The correlation between social support and attitudes of teenage girls towards their pregnancy and childbirth

Introduction

Providing social support for a teenager during pregnancy and after giving birth is indispensable. It should involve not only taking care of the newborn but also helping the girl find her way in the new situation. Pregnancy and childbirth mean a new stage in a woman’s life, but it is also a new stage in the life of those closest to her. Most reproductive-age women prepare for pregnancy and giving birth, both physically and mentally. From the medical, psychological, sociological, and legal perspectives, the moment of bringing a new life into the world, together with the whole period of pregnancy, childbirth and postpartum, seems to be one of the most important events, affecting the whole future of a woman, her child, and her family. A woman’s attitude towards her pregnancy and childbirth is shaped by a variety of daily life factors as well as factors pertaining to her personal life, which have a significant impact on the final shape of this attitude.
Social maturity is the ability to make responsible decisions [1]. The support of parents, close family and relatives, as well as teachers and peers gives an adolescent mother a sense of being less isolated, lonely, and rejected, and influences her desire to continue education. Family is a fundamental social base and a primary environment providing for material as well as emotional and spiritual needs. Well-being in motherhood, especially teenage motherhood, depends on various forms of social support. Both older and recent literature reports that adolescents who lose contact with their peers become socially isolated. On the other hand, providing them with support contributes to a sense of satisfaction in life, and reinforces proper maternal attitudes and parental acceptance [2–5].
There are several types of supportive behaviours. The most common are emotional, informational, instrumental, and appraisal support. Each of them aims at reducing stress, increasing the quality of life and managing crisis, bringing about psychological well-being [6–9].
It is assumed that one of the most important sources of social support is family, where, through a positive emotional bond, it is possible to satisfy the psychological needs of its members, especially the need for security and safety, belonging, solidarity and connection with the close family members, the need for acceptance and love. Close ties with immediate family provide protection against feelings of alienation and strengthen endurance. In addition to the support coming from the family (husband, children, parents, siblings, and relatives), literature on social support indicates also other sources such as friends, acquaintances, and neighbours [9].
Pregnancy and childbirth have an impact on the system of values and subsequent life attitudes of a teenage woman. Every crisis situation – and pregnancy, childbirth, and postpartum in an adolescent woman certainly constitute one – can contribute to personal development, initiate functioning on a higher level of maturity, and lead to a release of new abilities and formation of new attitudes and behaviours. A teenage mother can benefit from her situation provided she is offered effective help, and prenatal and postnatal care and support. How a young mother handles the new situation depends largely on how she is perceived in her family, society, and her peer group. If she is negatively perceived, help at various levels may be difficult to provide. The adopted attitude can go from extremely negative to positive, from a total rejection to acceptance and giving the mother all the care she needs [10–14].
There is a lot of research available on the role of perinatal social support and on maternal stress [12, 15]. There is no research, however, on the correlation between the social support and the types of attitudes towards pregnancy and childbirth in adolescent girls.
For the purpose of this paper 3 terms were adopted to describe a woman who gave birth before reaching the age of 19 years: ‘young mother’, ‘teenage/adolescent mother’, and ‘teenager/teen’. The selection of terms was preceded by an analysis of terms used in the literature and in everyday language, which showed that these terms are used interchangeably [5, 16–18].

Aim of the research

To determine the correlation between the levels and sources of social support and the attitudes towards pregnancy and towards childbirth presented by adolescent mothers.

Material and methods

Design

A cross-sectional study carried out in 8 selected hospitals in Poland according to the STROBE guidelines [19].

Participants

A convenience sample of 308 adolescent mothers between the first and the third day postpartum. The inclusion criteria were as follows: age up to 19 years, good overall health condition at the time of the survey (general parameters: body temperature, blood pressure, heart rate, and obstetric parameters: normal postpartum discharge, fundal height and lactation), written informed consent for participation in the study, and, in the case of a minor, also consent of her legal guardian.

