soared from 9% to 23% during the period1.

Due to rising demands for teen pregnancy services, the Santo André Municipality set up a specific out-patient clinic in January 2014 just for pregnant teens, with a multi-disciplinary staff consisting of an obstetrician, an adolescent care physician, a nutritionist, a psychologist, a social worker and a dentist. At every appointment, girls attend lectures on breastfeeding, birth, dropping out of school and family planning, with attendance noted in their medical records. Conducting group sessions encourages them to exchange experiences with easier approaches, as their profiles tend to be similar10, with little schooling, low income, unstable relationships with their partners, and sometimes multiparas. This highlights the need for closer attention to this highly vulnerable segment of the population6.


OBJECTIVE

To identify difficulties faced by pregnant teens in complying with prenatal care requirements, characterizing pregnant teens seen at the Teen Prenatal Out-Patient Clinic and analyzing their compliance with prenatal care at a healthcare facility in the ABC Region of Greater São Paulo.


METHODOLOGY

The method used in this study is quantitative and exploratory, collecting primary data through a form with nineteen structured questions. Its population consists of pregnant teens signed up for prenatal care at the Teen Prenatal Out-Patient Clinic at the Capuava School Healthcare Center in Santo André, at any stage in their pregnancies. The girls included in this study were those receiving prenatal care at this clinic at the time the data were collected, excluding those who were unwilling to participate in the study.

The form was validated by three people who were not experts in the matter, in order to assess the clarity of this instrument, prior to collecting the data, which was then processed through the Epi Info version 3.5 and Excel 2013 software.

This project was submitted to the Research Ethics Committee for Research Involving Human Beings at the ABC Foundation, affiliated to the National Research Council Involving Human Beings, approved under CAAE Nº: 45927715.0.0000.0082.


RESULTS

Table 1 shows that 29.6% of these adolescents were under 15 years of age, with most of them (70.4%) between 16 and 18 years old, with a mean age of 16.1 years. Most (55.6%) were black, with 11.1% having completed their primary schooling and 51.9% dropping out of school when discovering that they were pregnant. Most (85.2%) of them were not employed in paid jobs and 22.2% were unable to state their family incomes, while among those answering this question, most (70.4%) mentioned incomes of up to 3 minimum wages.




As shown in Table 2, this was the first pregnancy for 96.3% of these adolescents, with a significant 85.2% of them unplanned. However, for 14.8%, their pregnancies were planned, which is unexpected at this stage of life.




Table 3 shows that 81.5% of them lived with their parents before becoming pregnant; once their pregnancies were confirmed, 33.3% began to live with their partners. It is also stressed that 7.4% received no support from their families, and 3.7% were not backed by their partners. Although the lack of family support for these girls ranked higher than the absence of their partners, good support levels were posted for both aspects.




Table 4 shows that 81.5% of these adolescents never skipped a prenatal appointment, which is a positive factor, as many of them live in remote neighborhoods with difficult access (as seen in Table 4). According to Table 5, 37% of them encountered difficulties in receiving prenatal care, with 33.3% of these difficulties related to distance.






DISCUSSION

In this study, the mean age of these adolescents was 16.1 years, although it must be borne in mind that the age bracket between 10 and 19 years of age is very broad, with pregnancy being very different for a 14-year-old girl or a young woman 18 years of age11. The literature shows that the highest teen pregnancy rates are found among the black segment of the population12,13,14,15,16,17, which is also confirmed in this study, with 55.6% of its respondents self-declaring as black.

Studies have found that higher education levels are linked to lower teen pregnancy rates, which contradicts the data in this study, of 70.4% of these girls had spent more than eight years in school, and 66.7% of them used the internet to communicate. However, there was a high drop-out rate (51.9%) which steps up the probability of the persistence of social and economic gaps for this segment of the population11-17.

When replying to the question on family income, they hesitated, with 22.2% unable to reply. Among those who answered, 70.4% mentioned family incomes of less than 3 minimum wages, indicating that this is a group with low purchasing power17,18. The fact that so many of them were unaware of family incomes reflects their limited involvement with the material realities around them and their own upkeep. The fact that they are not engaged in paid work (85.1%), together with the high school drop-out rate and low schooling levels indicate little likelihood of finding a job on an increasingly more competitive work market and, should they do so, it will be poorly paid. This will probably mean that they will be dependent on their parents and partners throughout their lives, as opportunities for social insertion and becoming upwardly mobile in economic terms are opened up through the education system, particularly in this age11-17.

