Facing the difficult experience even with support: the underage adolescent experiencing motherhood

ABSTRACT

Objectives

To understand the meaning of childcare for the underage adolescent mother, to reveal the demands of care and to build a theoretical model based on this experience.

Method

Qualitative research with symbolic interactionism as the theoretical framework and the grounded theory as the methodological framework; nine adolescents participated in the study. The semi-structured interview was used to collect data from September 2008 to September 2011, during paediatric nursing consultation at the Centro Assistencial Cruz de Malta, a philanthropic institution in the city of São Paulo/Brazil.

Results

Data analysis led to the construction of the theoretical model, Facing a difficult experience even with support.

Conclusion

The experience shows that the difficulties to care for a child, even with help, are not met, only mitigated, and that underage adolescents do not have the maturity to cope with this experience.

Pregnancy in adolescence; Mother-child relations; Child care; Millennium Development Goals

RESUMO

Objetivos

Compreender o significado do cuidar do filho para a mãe adolescente menor, desvelar as demandas para o cuidado e construir um Modelo Teórico sobre essa vivência.

Método

Pesquisa qualitativa: adotou-se o Interacionismo Simbólico como referencial teórico e a Teoria Fundamentada nos Dados, como metodológico. Participaram do estudo nove mães adolescentes. Técnica de coleta de dados: entrevistas semiestruturadas, realizadas de setembro de 2008 a setembro de 2011, na consulta de enfermagem em puericultura do Centro Assistencial Cruz de Malta, instituição filantrópica da Cidade de São Paulo/ Brasil.

Resultados

A análise dos dados levou à construção do Modelo Teórico, Enfrentando uma experiência difícil mesmo com apoio.

Conclusão

A experiência revelou que as dificuldades para cuidar, mesmo com ajuda, não são supridas, apenas amenizadas e que as mães adolescentes não apresentam maturidade para superar essa vivência.

Gravidez na adolescência; Relações mãe-filho; Cuidado da criança; Objetivos de Desenvolvimento do Milênio

RESUMEN

Objetivos

Comprender el significado del cuidado de su hijo para la madre adolescente menor, desvelar las demandas para el cuidado y construir un Modelo Teórico sobre esa vivencia.

Método

Investigación cualitativa, se adoptó el Interaccionismo Simbólico como referencial teórico y la Grounded Theory como metodológico; participaron del estudio nueve madres adolescentes. Como técnica de recolección de datos: entrevistas semiestructuradas realizadas entre septiembre de 2008 a septiembre de 2011, en la consulta de enfermería al niño en el Centro Asistencial Cruz de Malta, institución filantrópica de la ciudad de São Paulo/ Brasil.

Resultados

El análisis de los datos llevó a la construcción del Modelo Teórico, Enfrentando una experiencia difícil aunque con apoyo.

Conclusión

La experiencia reveló que las dificultades para cuidar, aunque con ayuda, no son suprimidas, solo amenizadas, ni presentan madurez para superar esa vivencia.

Embarazo en la adolescencia; Relaciones madre-hijo; Cuidado del niño; Objetivos de Desarrollo del Milenio

INTRODUCTION

In 2000, the United Nations promoted the Millennium Summit, in which leaders of 191 countries signed an agreement for a peaceful, just and sustainable world. At the meeting, the Millennium Declaration was adopted and the goals of this declaration (MDGs) were defined(¹). Brazil undertook to achieve gender equality, the empowerment of women and the reduction of child mortality, among other actions, by 2015.

The MDGs are directly related to the subject of this study, which is motherhood among underage adolescents between 10 and 14 years of age, with regard to eliminating disparity between the sexes, ensuring equal conditions and negotiation, and protection from any form of sexual exploitation; reducing child mortality, low birth weight, and early weaning; promoting decent conditions for childbirth and care provided to mothers at the maternity unit; and guaranteeing an infrastructure that is compatible with basic needs(¹), especially when it comes to girls who are confronted with the lack of opportunities and low quality health and education.

In light of the scarce knowledge of maternity among underage adolescents, the exact dimensions of the problem and an understanding of the negative repercussions of this experience for the mother and baby, this study provides a basis on which to discuss this subject and confront this important challenge.

