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The adolescent female’s experience of pregnancy Banks, Kathryn I. 1993

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THE ADOLESCENT FEMALE'S EXPERIENCE OF PREGNANCYbyKATHRYN IRENE BANKSB.N., Dalhousie University, 1986A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF SCIENCE IN NURSINGinTHE FACULTY OF GRADUATE STUDIESSCHOOL OF NURSINGWe accept this thesis as conformingto the required standardTHE UNIVERSITY OF BRITISH COLUMBIAJuly 1993© Kathryn Irene Banks, 1993In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(SignatureDepartment of Appl led 6c,ienceb - School of IVLAITA1116-The University of British ColumbiaVancouver, CanadaDate (I,LE(.14- lb )1993 DE-6 (2/88)AbstractAdolescent pregnancy is of concern to health professionals,adolescents themselves, and the communities in which they live.Much of the concern centers around health and social issues forthe adolescent and her child. Adolescent females who becomepregnant experience two developmental events simultaneously:adolescence and pregnancy. This makes their experience uniquefrom other pregnant females. In order to optimize the health ofadolescents and their infants during pregnancy, nurses need tounderstand the experience from the teens' perspective. Fewstudies have examined this experience from the adolescent'sperspective. There is a paucity of discussion about nursing's rolein the vast body of literature on adolescent pregnancy.The qualitative research method of phenomenology wasutilized to investigate the female adolescent's experience ofpregnancy, because it allowed the researcher to gain insight intothe participants' lives as they were lived. Data were obtainedfrom eight female adolescents during audio-tape recordedinterviews. Trigger questions were used to explore theadolescent's perceptions of their experience of pregnancy. Theinterview audio-tapes were transcribed verbatim immediatelyfollowing each interview. Giorgi's (1985) method of analysis wasused to identify themes in the data. Second interviews were usedto explore, clarify, and validate the emerging themes.iiAbstractTwo central interrelated themes emerged from the dataanalysis. First, the young women described ambivalent feelingsthat they experienced throughout their pregnancies. Secondly,they viewed their pregnancies as a life changing event. The lifechange was characterized by five phases: (a) suspecting thepregnancy, (b) confirming the pregnancy, (c) making decisionsabout the pregnancy, (d) living the reality of the pregnancy, and(e) experiencing a changed life. Each young woman's experienceof pregnancy was shaped by identified environmental and otherfactors that were important to her.The findings can assist nurses to provide better care foradolescents and their families Two major conclusions wereidentified: (a) pregnancy and motherhood provided young womenfrom unstable environments with meaning and a sense of purpose,(b) ambivalence captured the emotional impact of experiencingpregnancy and adolescence simultaneously for this vulnerablegroup. A variety of implications for nursing practice, education,research, and public policy are discussed.TABLE OF CONTENTSAbstract ^Table of Contents ^ ivList of Tables viiList of Figures ^ viiiAcknowledgements ixCHAPTER ONE: INTRODUCTIONBackground to the Problem^ 1The British Columbian Experience ^ 1Attitudes Toward Adolescent Pregnancy ^ 2Health and Social Implications of Adolescent Pregnancy ^ 3Problem Statement ^ 5Purpose ^ 6Research Question 6Definition of Terms ^ 6Significance of the Study ^ 7Overview of Method 7Assumptions ^ 8Limitations 8Organization of the Thesis ^ 9CHAPTER TWO: REVIEW OF RELATED LITERATUREIntroduction ^ 10Growth and Development ^ 10Growth and Development Interacting with Adolescent Pregnancy ^ 16Biological Development 19Psychosocial Development ^ 20Adolescent Decision-making about Sexuality ^ 22Decision-making about Sexual Activity 22Decision-making about Contraception 25Environmental Factors Influencing Adolescent Pregnancy ^ 29Poverty ^ 30Family 31Peers 36Choices for Pregnancy Resolution: Abortion, Adoption, or Keeping ^ 38Responses of the Health Care System ^ 41Education and Contraceptive Awareness ^ 42Care of Pregnant Adolescents 45Interventions for Decreasing Repeat Pregnancies ^ 46Issues that Need to be Addressed ^ 47Summary ^ 51ivTable of ContentsCHAPTER THREE: METHODSIntroduction ^ 54The Phenomenological Perspective ^ 55Selection Criteria and Sample Selection 56Selection Criteria ^ 57Sample Selection 58Procedures for the Protection of Human Participants ^ 61Data Collection and Analysis ^ 62Data Collection ^ 63Concurrent Data Analysis 69Scientific Rigor in Qualitative Research ^ 79Credibility ^ 80Fittingness 82Auditability 84Confirmability ^ 85Characteristics of Participants ^ 86Summary ^ 87CHAPTER FOUR: PRESENTATION OF FINDINGSIntroduction ^ 89Ambivalence and Pregnancy as a Life