RESEARCH ARTICLES

Care to pregnant adolescents: perspectives and performance of community health agentes

Maiara Paixão de Oliveira^I; Nayara Mendes Cruz^II; Laísla Alves Moura^III; Jaqueline Gonçalves Moura^IV; Rodrigo Mendes Nonato Coelho^V; Mônica Cecília Pimentel de Melo^VI

^I Nurse. Graduated by the Federal University of Vale do São Francisco. Petrolina, Pernambuco, Brazil. E-mail: maiara.italo@hotmail.com
^II Gradute student in Nursing, 7º semester by the Federal University of Vale do São Francisco. Petrolina, Pernambuco, Brazil. E-mail: blaymendes@hotmail.com
^III Graduate student in Nursing, 7º semester by the Federal University of Vale do São Francisco. Petrolina, Pernambuco, Brazil. E-mail: laislaalves19@gmail.com
^IV Graduate student in Nursing, 7º semester by the Federal University of Vale do São Francisco. Petrolina, Pernambuco, Brazil. E-mail: enf.jaquelinemoura@gmail.com
^V Graduate student in Nursing, 7º semestre by the Federal University of Vale do São Francisco. Petrolina, Pernambuco, Brazil. E-mail: rodrigo.coelho.mendes@gmail.com
^VI Nurse. Professor of the Federal University of Vale do São Francisco, Women´s And Gender Health Area. Master degree in Nursing. Ph.D. in Nursing by the Federal University of Ceará. E-mail: monquinamelo@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2015.15580

ABSTRACT

Out of their training, community health agents must have incorporated concepts that value the needs of pregnant adolescents. This study aims at analyzing the care to pregnant teenagers through the perspective and performance of community health agents. This is a qualitative, exploratory and descriptive study, with agents that assisted pregnant adolescents. Five semi-structured interviews were conducted and followed up by notes in field journal, from September to October, 2010, in Juazeiro-BA, Brazil, on the basis of Bardin's content analysis. As health professionals, agents were found to have quite a few difficulties due to their insufficient skills resulting from lack of permanent education strategies. The fact they were community members proved to be decisive in the creation of links with the teenager. It must be highlighted that the subjects endeavor to give care despite the hindrances they come across.

Keywords: Family health; pregnancy; adolescence; nursing.

INTRODUCTION

Pregnancy during adolescence is a challenge in the socio-political and economic environment in Brazil, because of the implications for the health system and education, associated with social, biological and personal risks that compromise the development of the adolescent and the child¹. This association prevails to the present day, and the concept of risk and vulnerability is disclosed by the obstetric medicine, without worrying about the context in which the pregnancy occurs, covering economic, social and cultural factors, among whom the gender relations are realized².

When seeking to promote care actions to pregnant adolescents, the Ministry of Health³ focuses on strategies that value human relationships, the production of links, the reception and user autonomy in care. This care model prioritizes the multidisciplinary work in which all must be identified with a proposal of care that requires creativity and initiative for community and group work⁴.

Community health agents (ACS) have a very specific role that distinguish them from other team members. They intimately know the local reality because they are part of the community. They represent an opportunity to bring into the health teams the view of the population, revealing needs from a different point of view and, therefore, opening the door to a new universe of interventions⁵.

Therefore, starting from the principle that the ACS through the Family Health Strategy (ESF) must incorporate in their training, concepts that value women´s needs, with care actions, especially the care of pregnant adolescents. This study seeks to answer the following research question: What is the perspective and actions of the community health agent, inserted in the ESF, about adolescent pregnancy care?

It was tried to analyze the care of pregnant adolescents through the perspective and actions of community health agents.

LITERATURE REVIEW

Every user of the health service, regardless of socio-economic-cultural profile, seeks a chance of listening and resolution of their problems by the health professional. The users want to be accepted, guided, understood in their needs, as well as feeling confident that they are safe and well supported. Compared with adolescents, most of them feel shame, fear of being reprimanded and intimidated by the professional, making a difficult attitude seeking a health unit, needing some kind of courage⁶.

For this reason, it is essential that adolescents feel comforted and respected, so they can trust and get the information they need through a reliable source, and not by the media or friends, as many of them get it, usually obtaining the information incorrectly⁷.