The report of the World Population Situation 2013 of the United Nations Population Fund emphasizes the subject of motherhood among underage adolescents and denounces that 2 million girls get pregnant every year all over the world, and that this number will reach 3 million in 2030 if no government policies are put into practice(²).

In Brazil, in 2011, there were 27,785 births of babies of adolescents between 10 and 14 years of age(³), which shows the need for urgent efforts from the authorities and society to reverse this problematic.

There are few recent studies that address pregnancy and maternity among underage adolescents and the relevant distinctions in relation to other age groups(⁴). Existing studies focus on the biological risks of pregnancy among underage adolescents and the negative experience of mother-child interaction(⁵).

With regard to the biological risks, the World Health Organization warns of the physiological complications of the mother and baby, such as anaemia, hypertension, miscarriage, prolonged labour, premature birth and maternal death due to the physical, functional and emotional immaturity(⁶). It stresses that the risk of these complications is related to low education, drug use, absent or inappropriate prenatal follow-up, low socioeconomic condition, short interbirth intervals and a compromised nutritional status(⁶).

In addition to the mentioned risks, these babies are more vulnerable to presenting a low Apgar score, birth trauma, respiratory tract diseases, developmental disorder, low intellectual quotient, blindness, deafness, perinatal death or death during infancy(⁶).

Another approach emphasizes that motherhood in this age group is related to sexual violence, which leads to negative psychological repercussions in terms of sexuality and during the course of pregnancy, childbirth and the puerperium(⁴).

Regarding parenting, that is, the care provided to the child, studies presuppose that these mothers present low levels of cognitive development and are therefore exposed to avoidable risks(², ⁷). They also stress the mother’s lack of competence to care of herself and that her children are subjected to physical and psychological abuse and development problems due to her lack of tolerance and more punitive approach(⁷).

In addition to the above-mentioned conditions, these mothers are more susceptible to depression, which leads to lower emotional availability and a less affectionate relationship with their children(⁷-⁸).

Consequently, pregnancy and motherhood among adolescents are characterised as a risk. Only after the age of 15 do adolescents develop deductive reasoning and the ability to propose hypotheses and arguments to solve problems(⁷, ⁹). Therefore, mothers under the age of 15 lack the cognitive and emphatic abilities to assume the maternal role.

In view of the difficulties experienced by underage mothers in relation to maternity and parenting, our question is: how do these mothers experience taking care of their children? In order to answer this question, we outlined a study with the following objectives: to understand the meaning of taking care of a child from the viewpoint of the underage mother; to reveal the demands of care; and to build a theoretical model based on this experience.

METHODOLOGY

This is a qualitative study based on the theoretical framework of symbolic interactionism to analyse human experiences and the nature of interactions(¹⁰). The adopted methodological framework was the grounded theory, which proposes the development of theories based on systematically obtained data and comparisons in a non-linear process during the research itself(¹¹).

The scenario was the outpatient childcare nursing unit of the Centro Assistencial Cruz de Malta, which is a philanthropic institution in the city of Sao Paulo that offers a teaching programme called the Programa de Integração Docente Assistencial with the department of paediatric nursing of the Escola Paulista de Enfermagem of the Universidade Federal de São Paulo.

Nine mothers who gave birth between the ages of 12 and 14 participated in the research. This number was established using theoretical sampling. This process aims to generate the theory, for which the researcher collects, encrypts and analyzes data and decides which information will be collected next and where to find it(¹¹).

The process resulted in three sampling groups. The first group consisted of mothers who had suffered abuse in childhood, confrontational relationships with problems and poor family dynamics. The second group consisted of four mothers who had had supportive families during their childhood, pregnancy and birth of their children. The third group consisted of mothers who were already adults, but who had experienced underage adolescent motherhood; one of these mothers had received the support of her family and social network, while the other had not, which meant their past experiences with maternity were similar to those of the adolescents of the other two groups, thus reaching theoretical saturation(¹¹).

The strategies were participant observation and semi-structured interviews based on the guiding question: Tell me (mother’s name) how you are experiencing taking care of your child (child’s name)? The interviews were conducted at the outpatient unit or at the home of the adolescents, according to their preference, and they were recorded and transcribed in full.