Change Event ^ 90Phase One: Suspecting the Pregnancy ^ 93Not Expecting the Pregnancy to Occur 95Initially Denying the Pregnancy 97Phase Two: Confirming the Pregnancy ^ 98Seeking Confirmation ^ 99Self-questioning 100Telling Others About the Pregnancy ^ 103Phase Three: Making Decisions About the Pregnancy ^108Prior Life Experiences Influencing Decisions 109Reviewing the Options ^ 111Discussing Their Decisions 115Phase Four: Living the Reality of the Pregnancy ^118Accepting the Pregnancy ^ 118Living with the Bodily Changes ^ 119Forming a Self-identity 122Thinking About Me as an Adolescent ^122Fantasizing About Being a Mother 124Thinking about Parenting ^ 128Concern Regarding Their Ability to Parent ^128Influence of Their Families ^ 132Influence on the Rate of Maturation ^134Dealing with Supportive and NonsupportiveRelationships ^ 139The Supporting Role of Families ^139Coping With Other's Reactions 143Dealing with Social and Environmental Influences ^146Phase Five: Experiencing a Changed Life ^ 151Table of ContentsChanged Thinking ^ 152 viExperiencing a Sense of Hope for the Future ^154Caring for the Infant 156Caring for Oneself ^ 158Influence of Previous Life Experiences ^159Thinking About Future Roles ^ 162Thinking About Contraception 163Changing Relationships ^ 164Families ^ 165Boyfriends 167Coping with the Maternal Role ^ 172CHAPTER FIVE: SUMMARY, CONCLUSIONS, AND IMPLICATIONS FORNURSING ^ 177Introduction 177Summary of Findings ^ 177Conclusions ^ 179Implications for Nursing 185Practice 185Education ^ 200Research 203Public Policy 209REFERENCES ^ 215Appendix A: Letter to Agency ^ 228Appendix B: Letter to Attending Physician ^ 230Appendix C: Letter to Participant^ 232Appendix D: Client Consent Form 233Appendix E: Parental Consent Form^ 234Appendix F: Demographic Information 235Appendix G: Trigger Questions ^ 236LIST OF TABLESTable 1Subconcepts Influencing each Phase of Adolescent Pregnancy as aLife Change Event ^ 94vii.LIST OF FIGURESFigure 1Phases of Adolescent Pregnancy as a Life Change Event ^ 91viii.AcknowledgementsTo each young woman who shared her story, I extend mygratitude. The honesty, hope, and resilience they displayedduring their interviews was a source of inspiration, and allowedme to appreciate what it was like for them to be young, pregnant,and faced with many decisions. Their assistance has enhanced myknowledge and skills for working with adolescents. I applaud theyoung women's determination to be good mothers.I wish to thank my committee advisors, Anna Marie Hughesand Wendy Hall, for guiding me through the research process,providing me with critical and invaluable advice, for encouragingme when I thought this would never end, and believing that thiswas a worth while research project. I also thank Elaine Carty asthe third member of my thesis committee for providing criticalfeedback.Thanks to my family, friends, and Douglas Fentiman forbelieving in me, and encouraging me when I needed it most.ixCHAPTER ONEINTRODUCTIONBackground to the ProblemThe phenomenon of adolescent pregnancy has concernedteachers, social workers, physicians, nurses, parents, andteenagers themselves (Barr & Monserrat, 1986; Bergman, 1988). Areport by Health and Welfare Canada (1990) noted that in Canadathere has been a shortage of data on adolescent sexual andreproductive health, as well as inadequate use of this data byhealth care professionals.The British Columbian ExperienceIn 1989, women under 20 years of age accounted for 5.8% ofall births in British Columbia (B. C. Vital Statistics, 1989). In thesame year there were 3,075 births to mothers aged 12 to 20 in theprovince of British Columbia (B. C. Vital Statistics, 1989). In thecity of Vancouver alone, during 1989, 3 females who were 10 to 14years of age and 209 females who were 15 to 19 years of age gavebirth (Blather wick, 1989). Rekart's (1988) population forecast for1986-2011 projected that the rate of teenage births for the city ofVancouver would remain at current levels. This informationsuggests that a significant number of pregnant adolescent femaleswill continue to require nursing care in the foreseeable future.1CHAPTER ONE2Attitudes Toward Adolescent PregnancyNursing care of adolescents who become pregnant isinfluenced by the attitudes of society toward adolescentpregnancy. Prior to the 1970s, pregnant adolescents were viewedas social deviants (Humenick & Wilkerson, 1991). Phipps-Yonas(1980) in a review of the North American literature of the 1970s,concluded that characterizing teenagers who had conceived at ayoung age as deviant was not supported by empirical data. Inthe 1980s, adolescent pregnancy was portrayed as a phenomenonthat was a problem for adolescents and these adolescents wereportrayed as a problem for the communities in which they lived(Chilman, 1980a; Davis, 1989; Grinstaff, 1988; Mercer, 1985).Teenage pregnancy was frequently characterized, in the literature,as being of epidemic