Percepções de adolescentes sobre o apoio social na maternidade no contexto da atenção primária Perceptions of adolescents concerning social support provided during maternity in the context of primary care

Objective: To analyze the perceptions of adolescents experiencing motherhood concerning social support. Methods: Semi-structured interviews and network maps were used to collect data, which were analyzed according to thematic content analysis. The participants were 20 adolescents aged between 10 and 19 years old experiencing motherhood. Results: The results showed perceptions of both support and abandonment. The first came from family, partner, friends and access to health services. The second derived from an absence of social support, especially on the part of partners, friends and health professionals. Conclusion: The adolescents perceived support as being fragile and inconsistent. In this sense, nursing plays an important role as it can use the concept of social support as a protective factor, contributing to the construction of integral healthcare and improving the life conditions of adolescents.


INTRODUCTION
The object of this study was social support as perceived by adolescents experiencing motherhood, which was analytically supported by Bullock's theory of Social Support 1 .Social support is defined as an important factor to reduce stress and enhance the development of one's skills to cope with and adapt to crisis situations, which is key to promoting health, as well as to mitigating the negative effects of stressful events affecting quality of life.The manifestation of this construct depends on sources of provided or received support and can be categorized into four types: emotional (affection, esteem, concern), reinforcement (feedback, confirmation), informative (suggestion, counseling, information), and instrumental (help with chores, money, time) 1 .
Social support refers to relationships among people, to the structure and quality of these relationships, and to concrete actions such as material help, sharing of information, being supportive in critical moments of life and sensitive to the perceptions of people concerning all these aspects, which enables them to have greater autonomy and, consequently, satisfactorily respond to intrusive experiences 2 .
Motherhood during adolescence consists of an important time in the life of adolescents and having social support at this time enables individuals to understand motherhood as a process in which women can develop empirical knowledge concerning health and which can extend to motherhood-related experiences, that is, from the time of conception through prenatal care, delivery and childcare 3 .
Even though pregnancy during adolescence is a subject in evidence in the literature, few studies deepen the analysis or enter into discussion of social support directed to the experience of motherhood at this time of life, giving a priority to the pregnancy itself [4][5][6][7] .The conclusion of these studies suggests that support to overcome fear and the challenge of motherhood is needed.Sometimes these studies report predominantly negative experiences and sometimes they reveal predominantly positive experiences.Other studies [7][8][9] conclude that the main sources of social support providing material and affective support to the adolescents included parents, friends, and partners, while the last are the ones who less frequently provided support 10 .In regard to information received, one study conducted in Passo Fundo, MG, Brazil addressing the perception of pregnant adolescents concerning the supply of information during pregnancy revealed that it derives from common knowledge or traditional knowledge, while the emotional aspect is related to the family core, restricted to the closest individuals 8 .The same study showed that extra-family support including health services was fragile, generating psychosocial difficulties, such as dropping out of school, an idealized view of pregnancy and future projects, and a concern with biological aspects 8 .Therefore, it is essential that the routine practice of health workers incorporate actions capable of enhancing social support, as well as able to establish bonds and meet the health needs of these individuals, such as breastfeeding, post-delivery care and health education 10 .
It is important to note that regardless of motherhood, adolescence by itself involves many challenges and changes, and can be a vulnerable moment in life, because adolescents become more exposed and more sensitive to the problems encountered in their social context.Aspects related to health problems, unfavorable socio-economic conditions, school dropout, and difficulties finding a job, can be the main factors contributing to greater vulnerability among adolescents experiencing maternity 2,11 .
In short, when experiencing early motherhood, adolescents should receive consistent social support from their families, the community, school, health services and any other institution capable of providing such support.Therefore, it is extremely important to identify sources of support for motherhood during adolescence.Adolescents who receive this type of support may feel better-prepared to deal with difficulties arising from maternity, possibly, achieving higher levels of health and quality of life 7 .
It is worth noting that, in addition to the study's conceptual justifications, we also sought to answer the following question: what are the perceptions of adolescents concerning social support during motherhood?For that, we analyzed the strengths and weaknesses of social support provided during motherhood from the perspective of the adolescents themselves, in order to contribute to the debate concerning the need to strengthen social support as a protection factor to support the practice of health workers and enable changes in maternal/infant care.