Research instruments

The questionnaire used in the study consisted of 3 parts: Part 1 was an original questionnaire the purpose of which was to collect information about the age of the respondent and the age of the father of the child, her overall social and living conditions, and the type of help expected.
Part 2 was a questionnaire the purpose of which was to measure the attitudes of women towards pregnancy and childbirth, used with permission of the authors [20, 21]. The questionnaire contained 8 statements concerning the pregnancy and 8 statements pertaining to the childbirth, and it used the Likert scale with 5 possible answers: I strongly agree, I agree, I neither agree nor disagree, I disagree, and I strongly disagree. Positive statements (1, 3, 5, 7, 9, 11, 13, 15) were assessed in the following way: I strongly agree – 5 points, I agree – 4 points, I neither agree nor disagree – 3 points, I disagree – 2 points, and I strongly disagree – 1 point. Reverse scores were applied to negative statements (2, 4, 6, 8, 10, 12, 14, 16). The maximum number of points in both parts was 40. A score of up to 16 points meant a negative attitude, and above 16 points meant a positive attitude. The Cronbach’s  reliability coefficient was 0.76 for the pregnancy subscale and 0.82 for the childbirth subscale. The mean correlation between the statements was 0.3 and 0.37, respectively.
Part 3 was the Social Support Scale (SSS), used with permission of its author [7, 8]. This scale, based on Tardy’s theoretical assumptions, is used to measure the type and strength of support a person receives from specific social groups – parents, siblings, other relatives, schoolmates, young members of the local community, teachers, and strangers. It consists of 16 statements, each of which should be applied to the aforementioned 8 social groups. The statements relate to 4 types of support (4 statements to each group), each including 3 positive and one negative statement. The Social Support Scale allows the measurement of the overall social support as well as its 4 types: emotional, informational, instrumental, and appraisal. It also allows us to determine from which social groups the surveyed person receives the support. A “yes” answer marked by the respondent indicates a statement very strongly saturated with the given type of support, “rather yes” means strongly saturated, “rather not” - weakly saturated, and “no, not applicable” means not saturated at all with the given type of support. It is worth mentioning that the Social Support Scale can be used in adolescents and in adults, and its model, along with the key, can be found in the appendix. In accordance with the scale key, the following scores were adopted for the positive statements: “yes” – 3 points, “rather yes” – 2 points, “rather not” – 1 point, and “no, not applicable” – 0 points. Reverse scores were applied to negative statements. The overall score allowed us to determine the level of social support within one selected support group without differentiating it into types. The possible overall score ranged from 0 to 128 points, with 128 points indicating full support and 0 indicating no support at all. For individual types of support the possible scores ranged from 0 to 96 points. The raw scores were then converted to standard sten scores to enable the assessment of the strength of the support. A score between 7 and 10 sten indicated strong support (overall support and the specific types); 5–6 sten meant moderate support; and 1–4 no social support. The reliability of this method is satisfactory; the -Cronbach coefficient for the individual subscale is 0.51–0.87.

Data collection

The study was carried out in a wide geographical area; therefore, it was necessary to use the assistance of ward midwives with a master’s degree in nursing or midwifery. The persons who conducted the survey and the participants – puerperae and, in the case of minors, also their legal guardians – were instructed on how to complete the questionnaire. While giving these instructions, strong emphasis was placed on the issues of anonymity and voluntary participation in the study. The participants were also informed that the collected data would be used only for the scientific purpose of the research, the aim of which is to improve the quality of care for adolescent mothers. The time to complete the questionnaire was not limited, and, if in doubt, the respondents could obtain additional clarification at any time. A total of 328 questionnaires were distributed, of which 20 were excluded from the study, mainly because they were incomplete.

Ethical issues

The study protocol was approved by the Bioethics Committee of the Medical University of Lublin (Resolution No. EC – 0254/157/2012). In addition, the guidelines of the Helsinki Declaration were followed throughout the study [22]. The participants were informed of the purpose of the study and were told they were free to withdraw at any time without giving a reason. Participation in the study was preceded by the young mother giving informed consent and in the case of a person under 18 years of age also by her legal guardian.

Statistical analysis

The obtained results were subjected to statistical analysis. The values of the analysed parameters measured on a nominal scale were characterized by the number and percentage, and measured on a ratio scale characterized by the mean value, standard deviation, median, and lower and upper quartile with the range of variability. Contingency tables and homogeneity or independence ² tests were used to assess the existence of differences or dependencies between the analysed non-measurable parameters. For the small data samples in the studied subgroups (below 5) the Yates correction was used. Cronbach’s alpha coefficient was used to assess the reliability of the scales for the binary items. Because of the skewed distribution of the studied measurable parameters assessed by the Shapiro-Wilk test, non-parametric tests were used to analyse the existence of differences between the studied subgroups. For comparing differences between 2 independent groups the Mann-Whitney U test was used, and for comparing more than 2 independent groups the Kruskal-Wallis H test and post-hoc multiple comparisons were used. For comparing 2 dependent groups the Wilcoxon matched-pairs test was used, and for comparing more than 2 dependent groups Friedman’s ANOVA test and post-hoc multiple comparisons were used.
A 5% inference error and the associated significance level of p < 0.05, indicating the existence of statistically significant differences or dependencies, were assumed. Statistical analyses were performed using Statistica software version 10.0 (StatSoft, Poland).
In the study the subjects were divided into 3 age groups: 13–15, 16–17, and 18–19 years of age. This criterion is consistent with the legal status of women, which is based on age. In Poland 18- and 19-year-olds have full legal capacity, which means they may enter into marriages without any restrictions. Sixteen- and 17-year-olds may do so with the consent of the court. Younger women, however, cannot get married, and if they give birth, they cannot disclose the father of the child without the risk of exposing him to criminal sanctions [23–26].