proportions (Adams, 1983; Grinstaff, 1988;Miaoulis, 1989; Stafford, 1987). It was thought that the epidemicof adolescent pregnancy could be remedied by sex education andby making contraceptives available (Humenick & Wilkerson, 1991).In the 1990s attitudes are changing. There is a recognition thatthe problem may be related to environmental influences, and notbe totally with the adolescent herself. Humenick and Wilkersonhave presented adolescent pregnancy in the 1990s "as a symptomof both rural and urban, family and community, [and]socioeconomic problems" (p. x). This approach acknowledged thata variety of social and psychological factors influence theCHAPTER ONE3occurrence of adolescent pregnancy and affect the health of anadolescent and her expected child.Health and Social Implications of Adolescent PregnancyThe literature indicated that adolescent pregnancy results inincreased health risks for both the mother and infant. Fourcommon health risks have been identified' (a) anemia, (b) toxemia,(c) premature deliveries, and (d) low birthweight babies(Breedlove, Judy, & Martin, 1988; Stafford, 1987). Lee and Corpuz(1988) noted that pregnant teenagers appear to be at higher riskthan older women for bearing low birthweight babies. They statedthat this contributed to a higher incidence of neonatal mortality.The literature also noted that low birth weight infants are atrisk for developmental and long-term behavioral problems (Reedy,1991). Reedy suggested that once these children enter schoolthey may display hyperactive or impulsive behavior, and havepoorer communication and reading skills than their peers. Inaddition to the children's intrinsic difficulties, their behaviorsrelate to the adolescent mother being less accepting, lesscooperative, engaging in less communication, and being lesssensitive to her child than a mature woman (Reedy, 1991).The literature stated that teenage parents are more likely tohave problem marriages and to neglect or abuse their children(Stafford, 1987; vonWindeguth & Urbano, 1989). In addition,CHAPTER ONE4adolescent females who become pregnant disrupt their educationand often obtain less post-secondary education than their peers;consequently, they have limited labor force participation whichusually results in low incomes (Moore & Burt, 1982; Ruff, 1987;vonWindeguth & Urbano, 1989).Poverty and unemployment have been identified as factorsthat influence early sexual intercourse and childbearing inadolescence (Flick, 1991; Frager, 1991). Flick (1986) noted that"poverty is associated with early sexual activity, decreased use ofcontraceptives, and lower abortion rates, regardless of race"(p. 142). In addition, Reedy (1991) suggested that the younger awoman is when her first child is born, the greater the risk ofpoverty and her need for social assistance.While working as a community health nurse, this researcheridentified a discrepancy between teens' concerns and the concernsof health care workers in teen pregnancy programs. While theliterature has explored the changing attitudes and the health andsocial implications of adolescent pregnancy for mother and childfrom the professional perspective, there remains a gap ininformation from the pregnant teenager's perspective. Consider,for example, the work of Foster (1988), a social worker, whocarried out phenomenological research with pregnant adolescents.Although her report is very informative on social issues andchronicles several young women's experiences of bearing childrenCHAPTER ONE5as teenagers, it did not specifically address the adolescent'sperceptions of being pregnant. Exploring the adolescent'sperception of pregnancy benfits health care workers, because theinformation could be useful in identifying some of their prenatalcare needs, in assisting adolescents and their families to cope withpregnancy, and in viewing the efficacy of current programs forfemales in this developmental stage.Problem StatementAdolescent females who become pregnant experience twodevelopmental events simultaneously: adolescence and pregnancy.Thus their experience differs from that of other pregnant females.Although health care providers have devised special programs thatattempt to address this phenomenon (Chilman, 1980a; Mercer,1979b; Phipps-Yonas, 1980), there has been little documentedresearch that speaks to the experience of pregnancy from theteenager's point of view (Anderson, 1985; Blum & Smith, 1988).Humenick and Wilkerson (1991) noted that even though it isrecognized that adolescent pregnancy puts the adolescent femaleand her child at risk, there has been a paucity of discussion ofthe clinical implications for nursing. If the nursing researchliterature does not address the phenomenon of teenage pregnancyfrom adolescents' perceptions, programs will continue to bedesigned without addressing adolescents' views of theirCHAPTER ONE6experiences. To optimize adolescents' and their infants' healthduring