The ACS has a fundamental role in bringing adolescents to the basic health units (UBS). During their home visits the agent should encourage adolescents to seek the reference UBS before any problems or questions, informing them of the existence of specialized services and activities that occur and are directed for this group. It is necessary to remember that many adolescents stop seeking help and/or treatment because they unaware the services offered to them and fear the kind of reception they can find in UBS⁷.

The ACS needs to be aware of pregnant adolescents in the community and guides them about the importance of prenatal care and where they can do it. Group activities can be organized to work issues such as adolescent pregnancy, breastfeeding, immunization, STD, family planning, among others, not only for these future mothers but for all adolescents. When they are in group adolescents feel more secure and confident to interact with others and expose their questions to colleagues and to the coordinator, which can be a health professional, including the ACS⁸.

It is important that there are groups of adolescents and young people in specific situations of diseases, which should be prioritized in health care. This requires the development of different strategies, such as the creation of integration mechanisms with the institutions that deal with these groups ⁹.

METHODOLOGY

This is a qualitative study of descriptive character. It was held at the Health Unit of Tabuleiro Family, in Juazeiro city - BA. The sample consisted of five community health agents who were monitoring pregnant adolescents, from 10 to 19 years old, in any pregnancy trimester period and enrolled in prenatal care. They should be working in the community for more than a year, important for the research to create bonds with the pregnant woman. Those who agreed to participate should sign the free and informed consent (TCLE). Subjects were excluded if they refused to participate in the research, with less than 1 year of participation in the community, not monitoring pregnant adolescents in their area and/or people with special needs that could interfere with the interviewee-interviewer communication.

The data collection period was in September and October 2010, after approval by the Ethics Committee in Research of the Federal University of Vale do São Francisco (UNIVASF) under Protocol 0038.0.441.441-10. To ensure anonymity of respondents, they were identified by numbers, according to the order of the interviews.

To data collection, first, the ACS were invited to participate in a conversation circle, providing the research objectives and answering their doubts. Schedules were made to monitor the home visits conducted by the ACS because at this stage, the non-participant observation and unstructured was used as a collection instrument, recorded in the form of a field journal, which contained some socioeconomic and obstetric data of the pregnant woman, provided by the ACS. The number of visits observed for each ACS depend on the quantity of pregnant adolescents that they had in their operating location during the collection period. Thus, it was trying to cover a larger universe of the studied object.

Right after the visit, the semi-structured interview was proceeded, in which data were recorded on audio and transcribed in full, only with spelling and language vices corrections without losing the essence of the speeches. Data analysis was based on Bardin¹⁰ content analysis with results interpreted to be meaningful and valid.

RESULTS AND DISCUSSION

The age of the women ranged from 15 to 18 years old. Regarding the level of education, one of them had completed high school; one incomplete high school and was studying; three incomplete elementary school, and one stopped studying in 8^th grade. Four of them remain with their partners and only one was single. The predominant color/ethnicity was brown skin. It was observed a case of pregnant women miscarriage among the visited ones.

Among the ACS participating in the study, all had completed high school and were married. They were from 30 to 42 years old, operating time ranging from 2 to 18 years. The religion that prevailed was Catholic, and only two had training option in adolescent health.

The contents of the interviews and observations collected with ACS were divided into categories and subcategories for better verification of the results.

ACS's role in dealing with pregnant adolescents

This category includes two sub-categories analyzed below.

Care during pregnancy and prepare for motherhood: technology prevalence

In this subcategory, care guidelines during pregnancy and prepare for motherhood of the pregnant adolescent were found made by the ACS, based on technical assistance, such as care with vaccines, prenatal consultations, weight control and blood pressure, prenatal booklet, prevention of obstetric complications, among others.

