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INTRODUCTION
Adolescence is a time in a person’s life characterized by various transformations involving new ways of feeling and relating. Some people tend to prefer risk and vulnerability, while others veer towards potentiality and development 1. The Pan-American Health Organization (PAHO) places adolescence between 10 and 19 years of age 2, a stage that involves countless complex changes which make it a specially critical time in life. It is important to underscore that changes in adolescence cannot be lumped into a homogeneous group, because there are variations in duration and intensity “according to the times, and the cultural and socioeconomic conditions” 3.
The literature indicates that adolescence ought to be the best years of our lives because of the highest physical and psychological potential, the enhanced ability to enjoy life, love and friendship, and blooming of ideas and creativity 4. When pregnancy occurs during adolescence, besides having to cope with the physical, psychological and social changes inherent to that age, the adolescent girl must face the process of gestation and motherhood, perhaps placing her in a situation of vulnerability 5.
Different authors propose that pregnancy during the teenage years is an issue with negative social and health implications for the adolescent as well as for the nuclear family, and a weighty problem for society at large, i.e., a public health problem, given the growing numbers 6-13. According to World Health Organization (WHO) reports 14, children born to teenage mothers represent 11% of the births at a world level, and they account for 23% of the global morbidity burden attributable to pregnancies and deliveries among women of all ages; moreover, in less developed countries, pregnancy and delivery complications are the primary cause of mortality in women 15 to 19 years of age. The reports also state that Latin America has a high incidence of teenage pregnancies, second only to Africa.
In Colombia, motherhood in adolescence evolved discretely between 2008 and 2014, when 23.4% of the total number of institutional deliveries (1,107,144) were in teenage girls 15. The National Family Observatory points to the fact that the proportion of adolescents between 12 and 19 years of age who have had children or are pregnant dropped from 12.4% in 2008 to 11.9% in 2014. An analysis of the situation in the group between 15 to 19 years of age shows a 2-point improvement, from 19.5% down to 17.5%, while the indicator for the group between 12 and 14 has increased from 1.2% to 1.7% 16.
Many interpretations emerge regarding sexual activity and pregnancy in adolescents, in an attempt at explaining the circumstances and elements characterizing those events. Although sexual activity in adolescents is a multifactorial phenomenon, family characteristics play a key role 17. Granados et al. attach primary importance to the role of the family as the key to shaping the general characteristics of its members 18. Regarding teenage pregnancy, Betancur et al. state that families are complex organizations of varying origins which do not protect teenagers from pregnancy and act only as normalizers when pregnancy occurs 19.
It is essential to recognize the mediator role of the family in the health-disease process of its members. Great confusion emerges when children reach adolescence, and this is compounded by pregnancy during that stage of life, demanding adaptations at all levels. Consequently, the attitude of the family is very important for optimizing health processes beyond biological considerations 20; when this endeavor is insufficient, pregnant girls under 18 years of age become more vulnerable and perceive an undermining of their opportunities to access education, health, and protection, that is to say, to an adequate standard of living, and are forced to take on adult roles by the family dynamics itself 21.
Considering that teenage pregnancy is a health issue with bio-psycho-social repercussions, and given the importance of taking into consideration the coping experiences of adolescent girls when faced with motherhood, the objective of this study is to make a qualitative approach to the original family dynamics and structure from the perspective of the life stories of a group of adolescent mothers seen at Engativá Hospital, in an attempt at acquiring new knowledge to build on the strategies designed to prevent this problem and respond to it. The question the study seeks to answer is “What are the dynamic characteristics of the families of these pregnant girls?”
MATERIALS AND METHODS
Design and population
A qualitative biographical study of a historical type was proposed based on life stories, leading to an approach to the contexts, experiences and beliefs in the family environment of the participants. Life stories may span the entire vital journey of an individual, or refer to an event in that story, or to different time points 21. Complementing this concept, Rodríguez 22 concludes that the biographical method examines the real situation in its natural setting, seeking to “recognize the experience and the validity of reported subjectivities” 23.