pregnancy, nurses need to work with the adolescents toattempt to meet their needs as they perceive them. Therefore,research exploring the adolescent female's perspective iswarrented.PurposeThe purpose of this study was to describe the experience ofpregnancy from the female adolescent's perspective.Research QuestionWhat is the experience of pregnancy from the femaleadolescent's perspective?Definition of TermsAdolescent - a female who reads and speaks English,ranging in age from 13 to 16.Pregnant adolescent - an unmarried female adolescent in herlast trimester of pregnancy (i. e., between 33 and 40 weeksgestation), who intends to keep her baby.Nurse - nurse will refer to a Registered Nurse.CHAPTER ONE7Significance of the StudyUnderstanding how the adolescent female experiences herpregnancy is beneficial for the following reasons: (a) to providecurrent information regarding the pregnancy experience for agroup of adolescents in Vancouver in 1991; (b) to increaseunderstanding of why adolescents do or do not access antenatalservices; (c) to provide information from which prenatal programscan be designed to address the identified concerns of thepregnant adolescent; (d) to provide information that can be usedto consider the efficacy of current programs for pregnantadolescents; and (e) to assist nurses to view the experience ofadolescent pregnancy in a holistic way.Overview of MethodThis study was guided by the interpretive approach ofphenomenology. Phenomenology seeks a fuller understandingthrough description, reflection, and observation of a phenomenonto ascertain the multiple meanings of the phenomenon (Ray, 1990).The purpose is not to ask the "how" of something from the causeand effect perspective, but rather what is the nature of theexperience or meaning of the phenomenon so it can be betterunderstood (Ray, 1990). This method is useful to nursingresearchers, because it focuses on how the phenomenon isperceived by the person living it. Omery (1983) noted that theCHAPTER ONE8phenomenological method assists the researcher to understandboth the cognitive, subjective perspective of the person who hasthe experience and the effect their perspective has on his or herbehavior.AssumptionsThe author made the following assumptions: (a) thepregnancy experience of the adolescent who is unmarried isdifferent from that of the married adolescent; (b) the pregnancyexperience is different for the adolescent female than for theadult; and (c) the adolescent who is interviewed will present anhonest factual account of her experience.LimitationsThe sample size was small and included a specific segmentof the population, which limits the extent to which the studyfindings can be generalized. These study findings can be relatedto English speaking female adolescents 13 to 16 years of ageliving in an impoverished urban environment, experiencing apregnancy and choosing to keep their babies. It is an acceptedpremise that data obtained utilizing the phenomenological methodare biased toward individuals who are describing their experience,but this is precisely the reason that it was chosen (Field & Morse,1985).CHAPTER ONE9Organization of the ThesisThe first chapter has provided an introduction to theresearch study. The introduction has included a discussion of thebackground to the problem, problem statement, purpose of thestudy, research question, the significance of the study, definitionof terms, an overview of the research method, assumptions, andlimitations. Chapter Two presents a critical review of theliterature relevant to the proposed study. Chapter Three outlinesthe inductive research methodology, phenomenology, and describesin detail sample selection, procedures for the protection of humanparticipants, data collection, data analysis, issues of scientificrigor, and the characteristics of the participants. Chapter Fourpresents the findings of the study and discusses them in relationto pertinent literature. Chapter Five presents a summary of thefindings and conclusions that arise from the study as well asimplications for nursing practice, education, research, and publicpolicy.CHAPTER TWOREVIEW OF RELATED LITERATUREIntroductionIn this chapter, relevant literature about adolescentsexuality and pregnancy will be discussed. Due to the substantialbody of literature on adolescent sexuality and pregnancy, onlyarticles that illustrate the areas related to this research will beincluded in the review. Literature from the following areas willbe reviewed: (a) adolescent growth and development, (b) factors inthe adolescent's biological and psychosocial development thatinfluence pregnancy, (c) factors influencing adolescentdecision-making about sexuality, (d) environmental factorsincluding--poverty, family, and peers, (e) choices for pregnancyresolution--abortion, adoption, or keeping, and (f) responses ofthe health care system to adolescent pregnancy. The informationgained from this