Results

Study participants

The youngest age group (13–15 years of age) comprised 7 (2.3%) women. In 116 (37.7%) cases the father of the child was of the same age as the mother. Nearly half (94; 45.4%) of the school goers discontinued their education after diagnosis of pregnancy. Most of them (191; 92.3%) intended to return to school after giving birth. The remaining 16 (7.7%) declared that they did not intend to do so. For 275 (89.3%) respondents it was their first pregnancy, for 28 (9.1%) it was the second pregnancy and for 5 (1.6%) it was the third or further pregnancy. During pregnancy 240 (78.0%) girls lived with their parents and/or siblings, 58 (18.8%) lived with the child’s father or with him and his parents, and 10 (3.2%) lived alone or in an orphanage. After giving birth the distribution was 108 (35.1%), 193 (62.7%), and 7 (2.2%), respectively. Detailed characteristics of the study group are presented in Table 1.

Support received by adolescent mothers

When comparing the 4 types of support received by adolescent mothers (informational, instrumental, appraisal, emotional), it was noted there was a significant difference between them (² ANOVA = 301.3; p < 0.000001) (Table 2). In terms of social groups, a significant difference was found (2 ANOVA = 1150.9; p < 0.000001) – the level of social support received was significantly different between the groups providing it (p < 0.0000001).

Social support and attitudes towards pregnancy

The correlation between the level of social support received and the attitudes of young women towards pregnancy and childbirth are shown in Tables 3–5.
The overall level of social support was not significantly related to the type of attitude towards pregnancy and childbirth presented by the respondents (p > 0.05). Only in the case of attitudes towards childbirth and emotional support received was the difference borderline statistically significant (p = 0.05). In other cases, the differences were insignificant (p > 0.05).
A significant correlation was found between the attitudes towards both pregnancy and childbirth and the support received from teachers (p = 0.004 and p = 0.02, respectively). In the case of attitudes towards pregnancy, support from strangers (p = 0.05) and young members of the local community (p = 0.09) were close to significant. No other correlations were found (p > 0.05).