Most (85.2%) of the adolescents did not plan their pregnancies, with this high figure reflecting the fact that adolescents are becoming sexually active at increasingly younger ages, often neglecting to use contraceptives, particularly condoms. In addition to paving the way for pregnancy, this also exposes them to sexually transmitted diseases11-12-14-16-18. Even if adolescents endowed with reasonable schooling levels and at least minimal knowledge of sexuality, they are unable to transpose this information into changes in their behavior and safe sex10,11. However, other studies have shown that the lack of sex education in schools and family planning programs at government health clinics are factors that may foster the appearance of unwanted pregnancies11-17.

The occurrence of more than one pregnancy during adolescence (3.7%) is ranked as a major problem, reflecting irresponsible sexual behavior and the inability to break away from a vicious circle, in addition to problems deriving from only brief gaps between births, greater likelihood of low-weight newborns, and very often imposing psychological overloads on adolescents who must frequently care for their homes, their partners and two or three children11-18. Although planned pregnancy is not expected during this life stage, it was reported by 14.8% of the respondents, indicating that eagerness to become a teen mother may be related to the wish to feel more of a woman, as this is a time of transition when girls move away from being daughters towards becoming mothers, tying down their boyfriends, getting out of school or away from their parents´ homes as a way of showing their independence, or even giving more meaning to an empty life10-11-18.

Table 3 shows that a high (59.3%) number of girls continue to live with their parents after confirmation of their pregnancies. This reflects a direct link between unstable relationships with their partners, age and the inability of these youngsters to support themselves financially, as they continue to live with their parents while pregnant, remaining financially dependent on them and often frustrating their own quests for freedom and independence11.

In terms of the support received by these adolescents for their pregnancies, they are generally backed by their families and partners (92.6% and 96.3% respectively), with less family support (7.4%), which is not commonly found in other studies9. However, some projects state that positive family reactions and backing for pregnancy may be a factor underpinning repeat occurrences, in addition to living with partners (33.3%), which is a situation also found in this study18.

Setting up programs that encourage full compliance with prenatal care schedules is beneficial, as pregnant girls seen regularly at clinics have fewer diseases and their babies present better intra-uterine growth, with lower perinatal mortality and infant death rates. The number of prenatal appointments is also directly related to better mother-child health indicators19.

The Stork Network (Rede Cegonha) is a strategy launched by the Brazilian Ministry of Health that is intended to implement a care network that endows women with the right to reproductive planning and humane care during pregnancy, birth and the puerperium, in addition to guaranteeing the right to safe birth for their babies followed by healthy growth and development. This strategy is intended to structure and organize mother-child healthcare in Brazil13.

In 2006, the Paulista Mother´s Protection Network was set up in the São Paulo Municipality, as a strategy aligned with the Stork Network principles in order to provide care for pregnant women, ranging from at least seven prenatal appointments through to birth and the puerperium, continuing through to the second year of life of their babies. Pregnant women receive travel vouchers to ensure that they make all their appointments and tests, through a travel card with credits released as required for its use, after assessment during appointments with doctors, as well as a kit with clothes for their newborn babies after giving birth. During the six years of this program, 98% of registered pregnant women were monitored through to the end of their pregnancies20.

Among the respondents in this study, 81.5% said that they had never skipped a prenatal appointment, with this situation also reflected in other studies, rated as very positive11-18. This may be explained by the fact that they are seen at an outpatient clinic set up specifically for pregnant teens, with individual appointments and also group sessions with other girls sharing similar concerns and characteristics. This helps them cope more easily with difficulties that may hamper the smooth progress of their appointments, in addition to soothing concerns over biological aspects related to pregnancy11.


CONCLUSION

Teen pregnancy is today a public health problem, due to the large number young mothers giving birth. This research project led to a better understanding of factors encouraging and hampering compliance with prenatal care and acceptance of the specialized clinic. The care provided at this specialized facility reflects positive acceptance by patients during their appointments, as once they sign up for prenatal care, the number of missed appointments was low, despite difficulties related to distance reported by one third of these adolescents.

The sample of these adolescent respondents reflects the profile of the patients receiving care: unmarried, mainly living with parents, more than eight years of schooling, but with some drop-outs after confirming pregnancy, and most of them not engaged in paid work. First pregnancies constitute a common factor among these adolescents.

Due to strong compliance at this specialized outpatient clinic, it makes sense to suggest that these services should be expanded in basic healthcare clinics at strategic locations, in order to build up stronger links with these girls, as distance was reported as one of the main hurdles hampering prenatal care. By decentralizing these facilities, this care would become more accessible; alternatively, until these facilities are more widely available, transportation options should be provided to the reference center.


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