review will familiarize the reader with thecurrent state of knowledge about adolescent pregnancy, and placethe research question in the context of the literature.Growth and DevelopmentPuberty, the period when secondary sexual characteristicsdevelop, is a biologic process that occurs for females between theages of 8 and 14 (Reedy, 1991). As a result of the body changes10CHAPTER TWO11that occur in puberty, the young person becomes physically ableto reproduce. While puberty is a biological process, completingadolescence is both a biological and a psychological process.Adolescence is the period when rapid physical growth andsocial and psychological maturation take place simultaneously andgenerally occurs between the ages of 12 and 19. Johnson (1986)refers to adolescence as a social-psychological process duringwhich individuals accomplish two major tasks:(a) emancipation--separating themselves in thought from the groupwho has nurtured and supported them throughout childhood,usually their family; and (b) formation of a sexual, an intellectual,and a functional identity.Adolescent growth and development constitutes a complexand demanding time in an individual's life (Adams, 1983; Fuller,1986; Mercer, 1979a, 1983; Nelms, 1981). Mercer (1979a) hasidentified six tasks, associated with the biological andpsychological growth that occur during the period of adolescence,which have expanded on Johnson's (1986) work: (a) gainingcomfort with and acceptance of body image, (b) internalizing asexual identity and role, (c) developing a personal value system,(d) preparing for productive citizenship, (e) striving to achieveindependence from parents, and (f) developing an adult identity.During this period the adolescent also develops skills inCHAPTER TWO12decision-making and problem-solving. This is a person who is inthe process of becoming an adult.The process whereby an adolescent evolves from childhoodinto adulthood can be subdivided into three phases: early, middle,and late adolescence. In early adolescence, young teens strugglewith their identities. They are concerned about their body image,whether they are developing normally in comparison to their peers(Reedy, 1991). "The peer group is a key factor in adolescentdevelopment because it provides opportunity for modeling andpractice by doing" (Reedy, 1991, p. 216). This is the time whenadolescents begin to assert their independence from their parents(Nelms, 1981). Early adolescents are concrete thinkers; they livein the here and now, and they have not yet developed the abilityto conceptualize the future (Reedy, 1991).In middle adolescence, conflicts arise as teenagers strive todisengage from their parents. Reedy (1991) noted that duringthis turbulent period some adolescents run away from home. Theadolescent's peer group is very important to them for definingbehavior and dress (Reedy, 1991). Development of heterosexualrelationships are also important to middle adolescents; theyfrequently date a series of their peers during this stage (Mercer,1979a). Middle adolescents are developing formal operationalthinking. Their reasoning ability still involves trial and error,but this enables them to conceptualize their own thoughts and toCHAPTER TWO13begin to conceptualize the thoughts of others. They are, however,limited in their abstract reasoning which involves applyinginformation to future events (Reedy, 1991).In late adolescence, teens focus their attention on careersor life work and on the ability to maintain stable relationships(Mercer, 1979a). They are able to make purposeful decisions whileconsidering long-term implications (Reedy, 1991).As adolescents mature, proceeding from early to middle tolate adolescence, their cognitive development undergoes thechanges previously described. Orr, Brack, and Ingersoll (1988) instudying the relationship between puberty and cognitivedevelopment of 135 students aged 11 to 19, measured generalintelligence (IQ), cognitive complexity (conceptual level), cognitivestyle (perceptual field dependence-independence) and sexualmaturity (Tanner stage). The quantitative data suggested thatchanges in cognition occur in adolescence in relation tochronological age. When the effects of age were controlled,physical growth and development were not found to be a predictorof mature cognitive development. This study indicated that thelevel of cognitive maturity may not be concurrent with sexualdevelopment, and that cognitive maturity may be overestimated inrelation to early sexual development in the adolescent.In understanding adolescent behavior, adolescents' evolutionfrom complete egocentricity to less egocentricity, must beCHAPTER TWO14recognized. Elkind (1967) described early adolescents asegocentric, having difficulty differentiating between the cognitiveconcerns of others and those of themselves. This adolescentegocentrism gives rise to two mental constructs, which Elkind calls"the imaginary