Discussion

Bajcarczyk et al. [10] analysed the literature, legal acts, and statistical data on the contemporary situation of single mothers in Poland. They draw attention to the fact that the law and social services have changed, which have led to an improvement in the social situation of this group of women. The increase in the state’s financial outlays for family policy improved the economic situation of single-parent women. On the other hand, the main non-financial reason for these women staying in Single Mother Homes is domestic violence or a lack of ability to cope with a crisis. According to the authors, help for women staying in Single Mother Homes should focus not only on solving the difficult situation they find themselves in, but also mainly on shaping positive patterns of behaviour and social competences. In this regard, support in its various dimensions is necessary.
The research referred to the issue of social support received by teenage mothers, and its scope and sources. In our study the overall level of social support was not significantly correlated with the type of attitude towards pregnancy and childbirth held by teenage girls (p > 0.05). Detailed analysis has also shown that the only case when the correlation was on the border of statistical significance (p = 0.05) was that between the attitudes towards childbirth and emotional support received. In relation to pregnancy, no such correlation was found. Also, in the case of other types of support (informational, appraisal, and instrumental) the differences in the frequency of encountered attitudes were not statistically significant (p > 0.05).
The occurrence of an unplanned pregnancy in a young women can present a situation in which she needs support, primarily from those close to her, i.e. family, teachers, and friends [5, 27, 28]. A study that compared the level of support received by teenage mothers and by mothers aged 20–34 years saw that older women were more likely to receive support from their parents than younger women (16.8% and 9.1%, respectively) [29]. The lack of support in this situation makes adolescent parents (both mother and father) feel disappointed with the relations within the family. It is not uncommon for one of them to leave home and move in with their partner, hoping to receive what they did not get from their parents [13]. Analysis of the presented material showed that most of the respondents (70.5%) did not receive parental support during pregnancy; in the Social Support Scale it was 1–4 sten. In contrast, they received significant support (7–10 sten) from their neighbours, strangers, teachers, and siblings. There was also a significant correlation between the attitude towards pregnancy and childbirth and the support received from teachers (p = 0.004 and p = 0.02, respectively). No other correlations concerning this issue were detected in the analysed material (p > 0.05). Good relationships with peers have a big influence on a teenager who is trying to settle in the role of a mother. Sometimes friends turn their back on a pregnant girl, cut ties with her, but it can also be the other way round – they take an interest in her fate, support and help her [28]. The help concentrates mainly on the assistance with childcare [30]. The presented research shows that the level of support received from peers (from school and from the neighbourhood) did not significantly differentiate the attitudes of the respondents towards pregnancy or towards childbirth. It is worth noting, however, that near-significant differences (in relation to pregnancy) were seen in the case of friends from outside the school (p = 0.09). Perhaps pregnant teenagers had more frequent contact with them and were simply less ashamed of their condition. Acceptance of early motherhood in some social circles is definitely low; it depends on the culture, upbringing, accepted value system, as well as religion [31]. At a young age the most intense need is the need for emotional support, and the degree to which this need is satisfied determines the attitude of a teenage mother towards important events associated with motherhood and the quality of experiences associated with them [5, 25]. In our study 66.6% of the respondents did not experience sufficient emotional support; the SSS score was 1–4 sten in this group. The level of received emotional support did not significantly differentiate the women’s attitudes towards pregnancy. In the case of attitudes towards childbirth the differences were on the border of statistical significance (p = 0.05). In the study by Królikowska [5] the results were quite different. Most of the studied young mothers received this kind of support, mainly from the child’s father (75.5%), friends (74.5%), and parents (70.4%). It should be added, however, that that research was carried out by students who conducted in-depth interviews using a non-standardized questionnaire. Perhaps this was the reason for such large discrepancies.
Moseson et al. [32] in the United States conducted an in-depth interview study to see if adolescent mothers would experience stigma. It found that among the 25 young women surveyed, stigmatization was more common among black and Hispanic women. The research participants expressed the need to create programs that would integrate young people who experienced unplanned pregnancies. They offered the Internet, organized groups in women’s counselling, and college or high school grounds as support centres. This would be an opportunity to share perspectives and experiences, and to build emotional and informational support networks for each other.
Our study has some limitations that limit the generalisation of the conclusions. The study was carried out immediately after giving birth, at a time of huge hormonal changes. Hormones in this time affect not only the body, but also emotions and moods. Immediately after giving birth most women start to experience postpartum ‘baby blues’ and what is known as ‘breast fullness’. In this time a puerpera needs more support and understanding, not only from her closest family but also from the hospital staff in the form of intensified obstetric care. In this situation it is needed not only because of giving birth, but also because of the age of young mothers and the fact that the study group consisted mostly of women for whom it was their first pregnancy (275; 89.3%). Another limitation is the sampling for the study – it was based on a convenience sampling strategy, which may have influenced the results. Additionally, the material collected was based on subjective data reported by the respondents. Given the array of newly emerging research papers, clarification of all the issues, especially the correlation between the attitudes and social support during pregnancy and childbirth in adolescent mothers, will require further study.

Conclusions

The type of presented attitudes towards pregnancy and childbirth is not related to the overall level of social support received. It is, however, related to some of its sources. The life situation of teenage mothers must be considered difficult not only because of their young age but also because of the paucity of social support. This study fills the gap and adds to the knowledge on the attitudes of teenage mothers towards pregnancy and childbirth. It also proves that this is a complex issue that requires continued research of an interdisciplinary nature. Teenage pregnancy is partly a failure of the society, the family, the school, and the health care system. Therefore, using the results of this study can foster elimination of situations in which a pregnant teenager or a young mother is left without social support. It can also to encourage a counselling network that can subsequently be used in preventive measures designed to improve the level of support of teenage mothers. The conclusions of this research should certainly be replicated in the future on other representative samples. Replication of the obtained results should also be the subject of future cross-cultural studies. Future research should establish the correlation between the attitudes and the received social support for groups of different nature, including different cultures.

Conflict of interest

The authors declare no conflict of interest.

References