ORIGINAL ARTICLES

Attention to the parturient adolescent: access and reception – a descriptive study

Thais Jormanna Pereira Silva¹, Maria Veraci de Oliveira Queiroz¹, Francisco Herculano Campos Neto¹, Viviane Peixoto dos Santos Pennafort¹

¹Ceará State University

ABSTRACT
Aim: To analyze the access and reception of adolescent mothers in the parturition stage in obstetrics emergencies.
Method: This is a descriptive study, with data collected through the interviewing and observation of twelve adolescent mothers, in the Sector of Obstetrics in a tertiary hospital of the public hospital network of the municipality of Fortaleza, Brazil.
Results: The first category was the access that adolescent mothers had to a hospital unit, including the journeys that they made and the physical structure of the hospital. The second category was the reception that the adolescent mother received at the obstetric emergency.
Discussion: This study observed the precariousness of the physical structure of secondary hospitals, which leads to mass transference of pregnant women to higher complexity hospitals. Some women reported positive feedback as a result of the cordial and affectionate attitudes of the professionals they encountered. Other women, however, commented on the lack of understanding amongst health managers and policymakers regarding their specific needs.
Conclusion: Greater attention needs to be paid to adolescent mothers, especially during the delivery stage, where it is essential that genuine bonds are generated for the benefit of the parturients.
Descriptors: Nursing; Women’s Health Services; Pregnancy in Adolescence

INTRODUCTION

Adolescent pregnancy is a significant social and health issue because of its physical, psychological, social and economic implications. Pregnancies in Brazil tend to be unplanned, and in some cases unwanted. Nevertheless, risks during pregnancy can be minimized when is the process is supported by a professional healthcare team responsible for pre-natal care^(1,2).

As the adolescent moves into the first stages of motherhood, the normal course of her life is interrupted and she is faced with a number of dramatic transformations. These transformations will directly affect any studies the adolescent is undertaking, and of course her family life and her personal, social and professional development⁽³⁾.

In light of the findings of this study, it is important to consider that although biological complications during adolescent pregnancy are often related to the immaturity of the patients’ bodies, in many cases it is due to inadequate practices and habits of the hospital and the unsatisfactory pre-natal care that it offers. Other risks can also be minimized when these youngsters are able to confront and adapt positively to the circumstance of their pregnancy, by seeking support from their friends and family⁽⁴⁾.

Considering the complex lives that these adolescents seem to live, it is necessary that special attention be given during the whole period of their pregnancy and delivery in order to alleviate the aggravations of early pregnancy⁽⁵⁾.

These teenagers find it difficult to access certain health services for a number of reasons, including personal financial reasons, distance and availability of beds. Furthermore, hospitals often struggle to admit such adolescent mothers, partly due to high demand, and staff shortages. I addition, despite the fact the Brazilian Unified Health System (SUS, in Portuguese) insists on universal and equal access to health for all, the path that adolescent mothers take to the delivery services is unacceptable, and requires much adjustment⁽⁶⁾.

However, as access to health services, including reception at the hospital and support from pre-natal to follow-up from a health team are guaranteed to the pregnant woman, it is possible to have a satisfactory, comfortable and safe pregnancy. These adolescents experience a higher than necessary feeling of insecurity during the obstetric moment.

From this perspective, the concepts and practices of caring for the adolescent are based on what the healthcare providers deem necessary. The attention that the adolescent is given at this stage is very important for actual care providers and academic commentators, as it can impact on aspects of humanization and the formation of citizenship⁽⁷⁾.

In order to guarantee access to health services and as a way of organizing support networks, government public policies and programs (of varying complexities) are gradually implemented in federal, district, state and municipal levels. The primary care network of today is ineffective, and based on an integrated health system. As a result the hospitals are under extreme pressure and face excessive demand, pushing their responsive capacity to the limits, necessitating long waiting times and poor service⁽⁶⁾.