audience" and the "personal fable" and these helpto account for certain forms of adolescent behavior.Adolescent egocentrism is the result of the adolescent failingto differentiate between what others are thinking, and his or herown mental preoccupations (Elkind, 1967). Consequentlyadolescents construct an "imaginary audience" for whom they arethe focus of attention, which is usually not true (Elkind, 1967).Risk-taking behavior is often done to gain the attention of the"audience", particularly when the teen is struggling with his/herindependence from his/her parents. It also serves to affirm theteen's sense of identity. Risk-taking is a normal behavior usedby adolescents to develop independent decision-making skills.Unfortunately, the consequences of this method of establishingindependence for the young woman may be an unwantedpregnancy.A "personal fable" is another mental construct adolescentsuse to reflect their belief that their feelings are unique and thatthey themselves are immortal (Elkind, 1967). Elkind suggestedthat many young women become pregnant because their personalCHAPTER TWO15fables convince them that while others may get pregnant they willnot, and so need not take precautions.Another model of explaining adolescent behavior is offeredby Erikson (1963). Erikson has defined the developmental stagethat occurs in adolescence as identity versus role confusion. Themiddle adolescent, in passing through this stage, completes twodevelopmental tasks: (a) achieving independence from parents, and(b) the formation of a self-identity (Alexander, McGrew, & Shore,1991; Johnson, 1986; Mercer, 1979a). These developmental tasksaffect the decisions adolescents make regarding their sexualbehavior; decisions that can result in pregnancy (Holt & Johnson,1991). Shaw (1991) pointed out that a key to understandingadolescents is to recognize their search for identity and theirincreasing desire for independence. In searching for theiridentity adolescents experiment with sexual values and behaviors.Sexual values and behaviors are related to cognitive andmoral development. A component of the adolescent's intellectualidentity is their moral development, which is developed at thesame time as their personal value system. Chilman (1980b) noted:"Moral development, like cognitive development, proceedssequentially from simplistic, present-oriented concepts of rightsand wrongs to more abstract, complex principles" (p. 107).Adolescence is a maturational event, whereby individualsbecome independent from parents, and form self-identitiesCHAPTER TWO16composed of sexual, moral, and intellectual components, andprepare for future work. Reedy (1991) stated that adolescence isa developmental process that needs to be completed by eachindividual. Failure to complete the process results in apostponement of adolescence, which means the individual will liveout their adolescence at another point in their life. Reedysuggested that the 33-year-old "runaway housewife" who wants tofind herself and have a life, and the 40-year-old married man whobuys a sports car, gets a divorce or a mistress, and "sows hiswild oats" are two examples of postponed adolescence. Reedybelieves, and this author concurs, that this process would disruptthese individuals' and their families' lives. Thus it is importantthat adolescence be experienced during the teenage years ratherthan being delayed until adulthood, because adolescent pregnancycan disrupt development, it may not be completed until a latertime. In the next section the interaction between growth anddevelopment and adolescent pregnancy will be explored.Growth and Development Interacting with Adolescent PregnancyThere is an increasing awareness in the professionalliterature that pregnancy is connected to the adolescent'sbiological and psychosocial development. A teenager's ability torespond to pregnancy varies according to the stage of adolescentdevelopment she has reached. Adolescent development can beCHAPTER TWO17subdivided into three stages: early, middle, and late. In earlyadolescence, the adolescent is struggling to establish her identity,while her body is undergoing physiological changes (Mercer,1979a). Pregnancy complicates her ability to establish her identityand further changes her already changing body image. Althoughshe seeks out friendships with same sex peers, she is still relianton her parents for some decision-making. Pregnancy can alter allthese relationships.In middle adolescence, the teenager is striving to disengagefrom her parents and to develop heterosexual relationships.Pregnancy can reestablish her dependance on parents andinterfere with heterosexual relationships. The teen begins todevelop cognitive abilities for problem solving. However,pregnancy adds more and different problems for the teen to solve,and may challenge her problem-solving capabilities. Asdevelopment occurs, egocentricity decreases and the teen becomesmore