METHOD
This qualitative study is part of a larger study titled: "Adolescence and motherhood: analyzing social networks and social support".Qualitative research enables incorporating the meaning and intention of actions into relationships and social structures, making understanding of the subject-object relationship more likely and to immerse oneself in the meanings assigned by the subject to the object 12 .Specifically in this study, the meanings in question are those the adolescents assign to the maternity process and to the experience of having or lacking access to social support according to Bullock's definitions 1 .
This study was conducted in the interior region of São Paulo, Brazil.The criterion used to select a Primary Healthcare Unit (PHC) was being located in a region with the largest number of live births to adolescent mothers (between 10 and 19 years old) in 2010 13 .The adolescents received prenatal care in this unit.
Data collection was conducted in the second semester of 2010, after the unit's health staff was contacted.The records of the adolescents who were pregnant or had their children in that year were located using prenatal care records and searching the city's health record and information and management system.

Perceptions of adolescents concerning social support
Braga IF, Oliveira WA, Spanó AMN, Nunes MR, Silva MAI Afterwards, the adolescents were visited at their homes, always with the presence of a health community agent or a nurse to facilitate the contact and the parties ability to relate to each other.
A total of 20 adolescents who met the inclusion criteria participated in the study: adolescents aged between 10 and 19 years old, living in the area covered by the PHC unit chosen and who experienced motherhood in 2010.In the first meeting with each adolescent, we presented the study's objectives and those who agreed to participate signed free and informed consent forms.The parents or legal guardians of those younger than 18 years old signed the forms for those adolescents.Interviews were scheduled according to the availability of the participants, held wherever they found most convenient.Confidentiality of the adolescents' identity was ensured by the use of fictitious names from Greek mythology.The group of participants was defined through the saturation technique, which values the contexts and repetition of information provided to the main questions 14 .
Two techniques of data collection were used: Minimum Personal Social Network and semi-structured interviews.The Minimum Personal Social Network, proposed by Sluzki 15 , is composed of a drawing consisting of a circle divided into four main quadrants (family, friends, school/work and community relationships); one small fraction of the quadrant is marked by a dotted line that represents bonds with health systems and social services.These quadrants are filled with inner circles that indicate close relationships and those personal relationships with a lesser degree of commitment, without much intimacy, and the more distant that represent occasional relationships 15 .See figure 1.
In regard to data analysis, the maps were initially gathered in groups to identify the quality of bonds and relationships.Afterwards, the illustrations' structural characteristics were assessed according to the following criteria: size (amount of people: few, average or large); density (quality of bonds: meaningful, fragile, broken, nonexistent); distribution/composition (number of people or institutions in each quadrant); dispersion (geographic distance among members), and homogeneity or heterogeneity (diversity and similarities that compose the map).
Interviews were analyzed according to thematic content analysis taking into consideration the system of categories that emerged from the content, accounting for the frequency of the themes extracted from the set of reports, evaluated as segmented and comparable data 16 .
The analytical process followed the steps of: (I) organization and classification of data, transcription of the recorded interviews and focal groups, skimming and organization of reports, seeking a view of the whole set and reaching an initial classification; (II) exhaustive and repetitive reading of the material collected to compose the "corpus" based on the theoretical framework and the study's assumptions to construct relevant structures and thematic cores identified in the reports of the social actors; (III) final analysis, consisting of a dialogue between the empirical material, which is the point of departure and arrival of the analysis, and information provided by other studies and this study's theoretical framework, was established 12,16 .
Afterward, the results obtained from the maps and those categorized by the interviews were compared to develop an interpretative synthesis, seeking to relate the themes described and analyzed with the study's objectives, questions and assumptions.
All the study stages complied with requirements and guidance from Resolution 196/96 concerning ethical aspects regulating research including human subjects.The study was approved by the Institutional Review Board at the University of São Paulo at Ribeirão Preto, College of Nursing (EERP/USP) protocol Nº 0234/2010.