For me, it is to guide future mothers the right way to how to take care of the child and also guide them that she has the proper care during pregnancy, so she cannot have future problem, for example, vaccines, fetus monitoring done by the nurse, I think that's it. (Interview 1)

Here, there are the observations of the field diary:

The ACS goes to the pregnant woman´s home; asks how the mother is; adds the data from pregnant women to his record A; asks of consultations with the nurse, what she said; weight. He also asks of the mother´s record; talks about the importance of prenatal care; look at their records of vaccines, blood pressure; asks whether she's feeling something, some pain, complaint. He spoke of the number of prenatal visits, asks if she's taking folic acid and ferrous sulfate and the mother replies that is taking. He guided for the use of folic acid in the morning; the use of a topical oil to prevent stretch marks on the abdomen. He guides also to breastfeed the baby and the baby has to stay close to her mother, without having to stay on top of the baby and she must be attentive to vaccines and prenatal consultations and if she feels something she needs to look for the unit. (Observation 1)

During a home visit, in this report and observation mentioned, it is confirmed that the clinical model is the guiding principle of practices. Not that this kind of care is not required, but it is necessary to complement it with essential care of listening, valuing the more subjective needs of the pregnant women, which is also an adolescent and is inserted in a specific socio-economic context.

In a view from the perspective of gender and sexual and reproductive rights, which shows the woman as a social subject in the search for construction and affirmation of their identity in today´s society, breastfeeding is revealed as a possibility of female choice to decide on her body and her reproductive life¹¹.

In this same subcategory, there is ACS´s concern about gestational care associated with high-risk issue in adolescence pregnancy.

Monitoring through home visits. To inform about doing prenatal care, only with the nurse or doctor at the health unit. And it is through prenatal that the pregnant woman finds out if she has a high-risk pregnancy or not, so then she has a monitoring by the qualified professional until the child's birth. (Interview 2)

Here, there are observations from the field diary:

The ACS comes to the house of the mother, asks if she is feeling something, if she already went to the unit, if she was observed by the nurse. He says her prenatal care is high risk because it is her fourth pregnancy with three abortions. He explains to the mother that when it reaches the fifth or sixth month, she always lose the fetus, but thank God this pregnancy is going all right with this prenatal care. He guides the pregnant woman go to the unit to be with the nurse to get the referral to the hospital because the mother is already 9 months pregnant. (Observation 2)

The latest reports showed the health care of pregnant adolescents in high risk prenatal. It also adds the referral of pregnant women for a special service.

It is essential health services to develop their own mechanisms for early identification of these women, providing them with a differentiated prenatal care performed by sensitized professionals regarding their specific conditions¹².

In addition to the technical care with the adolescents

In this subcategory, it is possible to identify that ACS strives to suit the individual needs of clients, despite the observation revealing a greater prevalence of the clinic for the healthy development of the pregnancy, rather than listening and appreciation of the needs of adolescents.

It is to guide, forward, I can tell you that I even do independent of the function, we do more than what is required, we are mother, friend, psychologist and more other things. (Interview 4)

Field diary observations highlighted:

ACS comes to the house of the mother. It is a mud house with four rooms, where 15 people live there; some people slept on the floor, other in hammocks; no sink to wash the dishes; no laundry; firewood cook. Says good afternoon, asks the pregnant woman's record, look at the record and the gives date of the pregnant woman to return to the unit, asks about vaccines and checks records. He watches her expected date of delivery; asks if she's feeling something; guides the pregnant woman about contact with cats - because the house has a cat as a pet; explaining the cat´s disease - toxoplasmosis - and that she should not have contact with cats. ACS asks about feeding and ultrasound; and if she is feeling something. ACS advises pregnant women who need emergency care, and will take her to the unit to be with the nurse (Observation 4)

It is up to the ACSs, in their practices, to mobilize and articulate knowledge, skills, attitudes and values required by work situations, performing actions to support guidance, monitoring and popular health education from the concept of health as enhancing the quality of life and development of autonomy before their own health¹³.

Obstacles facing the ACS's role in monitoring of pregnant adolescents

This category was divided into two subcategories, examined below.

Lack of training

The problem of lack of training of ACS was highlighted, interfering in their operations through the lack of information on how to deal with adolescents´ pregnancy.

[...] We are not having training for some time. [...] So, I teach how to breastfeed, how to hold the baby, how she needs to behave when is feeling pain, what to do if she is doing all prenatal visits [...] (Interview 3)

A study about the ACS of the project QUALIS/PSF, in São Paulo city, identified that the ACS has no tools and technologies, including knowledge to the different dimensions expected of their work. This failure causes working with common sense, with religion and, more rarely, with the knowledge and resources of families and communities¹⁴.

The ACS and gender issues: difficulties in being male

In this subcategory difficulties when ACS are male were found in the collection of information of the pregnant adolescents.