In light of this, we turn next to the access and reception of adolescent mothers admitted to the obstetrics emergency department in a tertiary hospital. The surrounding literature suggested that it would be difficult to foresee how these elements would be integrated holistically into care^(5,6). This essay will approach this topic by investigating how female adolescent health is prioritized in the agenda of Brazil’s Ministry of Health.

This study reflects on various possible scenarios for patients and for health team members in the caring of adolescent mothers during the delivery stage. This article forms part of a wider study (coordinated by one of its authors) of the path of adolescent mothers to the delivery stage at a tertiary hospital. This part of the study aims to fulfill the following objective: to analyze the access and the reception of adolescent mothers during the delivery stage in the obstetrics emergency department.

METHOD

This is a descriptive study, with a qualitative approach, which investigates the experience of adolescent mothers, and how this experience relates to their social context. This study was developed in the Obstetrics Sector of a public tertiary hospital in the Brazillian municipality of Fortaleza. The hospital is an SUS hospital unit that specializes in high-risk pregnancies. The sector is divided into various units, including the obstetrics emergency, the ambulatories, the obstetrics center/delivery room, the hospitalization unit, and other diagnosing and therapeutic support services. This article focuses on the obstetrics emergency department.

The subjects of this research were adolescent mothers assisted in the obstetrics emergency and hospitalized during the delivery/parturition stage. The choice of these subjects, which includes mothers from ten to nineteen years of age, was intentional, and was made during first contact at the hospitalization unit. Subjects that were excluded from the study were women that: were physically or mentally incapable of answering the questions, had abortions or stillbirths, and adolescents that were hospitalized for other reasons than parturition. The number of subjects was chosen using theoretical saturation, a tool used to establish the final size of the sample. This tool dictates that the limit is reached when the information provided by the new participants of the interview no longer contribute significantly to the data already obtained, and will not improve the theoretical reflection of the data⁽⁸⁾. Ten pregnant adolescents were interviewed in the period of April to June 2012.

Data was collected using systematic observation and interviews based on the following guiding questions: How was the access to the hospital? How were the professionals that took care of you? Describe your experience of the reception in this sector. Describe your most pleasant experiences in obstetrics emergency.

The analysis of the date was divided into three stages: pre-analysis, material exploration and treatment of results, and interpretation⁽⁹⁾. In order to achive the aims of this study, superficial readings of the material and the constitution of the corpus were necessary. A classificatory operation is the part of material exploration, in order to achieve the core aims of the article.

Using this analysis and interpretation, it was possible to describe reality from the point-of-view of the participants. Therefore, the following categories were determined, each one representing the content of the testimonies of the subjects: access to the hospital unit (the path taken by the adolescent mothers and the physical structure of the care unit), and the reception of the adolescent mother in the obstetrics emergency. The testimonies of the adolescent mothers were identified by the letters “MA”, followed by a number.

This research project was approved a Committee of Ethics in Research of the studied institution under registry number 190505/10. All ethical and legal aspects were followed, according to the Resolution 196/96 of the Brazilian National Health Council, by the signature of the Free and Clear Consent Agreement by the participant or the legal responsible when the teenager was under the age of 18 years old.

RESULTS

The results of the study showed that the majority of the parturients were unemployed, lived with the father of the child and come from state’s capital, Fortaleza. Furthermore, of the twelve parturients, nine were in high adolescence (between 15 and 19 years old), and just one was still studying. Also, for eight of the twelve adolescents, this was their first pregnancy. Finally, all subjects had at least six consultations, as required by the Brazilian Ministry of Health, and five of them were held in hospitals. Clinical care is part of the service provided by obstetrics emergency departments. This, along with the relationships that are built by mothers with health professionals, is an important aspect of the experience of adolescent mothers during the stage of parturition.

Access to a hospital unit: paths taken by adolescent mothers and the physical structure of the care unit

Two adolescent mothers reported that, initially, they looked for health service in their neighborhoods to deliver their babies. However, the hospital did not have an adequate structure to guarantee a safe delivery, as it was predicted that the newborn would need a neonatal incubator. Hence, they were transferred.