RESULTS AND DISCUSSION
A total of 20 adolescents experiencing the maternity process participated in the study.All attended prenatal care and health follow-up at the PHC unit chosen and had full-term pregnancies without complications, according table 1.
Two thematic categories emerged from data concerning the perception of social support held by adolescents experiencing motherhood: Existent and significant support and Feelings of abandonment.

Mapping social support
Twenty maps were constructed, two of which were selected to illustrate configurations of support identified by the participants.The first (Figure 2) presents a configuration in which support was The maps were built with each participant who were also individually interviewed using a semi-structured script that included four dimensions: 1) experience of becoming pregnant; 2) services and people accessed during the pregnancy; 3) search for information about becoming pregnancy; 4) services and people accessed after the child was born during the initial care provided to the baby.This study presents an analysis concerning questions related to social support (dimensions 2, 4).Interviews were recorded and later transcribed.
Non-verbal information, observations and some additional information concerning the interviews were recorded in a field diary, which broadened interpretation and enhanced the analysis.

Perceptions of adolescents concerning social support
Braga IF, Oliveira WA, Spanó AMN, Nunes MR, Silva MAI perceived as meaningful and present while the other represents a feeling of abandonment (Figure 3).The mapping process of the social support provided to some adolescents showed that the quadrants of family and friends were broad and meaningful.The qualification of bonds present heterogeneous and significant density with almost no gaps in their composition.We highlight the presence, in many maps, of bonds with health professionals, social service providers, community health agents, physicians, nurses and social workers.
Data from Figure 3 show that the feeling of abandonment derives mainly from gaps in the bonds established with the individuals' families, partners, and friends, characterizing smaller maps, with fragile, broken or nonexistent density with important gaps and dispersion.
Two thematic cores were identified in the analysis of the maps after the material collected during interviews were organized, carefully read, the particularities were analyzed and data were qualitatively assessed: 1) Existent and meaningful social support and 2) Feelings of abandonment, which are described and analyzed as follow.

Existent and meaningful social support
The analysis of meaningful relationships in the lives of the adolescents in this study enabled identifying who shared their We note that the families of adolescent mothers face the hard reality of a social phenomenon, for which they often are not prepared.In this sense, the families also require care and support so they develop the ability to accept and deal with the situation, the adolescent and newborn child.The family needs to deal with new financial, emotional and social demands, in addition to other potential family conflicts 7 .
In addition to this domestic context of support, some health workers, such as the community health agent, nurses and physicians, social workers and teachers, were also mentioned by the participants as sources of social support.

[...] At school, after I became pregnant, everybody loved it, it was well accepted, everybody loved the idea. (Tessala).
The health services were accessed by the adolescents who mentioned the support of at least one professional.It shows that these services are accessed despite reduced support.The adolescents require professional support also in the provision of care for their infants, which shows the importance of the support provided by public social and health services 8 .
Corroborating the results of this study, another study 9 also identified the concern of adolescents with biological aspects and for this reason prenatal care was initiated early on and maintained for the entire pregnancy.This search for health services generates demands and when these demands are met, they strengthen the feeling of social support received in this dimension.
Concerning the types of support perceived during motherhood, the adolescents indicated four: emotional, informative, instrumental and reinforcement.
In regard to emotional support, the adolescents felt supported and embraced by their families, friends, and partners, especially during pregnancy.Reinforcement support is apparent in their statements, as well as positive feelings acknowledging support.anguish, doubts, uncertainty, suffering and joy and from whom they received support at this time in life.The adolescents mainly listed family, friends and partners as being supportive.

[...] My mother, my mother helped me a lot, he, Hercules (husband) helped me, [...] my aunt, my cousins, my father-in-law. (Hestia). [...] My mother, my husband, my father, [...] aunts, uncles, my godmother, my cousins, [...] from the family... only these people. (Hera).
Mainly families provided the social support necessary to strengthen the adolescents, enabling them to achieve a better quality of life and reduce factors of vulnerability.The study participants indicated their mothers were central figures in their family support, with whom they maintain intimate and meaningful relationships.The partners were, for some adolescents, a source of trust and intimacy, with whom meaningful bonds were established.In the process involving motherhood, specifically during adolescence, these close people are important in providing emotional support, reinforcement, and informative and instrumental support to the adolescents 8 .
Social support provided by the family contributes to a calmer and more stable pregnancy 3 and can alleviate the impact of events that negatively affect health; it is essential for the adolescents to feel confident and safe at the time they face maternity 7 .