The difficulties interfere even because I am man. Few adolescents trust. They like to rely more on women health agents, they like to talk, but until in my area there is not this distrust, because their pregnancy was not hidden; all of them are with a partner, so I did not find difficulties (Interview 1)

Although in a research when the adolescents were asked about how doubts to prevent pregnancy, they cited more frequently dialogue with males representing 32.2% and in dialogue with the female in 27.1% of the answers¹⁵.

Adolescents also reported in the same research that dialogues and answering questions about sex and adolescence pregnancy occurred more frequently with friends. However, they also emphasized that doubts about the prevention of pregnancy were discussed with their parents and with the health professionals ¹⁵.

Comparison between adolescent and adult prenatal

This category predicted two subcategories discussed below.

Biological and psychosocial immaturity

Here the comparison between adolescent and adult prenatal related to the biological and psychosocial immaturity were highlighted.

In my opinion, I think so, because the adolescent doing prenatal have to be very careful because her body is not fully developed to have a pregnancy, so she has to be very careful. Both she, as the nurse of the unit with that person (Interview 1)

Yes! For adult women, so I think already have their body formed, not the teenager. The formation of their body and life experience as well as prepare to have a child and after birth the child, be prepared and learn to take care of that child (Interview 2)

It was noticed that for these ACS pregnancy in adolescents is different from adult women because the physical transformations of the adolescents are not completed, and therefore they are biologically immature pregnant women.

Adolescents under 15 years old are a group of major obstetric risks because their growth can be influenced, given the early welding of the epiphysis, with losses in the final height; and the increased possibility of cephalopelvic disproportion due to a too narrow pelvis to the passage of the baby. They are also more prone to complications like eclampsia, anemia, premature birth and the newborn to have low weight¹² being more frequent in recent pregnancies that are repeated during adolescence, with short intervals between the deliveries, less than two years⁷.

For many adolescents, there is no direct relationship between pregnancy and the end of youth. There are new attitudes in the adolescent world, however, there are little known and contradict common sense with regard to the desires and dilemmas of this age group in relation to maternity¹⁶.

Need for specific prenatal actions for pregnant adolescents

The importance of having more specific educational activities for pregnant adolescents was highlighted.

So, the fourteen year old girl prenatal who is still a child should be different and have more familiarity with the practices, because they are doing home visits of a pregnant woman who is close to having the baby and one who already had it, for her see how the daily life of a mother is. The child sleeps, wakes up, belches, poops, how to clean and that should be shown in practices (Interview 5)

The adolescent pregnant care must meet their particularities, a differentiated service, as to set days and/or specific times for adolescents´ care; keep open agenda, no needing to make an appointment; the professional must be available to hear the adolescent, answering their doubts and providing the necessary clarifications, even requiring to spend more time in the consultation¹².

ACS interface facilitating factors and pregnant adolescents

Creating links as a confidence factor

It was noticed that the home visits and the fact that ACS live in the community contribute to a greater possibility of links, establishing a trust and intimacy relationship between the user and the professional.

[...] And the facility is intimacy because if you have intimacy with her and the family you can go directly and ask. [...] it makes it much easier when the mother is here from the same neighborhood. I just ask, I call out her house and talk, call up at home and talk to her (Interview 3)

The ACS has a very specific role that differs from other team members. First of all, they are people who live with the reality and health practices of the neighborhood where they live and work, so they feel identified with the culture, language and customs of their own community⁵.

Partnership with the nurse and coordination with service areas

The nurse is a very important member of the development of actions aimed at integral care to adolescents mainly on issues that require risk to their entirety. Along with the multidisciplinary team, humanized actions and valuing life must be implemented to ensure citizenship to this vulnerable people ¹⁷.

What makes it easier is the proximity to the nurse that we have. To do lectures, doing any initiative aimed that pregnant women learn something [...]. (Interview 5)

I think we do our best, but I think it is not enough that they do not become pregnant again. I think a work group, across the area, I think that would facilitate so they do not come to get pregnant again. (Interview 4)

Socio-economic situation of the clients

In the next statement, it was possible to highlight that the ACS working in disadvantaged micro areas, has more autonomy with users.