I was sent here. I came from the hospital from my neighborhood because they didn’t have a neonatal incubator. (AM7 and AM11)

In another testimony, the parturient said that she was transferred to the hospital researched by this study as she was at risk of eclampsia, one of the main causes of maternal mortality in the Brazilian state of Ceará today(10). The same was observed in another testimony, despite the fact that other adolescents reported additional occurrences or risks in the final stages of pregnancy.

I was transferred to here because my blood pressure was too high, and then I didn’t get better, and my pressure went up again, and then they sent me here. (AM2)

The testimonies of the mothers revealed the inaccessibility of the physical structure of secondary hospitals, both in the capital and in other parts of the state, and the resultant need to transfer to higher complexity hospitals.

The hospitalization of these patients can occur as a result of spontaneous demand from the obstetrics emergency department, the regulation center for beds, or by the bed allocation system of the municipality of Fortaleza, or even by the state’s available beds system. Usually the tertiary health service is not prepared to support this demand without previous contact, as demonstrated in the following testimony:

] I was at the maternity hospital Y and they didn’t have enough physical structure to take care of me. Then they told me they would transfer me here without “hospital” allowance. [...] The doctor said a lot of things, he said this was not supposed to happen, because they could sent someone who has something serious, and then there is not a bed, no place for the person to stay. The person is dropped there. (AM8)

Reception of adolescent mothers in the obstetrics emergency department

In regard to the reception of mothers, this study tried to collect testimonies that demonstrated the conditions of this reception, especially in terms of the actions of the caregivers, raising the discussion of integrity. This study focuses on the needs of these adolescent mothers, and the relationships that the built with the hospital professionals.

From the testimonies of the mothers, the reception in the obstetrics emergency was seen to be satisfactory as a whole. The following quotations exemplify this.

] I think she is a nursing technician (...) treating any person as if they were her private client. She used to go come here frequently. She was the person I was most connected with, who helped me when I was needing the most, in the way I was feeling. (AM8)

The doctor and the nurse were so polite, they were not rude at all! The nurse used to play with us to make us feel more comfortable, and because she was young as I am, and understood me when I was speaking or not. (AM7)

During the observations, it is important to mention that sometimes the nurse was unable to have a more welcoming relationship with the adolescent because the professional had a number of other responsibilities which often occur simultaneously, including the various administrative necessities at reception and the transference of the teenager to the obstetric center, the transference of patients to other hospitals and other managerial activities in the unit. Therefore, it is necessary that two nursing professionals be present in the unit, so that the administrative activities are shared between them.

On the other hand, some testimonies demonstrate a sense of dissatisfaction with the caring service provided. The following testimonies show situations in which the adolescents did not feel welcomed to the service in the obstetrics emergency:

The nurse was really boring. She did the stuff as if I knew everything. She was supposed to explain things. It was my first time. (AM5)

The physician that was taking care of me was really, really, really boring. I didn’t like her because she told be I had worms. I hated her. (AM9)

It was seen as important that the professional identify him/herself to the patient (name and category) so that the adolescent is aware who is providing the caring service, and ensuring a respectful and affectionate channel of communication.

They came in, said they were going to stay with me, taking care of me. Then they introduced themselves, saying their names, but there’s one I can’t remember the name. I was in so much pain that I didn’t even pay attention. (AM3)

A nurse assisted me, I think. I don’t remember many things. I’m not sure if it was a physician or a nurse. She mentioned her name, but I’m a not sure (...) All professionals acted the same, exactly the same. I think they were all the same. It was all the same way. (AM11)

DISCUSSION

Some adolescents that searched for caring in other health unit were sent to the studied hospital because they showed risk of complications during the pregnancy cycle, and therefore needed differentiated care, with more advanced resources and professionals qualified to provide specialized care.

