RESEARCH ARTICLES
Perspectives of sheltered teenagers on healthcare services in support of their motherhood
Lucia Helena Garcia PennaI; Joana Iabrudi CarinhanhaII; Vilma Villar MartinsIII; Valéria Aliprandi LucidoIV; Beatriz Yuan SoaresV; Gleice da Silva FernandesVI
IPhD, Associate Professor, Department Maternal-infant and Graduate Program in Nursing at the School of Nursing at the Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil, Email: luciapenna@terra.com.br
IIPhD Student, Graduate Program in Nursing and Substitute Professor, Department of Maternal-Infant School of Nursing at the Universidade do Estado do Rio de Janeiro, Nurse at the Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil, Email: iabrudi@yahoo.com
IIIMaster in Nursing, Graduate Program in Nursing at the Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil, Email: vilmavillar@ig.com.br
IVMastering in the Nursing Graduate Program at the State University of Rio de Janeiro, Rio de Janeiro, Brazil. Email: val.aliprandi@gmail.com
VAcademic fellow of undergraduate research at the Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil, Email: beatrizys@gmail.com
VIAcademic fellow of extension at the Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil, E-mail: gleicefernandesrj@gmail.com
ABSTRACT: This study aimed to discuss the role of healthcare professionals in relation to motherhood, from the perspective of sheltered teenage mothers. This is an exploratory and qualitative study with 10 teenage mothers carried out in two municipal shelters of Rio de Janeiro in 2009. There were focus groups and the data were interpreted according to content analysis. The results showed positive and negative aspects of attention, showing that health services have the potential to be a reference in support of motherhood for teenage girls sheltered, but the gaps remain large, especially by the prejudice and lack of sensitivity from professional on the situations experienced by these young women. Therefore, the health professional must know the life context of this group, whose modes of operation differ from what is usually socially accepted.
Keywords: Institutionalized teenager; pregnancy in adolescence; health services; teenager health.
INTRODUCTION
The institutionalization of children and teenagers is a historical Brazilian reality that involves complex aspects such as intense socio-economic inequality, disaffection and violence1,2. Inserted in this context, the question of motherhood represents a relevant demand and specific care towards health, considering the triple vulnerability situation in which this young person is: a teenager, woman and away from the family environment. This condition can lead to difficulties for the young woman in regards both to avoid unplanned motherhood, on how to cope with it upon become a reality3.
Considering the context of life of teenagers sheltered, a proper attention to the young woman who is living motherhood in this phase of life it is an important step forward to mitigate the vulnerability of injuries to their physical and mental health. In this sense, it is necessary to study the motherhood support provided by health institutions in view of sheltered teenage mothers.
Within the public health policies for women, teenage healthcare is a priority, as well as the promotion of obstetric and neonatal care quality for women and, in addition, there is the valuing of women as a citizenship subject from the incorporation of gender perspective4,5. However, it is worrying that the fact of having had 444,056 teenage births in the age range of 10 to 19 years, in Brazil in 20096. Data from the 8th Census of the juvenile population sheltered in the State of Rio de Janeiro, reinforce the concern about teenage motherhood as a public health problem by identifying that among 2,417 children and teenagers currently hosted in devices sheltering, 58.34% are between 10 and 18 years, and almost half of whom are female, in addition to revealing sexual violence and prostitution as the reasons for sheltering7.
From the interest in the intervention of this reality with a view to the construction of a healthy motherhood, the objective of this study was to discuss the action of health professionals in relation to motherhood in the perspective of sheltered teenage mothers.
LITERATURE REVIEW
The discussion about teenage pregnancy points to the need to expand the view and action for a human rights perspective - the right to social protection of motherhood8,9. This refers to the understanding that teenage pregnancy can follow unique courses for each young woman given the diversity of contexts in which they are inserted, which may represent a risk or protection factor for the young woman10,11. In the case the non-affiliated teenagers, the motherhood experience is also lived ambivalently12,13. Although, in many cases, pregnancy presents itself, as the young woman does not always see unplanned result of fleeting relationships and weak ties it as undesirable. In addition, many teenagers in these conditions express acceptance of pregnancy as a valorization mechanism and the creation of social identity.
Motherhood experienced in this context of strong social inequity requires special attention in the area healthcare, because it can compromise the quality of life and the teenager's rights. On the one hand, obstetric nursing has consolidated comprehensive care to women in a relational perspective, that breaks the curative model, and it is being valued by women as essential to their well-being14,15.