aware of others. Pregnancy can increase egocentricity asthe teen experiences body changes and increased attention fromothers wanting to help her.In late adolescence, the young woman strives to achieve theability to maintain stable relationships and to prepare for a careerand community responsibilities (Mercer, 1979a; Nelms, 1981).Pregnancy can interfere with establishing stable heterosexualrelationships and career plans.CHAPTER TWO18When pregnancy occurs during adolescence, formation of theyoung woman's self-identity is complicated. The young woman,already engaged in the developmental tasks of adolescence nowhas, in addition, the developmental tasks of the maternal role tothink about. Rubin (1984) describes the psychological processinvolved in maternal identity formation as a self system composedof three interrelated selves: the ideal self, the actual or knownself, and the body image self. The ideal self is the image of whothe woman wants to be as a mother; it draws on a variety of theindividual's life experiences. The actual or known self is how thewoman views herself at a given time in a certain situation. Thebody image self refers to physical sensations and activity changesthat occur as a result of the growing fetus. While the adolescentexperiences these selves in a similar way to adult women, she issimultaneously struggling with the developmental tasks ofadolescence. In addition, she has also had fewer life experiencesthan an older woman to prepare her for motherhood.Pregnancy in adolescence cannot be viewed, therefore, as anisolated problem, but one that is interconnected to other issueswithin the adolescent's world (Alexander et al., 1991; Holt &Johnson, 1991; Johnson, 1986). Flick (1986) identified four stepsleading to adolescent pregnancy and parenting: "becoming sexuallyactive, not using or incorrectly using contraceptives, carryingrather than aborting a pregnancy, and parenting rather thanCHAPTER TWO19placing a child for adoption" (p. 132). An adolescent's biologicaland psychological development, as well as a variety of factors inher social environment, will influence which path she takes andwhen these steps are encountered. Obviously, the earlier thesesteps arise the less ready an adolescent will be to deal with them.Biological DevelopmentZuckerman, Walker, Frank, Chase, and Hamburg (1984) notedthat there are no intrinsic biological barriers to satisfactoryperinatal outcomes for young mothers and their infants. Lowbirthweight as an outcome of pregnancy is associated with varioussociodemographic and health care factors, such as low income,single marital status, low educational level, smoking, drug abuse,inadequate prenatal care, and poor maternal weight gain inpregnancy, rather than biological maturity (Lee & Corpuz, 1988;Reedy, 1991). Several studies of programs that providecomprehensive prenatal care support the contention that teenagersbearing low birthweight infants reflect negative environmental andsocial influences, which can be ameliorated by the provision ofsocial and economic support (Gale, Seidman, Dollberg, Armon, &Stevenson, 1989; Piechnick & Corbett, 1985; Smoke & Grace, 1988).Even if there are no intrinsic biological problems related topregnancy during adolescence, adolescents may engage in denialand present late for prenatal care, thereby placing their ownCHAPTER TWO20health and that of their fetus at risk (Hayes, 1987). Reedy (1991)identified the following possible health problems that could putthe health of the mother and her fetus at risk: untreated sexuallytransmitted diseases, hypertension, preeclampsia, anemia, and poorweight gain. Trying to "stay thin" to hide the pregnancy may beanother form of denial, which places the nutritional status of themother at risk (Reedy, 1991).Psychosocial DevelopmentEvery woman who becomes pregnant engages in a series ofdevelopmental tasks that prepare her for the maternal role (Barr& Monserrat, 1986; Rubin, 1975). Barr and Monserrat identifiedfour psychological tasks of pregnancy: (a) pregnancy validation,(b) fetal embodiment, (c) fetal distinction, and (d) care-giving.The first task, acceptance of the reality that the pregnancy doesexist, is usually achieved in the first trimester. A woman'sacceptance of the pregnancy may be affected by her ambivalenceabout the pregnancy (Flagler & Nicoll, 1990). This author believesadolescents will be more likely to experience ambivalence, becauseof their under-developed value systems, in combination with theiradolescent developmental tasks and cognitive development, as wellas the acceptance of others.The second developmental task involves recognizing that thefetus does exist as part of her body. Denial can delay this taskCHAPTER TWO21(Barr & Monserrat, 1986). Denying she is pregnant may preventthe young woman from accepting the pregnancy and forming anemotional bond with the expected child (Flagler & Nicoll, 1990).The adolescent reviews her