Data were collected between September 2008 and September 2011 derived from a doctoral thesis in nursing(¹²). The collection proved challenging because the mothers were reluctant to participate in the study, and those who accepted had difficulties expressing such a complex experience in a logical and sequential manner. The adolescents were selected intentionally and data were analysed concurrently to data collection, which extended the time needed to achieve theoretical saturation(¹¹).

Furthermore, according to the grounded theory, data collected does not precede data analysis and should occur simultaneously. Analysis complied with the steps of open, axial and selective coding, identification of the core category and formulation of the theoretical model that represents the studied phenomenon(¹¹).

Regarding ethical aspects, research was approved by the ethics committee of the UNIFESP under Opinion No. 2025/07, in accordance with the ethical principles required in Resolution No. 196/96 of the National Health Council. The participants were notified of the purposes of the study and the guaranteed anonymity, after which the responsible adults and the adolescents signed an informed consent statement. To preserve their identities, the participants were given the fictitious names of angels.

RESULTS AND DISCUSSION

Data analysis made it possible to understand the meaning that underage adolescent mothers attribute to the experience of caring for their child and revealed two interactive phenomena, that is, interdependent phenomena that follow a mutual trajectory and present an interaction of effects. The first phenomena, coping with the tough, solitary experience of taking care of a child, expresses the difficulties, sorrows, fears and feelings of loneliness that the mothers experience and that affect their ability to adapt to motherhood. The second phenomena, getting help from the support network to care for the child, portrays the interactions with their support network in order to assume the role of mothers, take care of their children and get on with their lives.

The articulation of these two phenomena led to the identification of the core category and the construction of the theoretical model, facing a difficult experience even with support (Diagram 1). Below, a description of the model with the categories illustrated with excerpts of the empirical data of the statements and observations with their mothers.

Diagram 1
– Theoretical Model: Facing a difficult experience even with support

This experience begins at the hospital ward, after delivery, when the adolescents must interact with the initial child care without the support, love and understanding of the health professionals or family members, which leads to coping with the tough, solitary experience of taking care of a child.

Being without my mum, husband, alone and nobody to give you affection and help with the baby! That was too much, I had no idea how to even start the care[...] the baby and me, there, alone (Tsaphkiel);

I had to learn to take care of my son alone there in the maternity ward. My mother could only come at visiting time, and the nurse came, she gave the baby a quick bath and didn’t teach us anything! (Camael).

This finding is worrisome because the Brazilian statue of children and adolescents establishes that “health care institutions must provide conditions for the full-time permanence of a parent or guardian in the case of hospitalization of a child or adolescent”(¹³). This fact becomes more unsettling when we consider that the objective of the fifth MDG related to maternal health is to promote specialized and humanized care provided by health professionals during pregnancy and the puerperium(¹-²), which forces us to reflect upon the requirement of the presence of a companion for the adolescent mother during the entire period of labour, postpartum and hospitalization, especially considering the young age of this population.

We agree that the lack of this early support for the adolescent mothers to care for their babies can lead to irreparable damage in the relationship and emotional safety of the mother and child bond, as this initial care promotes the autonomy and self-confidence to cope with the demands of parenting(¹⁴).

When the mothers feel they are receiving initial support in the ward, with the help of the health professionals and the support network, they experience this situation as getting help from the support network to care for the child, and as being capable of performing their roles as mothers when taking care of their children, which favours feelings of self-worth and confidence and are critical for them to adapt and assume motherhood.

They [nursing staff] were nice! I got a lot of help there in the room to take care of my son. They taught us to bathe, change, every little thing, I learned to do everything right (Gabriel);

My mother’s support was everything! She helped me take care of my son. From the start, she guided everything and stood by my side to see if I was taking care of the baby correctly (Camael).

These statements show the importance of family support when the mothers are learning to cope with care. Studies support that such young mothers need help, supervision and guidance from their families, especially in the early days of the baby’s life when they feel fragile and vulnerable due to the new situation(¹⁴-¹⁵). Theyemphasize that help favours a more responsive parenting, particularly under stressful conditions, and promotes the development of a closer bond between mother and child and a better relationship with the family(¹⁴-¹⁵).

Health professionals are also recognized as an important source of support, information and emotional reinforcement, thus triggering feelings of belonging and appreciation and exerting direct influence on the biopsychosocial well-being and competence of the mothers for the exercise of motherhood(¹⁴-¹⁵).