Access to health units is considered important, and is seen here as an element that leads to a holistic service and must be guaranteed to the pregnant adolescent. It is also considered imperative to clear (or at least minimize) any obstacles to the admission of adolescents to the healthcare network, as proposed by the Brazilian Ministry of Health. The point at which the patient is received at reception and explains her situation, and the paths taken to resolve this can be described as the “entry door”⁽¹¹⁾.

Access refers to the experience of the adolescent in their paths to the entrance of the studied hospital unit. Two factors were observed in regards to access: the first one refers to the structural conditions of the original healthcare unit used by this pregnant adolescent, and the second the “peregrination” up to a specialized service. The longer the distance travelled by the parturient, the harder it is to access the services. In these conditions, the “peregrination” in the search for healthcare, and many times the ongoing delivery can become complicated and of high risk⁽¹²⁾.

Other studies have looked at  the difficulties found in a holistic healthcare service for women related to the biomedical reductionist approaches, structural questions that limit the access to health and the commitments in quality and quantity of the healthcare service provided⁽¹³⁾.

From this perspective, the responsibility of the central of beds is to find the best option. However, the formal, organizational and agreed mechanisms are often unable to singly respond to the necessities imposed on the unit on a daily basis⁽¹⁴⁾.

On the other hand, it was seen that in some cases, the cities of the Brazilian state of Ceará (except its capital, Fortaleza) did not have enough structure to provide care to its patients, and after contacting the central of beds, they do not wait for a vacancy and send the patient to another healthcare service without a previous note. This sort of mistake can compromise the quality of the healthcare service provided due to the overpopulation of the obstetrics center and neonatal unit and the shortage of professionals based on the real demand.

The quantity of adolescent mothers that have their deliveries in the capital coming from the rest of the state must also be taken into consideration. This situation was seen in Fortaleza, in 2010, where there were 7,959 deliveries by adolescent mothers, of which 6,375 were residents of the capital, while 1,346 were performed in cities other than the “Rede Cegonha” (in English, Stork Network) between Fortaleza and Cascavel⁽¹⁰⁾.

The studied hospital has a duty to avoid sending patients seeking healthcare back at all costs, respecting the principles established by SUS and the “Rede Cegonha”. This last network aims to organize a system of maternal and child healthcare service, guaranteeing access, reception and solvability. The identification of networks calls attention to the problems of access, identifying areas with little attention, finding choke points, or opportunities of desconcentration and alternative regionalizations, and the classification of fluxes according to the structure of the network, all of which provide rich material for investigation⁽¹⁵⁾.

Once arrived at the hospital, it is also important that the health professionals generate a welcoming environment for the mothers. Consequently, all professionals involved in the hospital can and must be welcoming. They must also listen to the patient in order to understand the issues raised by the adolescent mother, consolidating the bond and the responsibility between professionals and the patient, and permitting her to have humanized care according to the directives of women’s health, by SUS.

It was observed that as soon as the adolescent arrives at the healthcare unit, it is imperative that healthcare professionals be attentive and listen to these women so as to ensure that they feel welcomed and safe because at this point they are often anxious and exposed to many risks.

The reception that the mothers receive reflects the attitudes of the professional in showing their commitment to welcoming this mother, listen and treat her, taking into consideration her needs, and then building a relationship of mutual interest in order to resolve her demands.

In this study, the caring of the Sector of Obstetrics Emergency was considered satisfactory by the adolescents, and this was related to the way in which the professionals got close to the patients by listening to their needs, minimizing their tensions, guiding, providing support and, to a certain degree, becoming responsible for the caring of the adolescent mothers.

Based on this interaction between professional and patient, it is possible to deduce that one adolescent (AM7) may have experienced professionals that were rude, because she emphasized the fact that the physician and the nurse of the studied hospital were “ignorant”. Other testimonies refer to the positive experiences of the healthcare service. It was mentioned, for example, that the nurse was “younger”, which insinuates the possibility that this professional was more able to understand the needs of the adolescents.