Perceptions of adolescents concerning social support
Braga IF, Oliveira WA, Spanó AMN, Nunes MR, Silva MAI As already mentioned, the family's role is extremely important when adolescents face pregnancy, because the family can provide emotional support and also help them provide care for the baby.The family often helps with the responsibilities and accumulation of tasks with which the adolescent has to cope.Social support coming from the family causes the adolescent to feel able to overcome fear and a feeling of maternal incompetence.When these young mothers are satisfied with the social support received, they also have a feeling of wellbeing, which enhances their quality of life 7 .
In regard to friends, adolescents also felt they were embraced at the time they shared the news about their pregnancy and their feelings regarding it.Friends are a great source of emotional support, especially during adolescence, a period in which the group of friends exerts strong influence and value for adolescents 9,10 .Support provided by friends helps adolescents experiencing maternity feel understood, assisted, supported and guided 7 .
In regard to informative support, which deals with suggestions, counseling and information, the adolescents also felt supported by family members, friends and health workers.

[...] I don't even know how to explain, but they've helped me a lot, guided me, talked a lot [...] how to bath the child, these things, like... how to care, how to prepare food. (Hera).
The participants consider the health workers to have provided social support, which is relevant for affective support and, mainly, informative support.Adolescent mothers are empowered when they receive information and encouragement and develop the ability to provide quality care to their children, with less physical and emotional weariness 7 .Availability to listen or counsel, to show affection, concern and care, were listed by the adolescents as an important support provided by professionals, an aspect that can enhance their perceptions concerning other types and sources of social support.
Instrumental support refers to the practical and direct assistance in concrete activities and problem-solving.The adolescents felt supported in this aspect, mainly by mothers, friends, and partners.They were educated and helped when caring for their baby, and also received help in housekeeping.Instrumental support also meant financial resources and material required for the adolescent to be able to support and care for their child.This type of support was received both during the pregnancy and after the infant was born.

[...] C., the social worker helps me sometimes and also when I asked her to help me apply for government financial aid. (Selene).
[...] My mother helped me a lot, to give the baby baths, change, care for the belly button, she helped me with all these.(Ariadne).
[...] Like, when I need things, clothes, these things, they give me, everything I need they help me, they help me in any way.(Ilithyia).

[...] Only my husband provides financial help (Circe).
[...]He helps, but he (partner) works during the day, he helps me when he gets home.He baths her, feeds her, he helps me a lot.(Hera).
The type of social support they are referring to, i.e. help performing activities and daily interactions with the baby, favor their wellbeing.Research has shown that meaningful involvement with family and friends promotes one's health.For that, health workers should understand the nature of the influence concerning the social support provided, especially that support provided by this category of individuals, and use such resource to minimize the individuals' vulnerability, improving their quality of life 1 .
Additionally, there is a need to increase the reach and coverage of health services in order to provide social support to adolescent mothers.Because it is a situation of vulnerability, support is even more essential and, for that, appropriate planning is required, especially for multidisciplinary teams to provide instrumental and informative support.

Feeling of abandonment
This core portrays a feeling of abandonment experienced by the adolescents, whether by a lack of social support on the part of certain people or the absence of some type of support during the pregnancy and after delivery, or both.
Those who did not provide social support, from the perspective of the adolescents, included the children's parents, friends, some health workers and teachers.

[...] no, none of my friends helped me. (Hera).
[...] Ah I don't know, like, the physician didn't explain well, at the beginning of the pregnancy, I had pain at my bottom of my tummy, I was afraid I'd lose him.(Hebe).