What makes it easier on my micro area is the lack of them, the will they have to help us, it makes it easier because they like, they need. [...] (Interview 4)

Many pregnant adolescents arrive at UBS after the first contact with the community agent in their home, from the home visit, when the ACS visiting a pregnant adolescent prioritizes to identify the area in which the mother is present, her socio-economic status, marital status and risks factors ¹⁸.

It is undeniable that the adolescence pregnancy, especially in the poorest income groups, contributes to the perpetuation of a cycle of poverty and deprivation and that proper care can minimize such consequences¹².

CONCLUSION

The ACS has key role in prenatal care of pregnant adolescents, since their registration until the postpartum visit. The ACS when dealing with pregnant adolescents often search preparation for motherhood based on technique, centered on the record of the pregnant woman, consultations, vaccinations, medications, leaving aside the psychological and social condition of the client.

Searching for a special care with adolescents, many times the ACS encounter obstacles that hinder the monitoring of pregnant women, and even with all these difficulties, they try to meet their needs in home visits, answering doubts, scheduling the prenatal consultation and guiding its importance, heading for routine vaccinations and guiding questions that may arise in relation to breastfeeding.

It is necessary that the needs are met starting with the training of ACS for the care of adolescents to be differentiated and qualified as recommended by public policies aimed at this group.

REFERENCES

1.Paraguassú ALCB, Costa MCO, Sobrinho CLN, Patel BN, Freitas JT, Araújo FPO. Situação sociodemográfica e de saúde reprodutiva pré e pós-gestacional de adolescentes, Feira de Santana, Bahia, Brasil. Ciênc Saúde Coletiva. 2005; 10: 373-80.

3.Ministério da Saúde (Br). Secretaria de Atenção à Saúde. Manual de atenção à saúde do adolescente. Brasília (DF): Editora MS; 2006.

4.Loch-Neckel G, Seemann G, Eidt HB, Rabuske MM, Crepaldi MA. Desafios para a ação interdisciplinar na atenção básica: implicações relativas à composição das equipes de saúde da família. Ciênc Saúde Coletiva. 2009; 14: 1463-72.

5.Duarte LR, Silva DSJR, Cardoso SH. Construindo um programa de educação com agentes comunitários de saúde. Interface Comun Saúde Educ. 2007; 11: 439-47.

6.Rezende FM. O ir e vir dos usuários nas unidades da saúde da família [dissertação de mestrado em enfermagem]. Belo Horizonte (MG): Universidade Federal de Minas Gerais; 2007.

7.Ministério da Saúde (Br). Secretária de Saúde de São Paulo. Manual de atenção à saúde do adolescente. São Paulo: SMS; 2013.

8.Ministério da Saúde (Br). Secretaria de Atenção à Saúde. Área de Saúde do Adolescente e do Jovem. Marco legal: saúde, um direito de adolescentes. Brasília (DF): Editora MS; 2007.

9.Ministério da Saúde (Br). Secretaria de Atenção à Saúde. A saúde de adolescentes e jovens: uma metodologia de auto-aprendizagem para equipes de atenção básica de saúde: módulo básico. Brasília (DF): Editora MS; 2007.

10.Bardin L. Análise de conteúdo. Tradução por Luís Antero Reto e Augusto Pinheiro. Lisboa (Pt): Edições 70; 2004.

12.Ministério da Saúde (Br). A adolescente grávida e os serviços de saúde do município. Brasília (DF): Gráfica MS; 2013.

13.Ministério da Saúde (Br). Secretaria de Gestão do Trabalho e da Educação na Saúde. Departamento de Gestão da Educação na Saúde. Perfil de competências profissionais do agente comunitário de saúde. Brasília (DF): Editora MS; 2013.

14.Silva JA. O agente comunitário de saúde do Projeto QUALIS: agente institucional ou agente de comunidade? [tese de doutorado]. São Paulo: Universidade de São Paulo; 2001.

16.Costa TJNM. Gravidez na adolescência: um estudo de caso sobre a maternidade na faixa de 10 a 14 anos em Juiz de Fora – MG [dissertação de mestrado]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2002.

17.Costa RF, Queiroz MVO, Zeitoune RCG. Cuidado ao adolescente: contribuições para a Enfermagem. Rev enferm UERJ. 2012; 20:197-202.

18.Ministério da Saúde (Br). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Guia Prático do Agente Comunitário de Saúde. Brasília (DF): Editora MS; 2009.