Another reported of a meaningful interaction between patient and healthcare worker when the latter was evaluating the emotional status of the adolescent mother. The nursing technicians were mentioned as having especially close contact with the patients, who built relationships based on trust, perceiving needs beyond those made explicit by the patients.

The health professional will not see it as possible to build relationships with patients where they are tied up with administrative/bureaucratic responsibilities⁽¹⁶⁾.

However, some adolescents mention some dissatisfaction with the care that they received, commenting that some professionals were not cordial or attentive, and in cases failed to meet the needs of the adolescents during this very special moment.

This study considers the positions of various authors in the literature, while trying not to generalize about the experience of these individuals, which consist of their own particularities. At the delivery stage the mother experienced a considerable charge of anxiety, which can quickly turn to happiness and joy on realization that the baby is healthy, and that there were no surprises at birth. Care should therefore be the main motivation of the healthcare professionals in the obstetrics emergency departments.

The majority of professionals providing the care, on first meeting with the mothers, showed their identification and interacted cordially with them. However, in some cases the professionals were not interested in whether the adolescent had understood the message. We might say, therefore, that the communication was not clear enough.

In the Obstetrics Emergency department all professionals (inc. physicians, nurses and nursing technicians) use the same uniform as a standard of the hospital. It is therefore complicated for patients to tell these different professionals apart, especially when it came to identifying the nurse.

It is worth noting, however, that the adolescents also attributed such mistakes to the pain, fear, anxiety and tension that they were experiencing, rendering them less able to register the name of the professional. Other adolescents attributed this to the large number of professionals that cared for them, often a range of staff from more than one sector with alternated shifts. Where the professionals are more flexible and their actions less ritualized, they are more likely to engage in the sociocultural aspect of their work, working together to enhance professional relationships and provide better reception and access to the adolescent mothers⁽¹⁶⁾.

There is also a political dimension to these relationships between professionals and the parturients. It is important here to remember that a professional must present themselves in a way that informs the mother who they are, and what they do, as with each role comes with it a different power relationship, and varying limitations.

Hence, the listening, the accountability and the building of bonds, with the insertion of the gender approach, provides to the parturients, the possibility to be a subject included in a project involving the reorganization of the practices of holistic care⁽¹⁷⁾.

The challenge is to find a way of communicating the importance of interpersonal relationships to healthcare professionals, and to have them incorporate this into their daily practices. A realization of this will permit meaningful changes in the provision of care.

CONCLUSION

This research has shown that the paths taken by the adolescent mothers during parturition were unsatisfactory and inconsistent, as they depend on transferences and vacancies in a high-complexity sector. Moreover, this complicated path can implicate the mother and the baby physically. This process can be improved, however, with meaningful care. Listening to and welcoming the mothers at all stages of the delivery will alleviate stress for the mother, and her perception of safety will facilitate the birth.

In terms of reception, it is important to note that some professionals failed to indentify themselves, and the mothers were unable to differentiate the professionals. Especially considering the rate at which various professionals change shift, it is ever more important that professionals identify themselves in order to start a caring relationship.

Once these young mothers express their needs, it is important that qualified professionals are present to provide humanized care during partition in order to maintain the mothers’ physical and mental health.

The results demonstrated the care provided and the interpersonal relationships formed at this stage for young mothers, especially those formed between the mother and the nursing assistants. The fragility of these relationships between these professionals and the mothers was observed, indicating that more attention needs to be paid to mothers’ demands including: knowing the context of the life of the parturient so that caring has the highest effect possible, intensifying listening, giving more importance to the professional showing identification in order to build relationships with the adolescent mothers.

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Contribution of the authors
Thais Jormanna Pereira Silva: development and review; Maria Veraci Oliveira Queiroz: research tutoring and review; Francisco Herculano Campos Neto: development and review; Viviane Peixoto dos Santos Pennafort: discussion of results and review.

Received: 28/02/2013
Revised: 27/10/2013
Approved: 11/11/2013