The participants included were women who were delivered at Engativá Hospital in 2010 when they were adolescents, whose children were born alive, and who agreed to participate in the study. Pregnant adolescents who did not live in the Engativá borough, who had severe mental disease or cognitive deficit (based on the clinical record or identified at the time of the interview), or whose pregnancy had been the result of sexual violence, were excluded. The study was conducted at Engativá Hospital, now Engativa Health Services Unit (USS) which is part of the Bogota Northern Integrated Health Services Subnetwork (Subred Integrada de Servicios de Salud Norte ESE), an intermediate complexity hospital providing services primarily to a population belonging to the subsidized regime under the Colombian social security system. Convenience sampling was used and resulted in a group of five voluntary participants interviewed in 2016 who met the inclusion criteria and gave their informed consent to share their experiences.
Procedure
Identification of the candidates for the study involved reviewing the databases in search of pregnant women seen at the Hospital during the year 2010; the clinical records were then reviewed to determine compliance with the inclusion criteria and the absence of exclusion criteria. The candidates were contacted by phone and explained the importance and objectives of the study, and were invited to participate freely and equally.
The semistructured interviews used to guide the life stories were administered by two clinical psychologists, members of the research team. A pilot test was run previously, leading to the identification of four large categories: original family, school life, love relationships and life project. This paper reports only the first category in terms of family structure and dynamics. Audio recordings and literal transcriptions were made of the interviews for later analysis.
Measured variables
Emerging categories were identified with the application of text hermeneutics; each of the five researchers analyzed all the interviews independently, and a manual map was later built as work sessions evolved and common subcategories of family structure and dynamics emerged. Triangulation among the researchers was applied in order to improve the validity of the observations.
Ethical considerations
The Research Ethics Committee of Hospital Engativá approved the study which it considered as minimal risk research. It is governed by the principles of beneficence and non-maleficence. Likewise, willingness to participate was reaffirmed by means of the written informed consent. Confidentiality of the information was ensured.
RESULTS
Of the 708 adolescents delivered at Engativá Hospital in 2010, 306 were contacted by phone, while the location information contained in the clinical record of the other 402 was no longer accurate. Of the 306, 18 were excluded on the basis of the criteria definitions; 219 no longer lived in the borough; 35 were unwilling to participate; 34 showed some interest, only 9 agreed and, of them, only 4 complied. All of the 5 teenage girls who agreed to participate lived in neighborhoods classified as income bracket 2 (considered low economic income) and were affiliated to the subsidized health regime. Mean age was 16.8 year, and none of them had completed secondary schooling.
Family structure
According to their accounts, the participants come from nuclear families characterized by contentious relationships between the parents, resulting even in violent events and early separations with reconstitution of new households: “... they would fight a lot and my father attacked her and beat her, and then my mother made up her mind... and broke up with my father” (Participant 1). “... they broke up, my father had made another woman pregnant and the two of us were born almost in the same month; when I was born, my mother found out that the other woman was pregnant, so she broke up with him... and my father has remained totally absent from our lives since then” (Participant 2).
These transformations gave rise to new processes of social interactions in the family where the participants orbited around the new families formed by their two parents, with different fraternity relationships: “... my mother and father don’t event talk to each other, but we do; the two of us are my father’s daughters; one of us lives near him and I live here in Engativá; she gets to interact with him more frequently; my mother entered into that relationship when she already had three children” (Participant 3).
Considering the reconfiguration of the family structures, the fraternal bond results in three potential forms of interactions. Bullying from siblings: “... we had to endure many humiliations from my sister because she would say that she worked, she cooked for us, she would give us things... so we always felt abased... you know... the relationship with my sister was always very difficult, you know?” (Participant 2).
Siblings that take advantage of the other siblings, support being always conditional: “... she worked and she thought too much of herself, do you get me? And she would look down on us as if we were her minions. We would take care of her children, clean the house, wash the dishes… and there was fighting all the time... our mother would beat us because of her” (Participant 2).
Siblings supportive to a certain extent of the personal development of their other siblings: “... my sister Laura taught me almost everything. She taught me how to read, she would tell me where I had done wrong, or would say ‘why on earth did you do that’, if I had done poorly in a test” (Participant 3).
This fraternity plays an important role, even in mediation, as a means to receive and process important life events in the case of one of the participants who comes forward to acknowledge her pregnancy: “... I came home and called my older sister and told her... then she told our other sister and that other sister came to visit one day and told my mother” (Participant 3).