Upon returning home, the adolescents still have doubts and insecurities that were not addressed in the maternity ward, which leads continuing to experience difficulties to take care of the child. Without knowing whether the care she is providing is correct, she has to learn how to take care of the child on her own through trial, error and success.

In the beginning, I struggled to take care of my son. It was hard, giving him a bath, cleaning his belly button and changing nappies (Camael);

I was alone. Then I figured it out, realized what was not working and then found a way of improving.. I figured out how to look after him on my own (Tsadkiel).

Difficulties and fear of taking care of the baby are part of the stages of adapting to the new condition of motherhood and to the demands of parenting that the mother is not ready to fully exercise(¹⁴-¹⁵). This finding can be explained by the inherent characteristics of underage adolescents: being short sighted; wanting to find easy solutions; creating a personal system of values in the search for solutions and; pursuing an adult identity. As the young mothers take care of their children, they test their limits, reformulate concepts and experience a possible independence in order to overcome the fears and difficulties that dominate them(⁹).

Faced with such a difficult initial experience, the mothers interact with themselves and start to mobilize internal resources in order to care for their babies and mitigate the suffering that this causes. They start to recall childhood experiences, when they had the chance to help their own mothers to take care of other small children. This strategy, however, does not have the expected effect, leading to feelings of being surprised to encounter a different and unique experience, and the recognition that previous experiences do not provide the guarantees to take care of their own children.

It’s like I never helped take care of my little sister, I took care of her without problems! When I saw that tiny little baby, I didn’t think it would be so different, that I’d have so much trouble bathing him and cleaning his belly button, things that I have done before (Raziel).

This finding triggers reflection on the capacity to provide care related to memories of how the individual was taken care of and how he or she took care of others, considering that recollections can be accessed in the course of a lifetime to help make decisions related to self-care and taking care of others(¹⁶). This might be less frequent among underage adolescents given their difficulty in understanding and abstractly perceiving facts related to care acquired in childhood because the process of adjusting to motherhood/parenting requires psychological and emotional maturity to discern the experiences that must be assumed(⁷, ⁹).

Moreover, the difficulties are not restricted to the direct care of the child, but also to the feeling of being overwhelmed and overburdened with household chores and school, which were performed before childbirth and now cause fatigue and irritation.

It used to be just the house. Now it’s the baby, the husband and leaving everything clean and tidy (Mikael).

I’m tired and when I come home from school, I have to take care of my daughter and the house, I’m very tired and irritable. (Tsaphkiel).

According to symbolic interactionism, development of the Self among underage adolescents implies intensive structuring and adjustments, which lead to the redefinition of the identity that is being structured and feeling the weight of responsibility and renunciation(⁷, ⁹) in view of the situation.

Although returning to school can increase the burden that the adolescents mentioned in this study, school can provide the knowledge and development these mothers need to “be someone in life, and ensure the right conditions to grow, mature and achieve self-affirmation as an adolescent and mother(¹⁷).

The second MDG refers to ensuring universal basic schooling and quality education for youths between 7 and 14 years of age(¹-²), however, this is not the observed reality since truancy for most of these mothers is definitive and early due to their difficulties in reconciling their studies with the demands and responsibilities of care(¹⁷).

In addition, as the mothers take care of their children, new difficulties arise, such as their inability to interact with any illness or discomfort of the baby, which leads to suffering when confronted with the pain and the suffering of the child, and to feelings of pity, fear of a possible hospitalization or even of containing the child for vaccination.

I was afraid she [daughter] would get sick, I don’t know, of her being hospitalized. I was afraid a cold would turn into bronchitis. (Haniel);

I was afraid, like, afraid of the vaccines and holding her (Tsaphkiel).

A similar finding was reported in a study and reinforces that this situation affects the emotional immaturity of adolescents associated with the stress of having to encounter unusual and unknown situations for which they are unprepared(⁷, ⁹). However, this is not a prerogative of underage adolescents; mothers between the ages of 15 and 19 also reported fear of their children falling ill and being admitted, not only because of their own suffering, but also because of fear of being judged and even losing custody of their children(¹⁵).

In light of the demands they must cope with, these mothers turn to their family members for support and to mitigate the difficulties and fears that arise from the burden of the new demands. This support includes being accompanied to the clinic to avoid holding the child to be vaccinated.