[...] Even the teachers make comments, they treat you differently, it's not the same you know, it's weird, they don't treat you like they treat others. (Artemisia).
We note that some adolescents felt abandoned, especially in relation to friends and partners, showing fragile, broken, or nonexistent relationships.This type of experience overloads the adolescent mother, who may become more anxious when she realizes there is no one on whom she can rely, leaving her to feel abandoned and vulnerable 7 .When the partner abandons the adolescent, other people need to step in and provide social support and help care for the infant.

Perceptions of adolescents concerning social support
Braga IF, Oliveira WA, Spanó AMN, Nunes MR, Silva MAI The participants believe that, despite the strong social support received during the pregnancy, their friends became distant with the infant's birth, showing the mutable nature of social support, according to the history and time of life of those involved.Friends did not provide any other type of support, not even emotional support, which had been provided before.
[...] Wow, it changed a lot, it was better before, now everything has changed, friendships, I have no more, my friends went away.[...] I had many friends before, but now I have no one.(Gaya).

[...] Like real friends... I only have friends for a spree, but to help me here, nobody comes. (Phoebe).
Hence, friendship relationships, especially after the infant was born, became distant and unstable, and this study's findings show how the social life and routine of these adolescents changed after maternity.The friends often do not understand or acknowledge these changes and distance themselves.
In regard to the fathers of their children, the adolescents reported a lack of instrumental support after the child was born.

[...] He (child's father) helps sometimes, I call him and he gives me something but he complains. (Hebe).
[...]He first assumed fatherhood of the child, but then disappeared [...]He barely comes to see her, doesn't pay her support, one month he pays, the next, he doesn't.I found out, after I was already pregnant, that he had another family, so I split up.(Selene).
The feelings of abandonment these adolescents experienced on the part of their children's fathers was apparent.This lack of support was even more evident after the infant was born.The fathers did not pay child support, nor did they provide care or support to the adolescents or children.
It is known that lack of support from those the adolescents would otherwise take as models or depend upon makes them fragile and introduces feelings of abandonment, revolt and guilt, with consequences for the health of both mothers and children 17 .This feeling of abandonment is not only related to the real absence of these figures, but also to a lack of affective bonds or to emotional difficulties that may pose risks to the development of the children of adolescent mothers 8 .
The participants specifically reported lack of social support on the part of health workers because, at different points in time, they had many doubts and were unaware of many basic aspects of motherhood.

[...] Ah I don't know, like, the physician didn't explain it well, at the beginning of the pregnancy I had pain at the bottom of my tummy, I was afraid I'd lose him (Hebe).
Healthcare provided to adolescents experiencing the maternity process should value needs of the adolescents; understand their sexuality; facilitate access to information regarding topics from contraceptive methods up to their right to make choices and regarding childcare; ensure access to prenatal care and maternity through qualified professionals sensitized to the processes of life, valuing the individuals' sociocultural contexts, and aware that healthcare units are places that can provide significant support to the community.Therefore, these services should reassess their role in society and become important spaces to embrace people and strengthen health-promotion policies, contributing to the alleviation of the vulnerability of these adolescents and improve their quality of life 18 .

CONCLUSION
Social support can be a protective factor in the face of a situation of vulnerability, enhancing the life conditions of adolescents experiencing maternity.The perceptions of social support directed to maternity during adolescence reveal that the support these participants received was sometimes offered, significant and relevant, and other times, support was faulty or even absent.
The identification of the social support provided to adolescent mothers on the part of the health workers, or a lack of it, enables them to have greater understanding of the potential of such support in regard to health and health promotion.In this sphere, cooperation among the health services and their staff is important to the process of transforming situations of vulnerability in order to put into practice the rights of the adolescents to have a healthy pregnancy.
This study contributes to knowledge from the public health field, as it enables discussing social support as a resource that can enhance the practice of health workers in understanding and meeting the needs of adolescent mothers, to properly assess resources and the direction of individual and collective actions concerning health care delivered to this population group.Further studies, however, can broaden knowledge on the subject, seeking to discuss it in order to construct integral care intended to minimize harm and negative feelings related to maternity during adolescence.

Table 1 .
Characterization of the adolescents participating in the study according to age, marital status, number of children and with whom they lived