From this perspective, complex family structures stand out clearly from these life stories, revealing weak affective bonds, confusing parental roles, and third-parties who take over the roles of the parents. “My mother does no longer live there, she lives with her husband; we arrived at that little house where my mother worked as a maid… then she found a partner, my brother’s father. But the person who is really family there is my godmother, that is, my mother’s employer; the people there and I are not related, I just arrived when I was 11 months old, and I have since called them aunt and uncle. My mother still works there, but does not live in the house, she lives with her partner; I lived with them until I was 17, when I got pregnant” (Participant 1).
Family dynamics
The stories reveal that these adolescents come from nuclear families where authority tends to be matriarchal, where practical rules and strategies to meet needs are established, where the father figure may be easily challenged and defied, with the mother placed in the position of needing the protection of the older children: “one day, my father beat my brother because he came in asking about our mother; there was a row, they got into a fight, so then my two older brothers began to discuss the need to find a place to live and get my mother to break up with my father, and so it was done” (Participant 3). Absent or removed father figure, “... for example, it was painful for us because our father never went to our school... we never got circular letters because, for the school, we didn’t have a father; he just never showed his face there” (Participant 2). After the father is no longer present, the mother takes on the role of provider while the older children take on the job of raising and caring for the other siblings, “... I spent my childhood under the care of my sisters because my mother worked” (Participant 2); “in fact, my older sister was the one in charge because she was with us most of the time” (Participant 2).
Family norm hovers towards the values of the culture’s feminine ideal: “... my uncles would complain... what a nuisance! she is going to start going out and arriving late, and this and that. It maddened me because ...why couldn’t they trust me? Well, yes, sometimes you make mistakes and you forget the time, or you get home too late or lie and say you’re going to be in one place and go somewhere else” (Participant 1).
The stories also show glimpses of other types of life-style values that turn into growing psychosocial risks in a setting which should offer wellbeing and safety: “many times, my mother or my brothers would start drinking and would send me out of the room to watch television so that I wouldn’t see what they were doing” (Participant 2); “I would drink a lot and Mondays were hangover days; drinking was an everyday thing, and I would refuse to do what my mother asked me to do” (Participant 3).
They also recognize that things such as getting an education are less important considering that housework is imposed on them from an early age, giving rise to specific forms of child labor and pushing them to become early school dropouts: “... I didn’t get an education because my mother said I had to look after my sister’s little girls… they were very young, I would go to the pre-school one day but not the next” (Participant 2). “At the time, my dad made lamps and when we got back from school, he would ask us the help him the rest of the day. My school performance was poor... I was thrown out of school when I was 13, my parents had already split and I never went back to school. So, I started working in sales, first in a grocery store where I lasted three days; on the fourth day I arrived late and they had already closed. I then found an opening to sell clothes but it required peddling, which made me feel embarrassed, so I didn’t get the job. Then I started selling sneakers, a job that I kept for two years. That is where I met the father of my children, who asked me to stop working because he was going to support me” (Participant 3).
The narrations also showed that education in personal matters such as sexuality and affectivity was ambiguous and conflicting in the families of the adolescent girls: “... yes, they would only say that I needed to be careful, and that was all; at that time, my brother was living with his girlfriend at home and my sister too was living with her boyfriend” (Participant 5).
Moreover, these women have given continuity to the intergenerational conflict of their original families, repeating the same power struggle stories and patterns: “... since I was working, I would say to my mother that she had no right to impose, you know? I would give her money for groceries, utilities and other things. So, I said, I am paying for these things so you have no right to complain; and then I would just go away with my friends and do my stuff and not show up in three or four days” (Participant 3). On the other hand, it is worth noting that there are positive, resilient responses, and an inner drive to become independent that results in an endeavor to take charge of their own lives and their new families: “... I live with my cousin and my daughter and I work; I did some practice work in the company where my mother works and know I have a job as production supervisor […] I did two diploma courses with the Chamber of Commerce and that helped me with the implementation of good manufacturing practices” (Participant 5).