I didn’t have the heart to take my son to be vaccinated. The first time, my mother came with me, and the second time, my aunt and my husband. They held him (Mikael).

The adolescents must also deal withhaving the financial support and support to return to their activities, and must negotiate with their families to provide the financial means to ensure their livelihood and their early return to school.

To take care of a baby, you need money. For this, I depend on my family, I can’t support her now. (Metraton);

Everyone in my family supported me to go back to school. Even my mother’s boss allowed her to take him to work while I was at school (Mikael).

All this support strengthens the relationship with the family and helps the mothers feel less vulnerable and better able to deal with the physical and emotional ups and downs of care(¹⁴-¹⁵).

This finding leads us to the third MDG(¹, ²) that highlights the importance of equality between the sexes and women’s empowerment, which leads us to reflect that these mothers at such a young age may have social and economic development opportunities through education and the ability to improve their quality of life. These benefits are directly reverted to better care for their children and themselves and the perception of the importance of family support to provide this care.

The following young woman feels supported when she interacts with the nurses that carry out the nursing consultations and who are always eager to listen to her and guide her with regard to doubts and difficulties when caring for the baby and herself.

I got a lot of help from you [nurses]. You explained everything to me. I really learned how to take care of my daughter with you. I only managed to breastfeed my daughter because of you, who supported me so much (Raphael).

Although they recognize the importance of the support they get from their families, the manner in which this support is provided can lead the young women to graduallyperceive the loss of control over their role as mothers.This occurs when their mothers or grandmothers start to show concern regarding the quality of the care their babies are receiving. They feel monitored and intimidated due to the inability to provide care as they were taught by their mothers and grandmothers, and must cope with mothers who are making decisions without consulting them. Consequently, they gradually stop taking care of their babies or making decisions related to care, especially when they go back to school.

My mother was always watching me and she was afraid to leave me alone, taking care of him. She was afraid he would go hungry, that I would not give him the bottle or change his nappies (Metraton).

I was breastfeeding and went back to school, my mother went there and decided which milk to give him and took over all the care (Tsaphkiel).

Due to the difficulty in opposing their mothers, on whom they depend, they do not react and prefer to suffer in silence until they decide to leave school in order to regain their roles as mothers and the love of their children.

I am really sad, I think my son likes my mother more than he likes me! When we get home, and we both [mother and daughter] open our arms to pick him up, he runs to my mother! (Mikael).

When the young girls can count on the support of their mothers, in the sense of having her by their side, they feel motivated, reassured and confident, without feeling stripped of their role as the caregivers of their children. They eventually develop the autonomy to provide care, which does not mean they have overcome their fears or that they can meet the demands of motherhood singlehandedly. In this way, they develop the confidence to take care of their children and start to consider themselves good mothers with the acknowledgement of their families, which boosts their self-esteem.

The daily routines gave me the confidence to take care of my baby. My family was a big part of that (Tsadkiel).

They praise me all the time, everyone knows I am a good mother and take good care of my daughter! (Raphael).

Corroborating these findings, studies investigated the relationship of adolescents with their mothers in relation to taking care of their babies and the impacts of this relationship. One of these studies claims that these problems often precede childbirth and generate conflicts, especially when the mothers think they are too young and do not have the emotional conditions or skills to look after a baby(¹⁸).

Literature shows that reassurance and the ability to take care of a baby are the result of self-confidence in the interaction between the mother and child, which triggers favourable feelings that make these mothers stronger, creative and self-reliable(¹⁴-¹⁵). When they fail to develop this reassurance, the adolescent mothers immerse in a state of self-loathing, a high level of emotional stress and full disbelief of their roles as mothers(⁹, ¹⁸).

Becoming a mother is a rite of passage and transition that involves the organization of several roles that integrate the self-concept of what it is to be a woman(¹⁹). With the help of the support network, the adolescents strive and try to adjust to the role of good mothers because, culturally, the meaning given to maternal characteristics, regardless of their age, is related to feelings of giving, sacrifice, obligation, patience and care toward the child(¹⁹).

This concept should be reconsidered, especially among the mothers who are experiencing motherhood as underage adolescents, as they may fail to adapt to these characteristics because they do not have the psychological and emotional conditions to construct the identity of being a mother.