Furthermore, from the perspective of integrality, the complexity of the reality experienced by these teenagers requires intersectoral intervention that considers the context and their ways of living1,16. In this sense, health professionals, especially nurses, are identified as possible matrices of the attention given to these teenagers, building bridges between the health services, social assistance, education, justice and rights in order to meet the various demands1,3,17. Therefore, the involvement of health professionals with the problems teens may represent sheltered social and emotional support to young women18, particularly those who are experiencing motherhood.
METHODOLOGY
This is an exploratory research with a qualitative approach, carried out in two sheltering devices from the Municipal Department of Social Care of Rio de Janeiro (SMAS/RJ) that house teenager mothers, one of them being located in the northern region and another in the southern region of the city. It is worth noting that in the shelter located in the northern zone (mixed shelter for children and teenagers, with approximately 120 spaces) there is a Teenage Mother Program (TMP) which specifically welcomes up to 10 pregnant teenagers with their children, constituting one of the few spaces that develops this work in the municipality. The shelter located in the south zone, in turn, is a shelter exclusively for teenager women, with capacity for nine young people (mothers or not), however, does not accept the both mother and child.
In addition, it is useful to provide some performance characteristics of shelters in general. The teams consist of social educators (mostly with high school level of education) for the monitoring of young people in their daily life activities and social workers for the referrals required in accordance with the demands of each one, aiming at the social reintegration; in some teams, there is the psychologist for the monitoring of the young women and the team itself. The treatment of injuries to the physical and mental health is arranged as a priority through the reference to the units of the public healthcare network of the Unified Healthcare System (Sistema Único de Saúde – SUS).
The protagonists of the study were 10 teenage mothers sheltered in the said shelters (seven teenagers from TMP and three teenagers under the south), which agreed to participate voluntarily in the study after explaining the objectives and guarantee of anonymity, as well as removal or not to answer questions at any time if they so desired.
The age of the sheltered teenagers was from 13 to 17 years, being six teenagers with children between 1 and 24 months of age, two pregnant women and two pregnant women with children. The majority of teenagers have a history of life on the streets, drug use and domestic and/or community violence, in addition to weakened family ties. In spite of the diversity of vulnerability contexts that each teenager is inserted, in general, it can be inferred that some young women are struggling to regain custody of their children, while others strive to keep them close. In both situations, there is still a time of instability, in which the street experience is very much present, causing running away from the shelter, constant conflict with each other and professionals.
In this work the ethic and scientific requirements for research involving human beings were answered, and the Research Ethics Committee of the Municipal Health Secretary of Rio de Janeiro, Brazil (CEP/SMS/RJ) approved the project under protocol number 73A/09. In addition, participation in the study was voluntary and authorized by the sheltered teenagers, upon the signing of the informed consent, which was ratified and signed by the shelter - its legal representatives at the time.
Data production occurred in the period from June to July 2009 in two stages: the first consisted of visits prior for presentation and discussion of research with teams of shelters and with their teenagers. There was recognition of the reality experienced by teenage mothers sheltered concerning motherhood, identifying the involved and their expectations, raising problems in the situation, the characteristics of the population from the principle of participation, ie, through dialog with them. The main objectives of the research were established with teenagers having as its central topic the relationship between motherhood and the healthcare services. This first step also served for a necessary approach to building a relationship of trust with the teenagers in the data production.
In the second stage, focus groups (FG) were conducted with the teenagers sheltered in these devices (identified as GF1 for the shelter of the southern and GF2 for the TMP). The choice of this strategy favored the establishment of a dynamic group that has motivated the teenagers to participate in the research. It should be noted that the focus groups were digitally recorded and later transcribed. The groups were conducted in shelters on a set date and time above, with the participation of the researcher and a moderator. At the end of each meeting, in a dialogical proposal participants (teenagers, researcher and moderator) evaluated the activity.
The data produced in the focus groups were subjected to a categorical-thematic analysis19. After a brief reading of verbal depositions generated in the focus groups, units of record (UR) were delimited, ie, were performed cutouts of these texts (phrases) with meaning for the object of this study - the motherhood support provided by health institutions. Next, the URs of meaning were grouped under a general heading - units of meaning (UM). The UMs were quantified and, progressively, grouped according to the thematic similarity, called subcategory. Based on the quantity and quality of these subcategories, they were reorganized in most comprehensive sets, called categories, which were named as a result of the scientific knowledge that they expressed.