DISCUSSION
This study found that pregnant adolescents come from families with issues pertaining to structure and dynamics. As far as the structure is concerned, conflict between parents is poorly managed due to the creation of new households and the development of unclear roles, with a strong fraternal bond which is not always positive. In terms of dynamics, a matriarchal type of authority emerges, with cultural idealization of the feminine; lifestyles which take the form of psychosocial risks in the environment that should provide for safety and wellbeing; less value attached to education; and spaces of ambiguous and contradictory education regarding sexuality and affectivity. Repetition of the same life stories was also identified, as well as positive and resilient responses underpinning an inner drive to take responsibility for the future.
Complex structures and dynamics are identified in the family context of the participants. These families are heavily influenced by a matriarchal line, with a total or partial absence of the father and the presence of extended, single-parent families. This finding is consistent with other conclusions that point to the association between teenage pregnancy and family instability and strife 17,19; likewise, there is a predominance of women heads of households, with the resulting consequences in terms of poverty and lower level of education 24. On the other hand, it has already been described that the context in which teenage girls live is of the greatest importance for healthy development, 25 and that family settings and daily lives of pregnant adolescents are key determinants, beyond mere institutional care 19.
Regarding generational continuation of parental, connubial and fraternal styles where modeled behaviors are repeated, the literature shows that pregnant adolescents receive, internalize and adopt social, reproductive, biological and cultural patterns imposed by the sociocultural environments in which they live 26. It also shows that the majority of teenage mothers become pregnant in mid adolescence 27, power and subservience relationships develop among siblings due to the absence of the parents 16, and prevailing masculinity, under which power relationships are built between men and women, replicates the model of the traditional family 28. WHO-PAHO 2 and other studies 28-31 reaffirm the link between family conflict and the vulnerability observed in pregnant adolescents. It has been described that the original families fail to perceive that they are at risk 32.
Families must work hard to deal with the new situation, and teenage pregnancy defies its ability to cope with crisis situations. The findings in this study indicate that when the participants enter adolescence, which coincides with the start of middle education, families convey the experience of affective and social dereliction; supportive care and family bonds come to a halt, and this is a period during which the families and reference adults assume that the woman is ready and prepared to enter adulthood on her own. After applying the family Apgar tool, Rangel et al. found dysfunction in one-third of the cases studied, more so in the areas of growth and affection, suggesting that adolescents lack emotional maturity, fail to receive support and care from their original family, and feel compelled to hook up with a partner 28. Participants refer to this new experience in their lives as something nice, but they feel uneasy at the thought of having to take on new responsibilities for which they are unprepared. Teenage girls take on the historical role of women as care givers and find that they need to adjust their life plans to accommodate the new role as women looking after someone else. As mothers, or some of them as wives, they end up playing their role in the private realm of the home, allowing their goals and objectives to fall by the wayside 27.
On the other hand, inadequate coping with family conflict, as well as emotional and social abandonment at the beginning of adolescence, may result in breaches of family norms and ensuing punishment. Adding to this, other studies conclude that financial straits in the family, together with inadequate communication, affect not only gestational development but also the development of the family itself 32; communication issues between parents and children, and lack of appropriate knowledge to discuss sexuality, result in postponement of the discussion until the “age is right” 27. Studies also show that, as a predisposing factor, the greater the physical violence, the greater the probability of engaging in early sexual activity 28.
The stories also reveal that support in sexual development and education is characterized by inconsistent experiences and scant information. Other results show that sex education, frequently informal, affects individual autonomy and appropriate decision-making, self-esteem, self-image, bonding with the partner, contraceptive methods, and decisions pertaining to motherhood, father-hood and abortion. The mothers of the adolescents were unable to exercise appropriate social control to supervise dating and sexual behaviors of their daughters 16.
CONCLUSIONS
Our pregnant adolescents live in the midst of families with unfavorable structure and dynamics that prevent the nuclear family from responding appropriately to teenage pregnancy. Consequently, pregnancy is an unplanned and rarely desired outcome, and a situation in which the family just normalizes the pregnancy when it occurs. In this context, pregnant adolescents are the result of a chain of inequities, where schooling is not valued and competencies for coping with life cannot grow fully to become an input for development. The resilience of one of the participants is highlighted as a driver for undertaking new studies that focus on identifying those traits of the individual, the family and the couple that increase their ability to adapt to this new situation.