In the context of overcoming obstacles and valuing the Self, the adolescents start to define and expand the concept of care, which assumes larger proportions that are related to the measures of protection and safety of their children and the promotion of their development. Subsequently, they get emotional with their new skills, as shown below.

He started to say all our names. What a smart boy, I was thrilled! (Raziel).

It is dangerous to leave him alone, I’m afraid he’s going to get hurt. Even when I’m finished, I need to watch over him (Gabriel).

This mothers also recognize play as an important resource of care. In this regard, self-interaction rekindles significant childhood experiences and moments related to play that brought so much joy and pleasure. The mothers value play as an instrument that strengthens their relationship with their children, promotes their development and creates the encouragement they need to cope with the burden of care.

[...] I played a lot! At school, until the age of 7, she played blind man’s bluff and mother and daughter. Playing was wonderful, playing is a delight! (Camael).

When we’re playing, he wants the toy, he already crawls all over the house. Wow! I had no idea that playing like that was important (Gabriel).

We love to play together. I put the toys in the eiderdown, and we play for hours together (Raphael).

In addition to being an activity that promotes pleasure, fun and distraction, play is also an integrative activity of human beings. Epistemically, the word brincarin Portuguesecomes from brinco, that is Latin for bond, meaning to create ties, to connect. This reveals the importance of play for the development of children. During play, children interact with themselves, other people and their environment. It is also an activity that helps children understand or even redefine a situation(²⁰).

Play can represent a strategy of activities that are created with adolescents in order to express themselves, transform themselves and know themselves since during play they can interact, experience and understand the subjective and unique dimension of the various experiences they are confronting and interpret what is happening(²⁰).

As a consequence of this process, the adolescents realize they are being transformed with motherhood because they recognize that the interactions they establish with their children trigger positive feelings, like love for their children, and determine the transformations of their manner of being. They eventually define their children as being their joy and purpose in life.

After my son was born, I decided to change my life. I grew up and decided that I was going to have to take care of him (Zadkiel);

My son is my life, my passion! I fall in love with him more and more each day, I take care of him and love him even more (Raziel).

A similar finding was reported in a study with adolescent mothers from 15 to 19 years of age. This study revealed the feelings of pleasure, love of the mothers when taking care of their children and the development of strategies that helped them overcome obstacles and achieve the goal of taking care of their children(¹⁵).

The experience of the adolescent mothers in relation to taking care of their children seems to resemble a seesaw that tilts upwards and downwards. When the experience is considered difficult, it becomes a heavy burden that is more than the mothers can bear and the seesaw is tilted downwards. When the adolescents get the appropriate support, without being stripped of their right to play the key role in the care of their children, the burden of this experience is relieved and becomes lighter, so the seesaw goes back up.

This experience, however, even with some relief, continues to be difficult. Thus, facing a difficult experience even with support represents the essence of the meaning underage adolescents attribute to taking care of their children.

FINAL CONSIDERATIONS

We believe this theoretical model can contribute to the practice of health professionals and health education and shed light on the experiences of young adolescent mothers and the support they need to take care of their children and themselves, thus facilitating the continuity of their trajectory of life and the construction of their identity.

The different and important aspects revealed are directly related to the second, third and fifth MDGs, which have not yet been fully achieved and that led to reflection on pregnancy/maternity among underage adolescents, the implications and the importance of the role of the nurse in this context.

With regard to governmental action, specific programmes for underage adolescents that focus on supporting their development and the construction of skills and competencies must be rethought. Programmes that seek to improve maternity care services within the public health programmes should also be considered in order to validate actions to reduce pregnancy, recurrence and early return to school among this population.

Evidently, the nurses have the commitment and social and moral responsibility to promote and reduce the inequality and suffering that this experience may entail, in addition to ensuring excellence in care according to the transverse axes of universality, integrality and fairness.

Considering that the experience of caring for the underage adolescent mothers can be different to the experience of caring for other adolescents, and that the grounded theory results should not be seen as unchangeable and the produced concepts can be subjected to more comprehensive and thorough analysis, further studies should involve mothers with a better socioeconomic level in order to broaden the understanding of the experience, since this study was limited to investigating those who live in disadvantaged conditions.

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Publication Dates

• Publication in this collection
  2015

History

• Received
  29 June 2015
• Accepted
  02 Dec 2015