From this process, two thematic categories emerged the infrastructure of health services and relations between the sheltered teenager mother and the health professional. The data, therefore, were analyzed in a discussion of contextual reality, looking for the real meaning of the speeches of the social actors and their relationship with their historical, social and qualitative content.
RESULTS AND DISCUSSION
Infrastructure of the healthcare services
The studied teenagers indicated satisfactory and insufficient aspects regarding the infrastructure of healthcare facilities where they were assisted during the motherhood process.
On the one hand, there was a reported dissatisfaction with regard to the availability of materials for the completion of pre-natal examinations and other visits, highlighting the precariousness in healthcare services.
I think that the healthcare today is very precarious; they don't have material for nothing! (GF1)
On the other hand, the teenagers highlighted the procedures and exams to which they were subjected in pre-natal care (weight, obstetric touche, auscultation of fetal heartbeats, obstetric ultrasonography), as well as made positive reference to the physical environment of the motherhood, expressing their preference for certain healthcare unit which they consider as the ideal place to give birth. In addition, the young women have mentioned the participation in educational activities on the pregnancy, taking care of the baby, sexually transmitted diseases and health in general, during the pre-natal.
They weighted me. They performed a touch (gynecological) in me. There, at the unit [healthcare] they listen, they put a type of cone on your belly. She sent me there to the [hospital] to do the ultrasound, to see how my uterus was. (GF2)
There [in the motherhood] is a silence ... everything clean. (GF2)
[In the Pre-natal] they teaches everyone how to give a bath. They teach us how to take care of our child. (GF2)
The divergence of teenager opinions on the infrastructure of healthcare services reveals a side of the inequality in the care rendered by the SUS and on the other hand the importance of an appropriate healthcare environment as a measure of comfort and safety for the initiation and continuation of a healthy motherhood.
The referred precariousness reflects the difficulties in consolidating the Unified Health System - SUS, as well as the injustices and social inequities that puts a great part of the Brazilian population in a vulnerability situation by not participating in an equitable manner of production, management and consumption of goods and services20.
The physical structure of the health unit, the achievement of physical and laboratory exams, the educational actions, in addition to attention to the specificities of the teenager are targets for the guarantee of quality prenatal care recommended by the Ministry of Health21.
However, it is worth further consideration about the quality of healthcare, because survey on the importance of pre-natal care, particularly the educational actions, reveals that, despite the completion of the pre-natal consultations, pregnant women are not satisfied with the guidance received on childbirth, puerperium and caring for the baby22. We must take care not to develop a traditional educational action, in which the prescriptive guidance, regulations prevail to the detriment of dialogical action that questions the situations experienced2.
Thus, in addition to the recommended routine procedures, the quality of care is associated with the dialogical relation of young woman with the healthcare professional as seen below.
The relationship between the sheltered teenager mother and the healthcare professional
The relationship of teenage girls with health professionals was experienced antagonistically: some were satisfied, while others complained about the service provided.
The young women interviewed reported satisfaction with the quality of the care offered in healthcare services, manifesting themselves in a good relationship of the teenagers with health professionals, in the dialog between them (especially, for the clarification of doubts) and in the care free of prejudices (not perceiving differences in the case of being sheltered).
When I go for pre-natal, with my doctor I am treated very well. (GF2)
We take our doubts with her [doctor]. (GF2)
For me it's normal care, it's not why and they don't treat us different because it's a shelter. (GF2)
The health service seems to be a reference to support the construction of a healthy motherhood next to the sheltered teenagers. The aspects referenced by the young women can be the basis for the development of dialogical care:
Free from value judgments, which considers the possibility of a life history differently, understanding their roots, doesn´t confirm stigmas and labels sanctioned for this group, but accepts and respects their ways of seeing and being in the world and help them with affection to overcome the disbelief in themselves2:986.
Despite the positive experiences identified by the teenagers, the greater emphasis fell on the unfavorable aspects of the care. The complaints were the devaluation of maternal health by professional, the need to call the professional to meet their demands, the discrimination by professionals about their current situation in which they find themselves - teenagers, pregnant and sheltered, and the lack of space for clarifying doubts.
I think they [health professionals] think that their job is to work with the pregnancy and the child that is inside the belly; and screw the mother! (GF1)
Ah, I call the doctor's attention: 'Young man, I have this and this'. I make him take me into his office to examine me. (GF1)
[Health Professionals] speak that way: 'In addition to pregnant being, you have no place to stay. Are not you ashamed of having a child while still being in the shelter?' (GF1)
I looked to see [if I had a space to dispel doubts]. (GF1)
These aspects were also highlighted in another study that addressed the relationship of sheltered young and health institutions, showing a technocratic practice that it is not resolute and compromises the integrality17. The technocratic professional conduct mentioned by teenagers doesn't value the female particularities, especially the teenagers away from family, so fails to provide the psychosocial support needed at this time, as recommended by the policies of care for women4.21.
The discriminatory posture, in turn, neither contributes to the transformation of life of teenagers who have opted for pregnancy10. This discussion refers to the stigma over children and adolescents in the street and shelter situation who are seen as a threat to society and, therefore, are often discriminated against by health staff because of their condition of disaffiliation17.
It is worth pointing out also that the technocratic assistance problematic, associated with a feeling of contempt and prejudice from health professionals, compromises the establishment of the link, which may result in disengagement of the health service, as evidenced by the teenagers.
[I went to the medical consultation] because I lost him [the baby], I didn't even know.
I only went there to get a vaccine for my girl and her consultation. (GF2)
These statements show that the relationship with the healthcare service is given punctually such as in emergency situations and compliance with routine childcare. This way, it´s lost the opportunity for the effective development of education and prevention activities, which are possible only from a connection with the service.
With a complaining tone of voice, young mothers, in turn, have expressed the desire to have their rights preserved in respect to the relationship with the professional during the healthcare, regardless of the situation they are in.
Regardless of whether or not in the shelter, [healthcare professionals] should respect and treat equally, because everyone is human, we are also, no one is an animal! (GF1)
In addition, faced with the posture adopted by health professionals to the sheltered teenagers, they expressed not only their views about the service itself, but also reflected on what they consider to be most appropriate: a humanized and integral care. The humanization and integrality of health care, in the view of the teenager, reflected on the need to establish a dialogic relationship, free of aggressiveness and prejudices, as well as the recognition and appreciation of the reality experienced by them:
Talk more ... Not [judging so much]. Speak normally. Think it needs to change a lot of things, especially their way [health professionals], they judge the teenager too. [Health professionals should] know more the adolescents. (GF1)
The differences in the experiences of assistance in the healthcare sector explained by sheltered teenager mothers reinforce the need to encourage and facilitate the improvement of the quality of healthcare for women at this stage, especially at a time when they are in a situation of intense vulnerability as those who participated in this study.
Unlike the current reality reported by teenagers, the institutions and professionals who provide care to this clientele need to be involved and incited to help them in the construction of a healthy motherhood1,17.
In the case of sheltered teenagers, the ways of living and being in the world is different than expected socially and this might provide meanings for motherhood also divergent. So it requires the health professional redoubled effort to consider the stories and experiences of these young women throughout the healthcare process, including the exams realization and educational activities, so that from the shared construction of knowledge can effectively encourage their transformation2,3.
In addition, these professionals need to be constantly challenged to maintain this direction of work through articulation with another programs and services in an intersectoral way, integrating health, social assistance, education and justice.
CONCLUSION
Although this present study has addressed a local reality and a reduced sample of subjects, it was possible to build evidence on the contribution of the healthcare area to support the motherhood of sheltered teenagers.
It was found that health services have the potential to perform a vital function in motherhood support for sheltered teenagers through dialogical care, but the failures in this system are still great, compromising the quality of care. It is perceived that, often, the professionals are not prepared to meet the demands of this population group, whose historical roots and operating modes differ from what is socially acceptable. It is a stigma over their origin and that interferes with relationships that teenagers have with the world, including within an institutional setting such as in healthcare units.
It is essential that healthcare professionals are aware of their role as educators committed to transformative intervention of the reality of vulnerability and helplessness to motherhood experienced by sheltered teenagers. Considering motherhood as a process essential for the formation of powerful individuals (mothers and children), it is necessary pay attention to not to reproduce a prescriptive and normative acting, but cherish the life context, including the experiences and representations of motherhood in the planning and development of the care.
The differences found denounce the impasses experienced by the health area on the implementation of public policies for women's and teenager's health, as well as reinforce the challenge for managers and health professionals about the intersectoral and interdisciplinary work necessary to the formation of a care network for this group that is experiencing a situation of intense psychosocial vulnerability.
This research investigated in an exploratory and limited way the relationship of this specific group with health services, indicating the need for enlarged studies on the care network, including the perspective of the different actors in this scenario, as well as evaluating the impact of health actions on these young.
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