own relationship with her mother, eventhough she may be feeling the need to be "mothered" herself(Barr & Monserrat, 1986). This occurs in the context ofestablishing independence, establishing a self-identity, anddecreasing egocentricity.The last two developmental tasks are: fetal distinction andcare-giving. Fetal distinction, involves the woman recognizing thefetus as separate from herself with an identity of its own.Egocentricity may interfere with an adolescent's ability to viewher fetus as a separate person (Reedy, 1991). She may experiencea conflict between her own needs and those of her expectantchild. The adolescent in accepting her pregnancy, needs to"grieve" the parts of her life such as school, dances, or sportsthat she has had to give up (Barr & Monserrat, 1986).The young women may resolve some of their conflicts aboutbecoming a mother and about viewing the fetus as a separateentity by participating in programs with other young expectantmothers (Barr & Monserrat, 1986). The fourth task, becoming acare-giving mother, occurs after the child is born. Following thebirths of their babies, as the young women care for their babies,they take on the role of care-giving mothers (Rubin, 1975).CHAPTER TWO22Hayes noted that "studies of social and psychological factorsassociated with adolescents' sexual behavior concluded thatself-perception (not self-esteem)--that is, the sense of what andwho one is, can be, and wants to be--is at the heart of teenagers'sexual decision making" (1987, p. 120). Further research isrequired to understand how the variety of family backgroundcharacteristics, psychosocial factors, and environmental factorsinfluence young women's self-perceptions which, in turn, influencetheir sexual decision-making and risk for pregnancy.Adolescent Decision-making about SexualityThe decisions adolescents make about their sexuality includeengaging in sexual intercourse, and use or nonuse ofcontraceptives. Intellectual development, as well as, thedevelopmental tasks of adolescence influence their use ofcontraceptives.Decision-making about Sexual Activity Recently adolescent decision-making in general and,specifically, their decision-making about sexual activity have beenstudied as factors affecting adolescent pregnancy. Gordon (1990)provided an in-depth examination of the ways in whichcognitive-developmental change mechanisms can initiate or hinderformal thinking about the consequences of sexual activity andCHAPTER TWO23contraception. Important elements of formal operational reasoninginclude: (a) generating or envisioning alternatives, (b) evaluatingalternatives, (c) engaging in perspective taking, and (d) reasoningabout chance and probability (Gordon, 1990). Adolescents whohave not attained these abilities are at risk for pregnancy(Gordon, 1990).Intellectual development in the adolescent years is a factorin decision-making related to sexual behavior (Gordon, 1990; Holt &Johnson, 1991; Johnson, 1986). Holt and Johnson acknowledgedthat intellectual development is highly variable and notunidirectional. In times of stress all teens may revert to concretethinking. Adolescents who think concretely about their sexualbehavior do not consider the possibility of pregnancy and its longterm consequences. The young female adolescent has not maturedto the point where she can think about her actions as havingconsequences for the future. Whereas, teenagers who are usingformal operational thinking are more able to explore multiplefuture options in relation to their use of contraceptives (Holt &Johnson 1991). Dysynchronous intellectual and physicaldevelopment can create expectations that physically matureadolescents will think and reason as adults, when in fact theyremain emotionally and cognitively immature (Alexander et al.,1991).CHAPTER TWO24In the 1990s, the developmental tasks of adolescence havebeen considered as a factor in some adolescents' risky sexualactivity (Alexander et al., 1991; Gordon, 1990; Holt & Johnson,1991). The adolescent is striving to achieve the developmentaltasks of: (a) independence from parents, and (b) formation of an"adult" identity by integrating a gender identity, an intellectualidentity which incorporates moral and personal values, and acareer or work role identity (Johnson, 1986; Mercer, 1979a).Evidence suggests that these developmental tasks influence someteens' decision-making related to sexual behavior (Alexander et al.,1991; Holt & Johnson, 1991; Johnson, 1986). Teens who do not feela sense of independence or personal control often engage inbehavior that risks pregnancy in attempt to fulfill thedevelopmental task of achieving independence (Holt & Johnson,1991).Female adolescents who are experiencing role confusion maycling to a single intimate relationship, and use it to reflect,clarify, and integrate their identities (Holt & Johnson, 1991). Holtand Johnson noted that female adolescents who choose to engagein risky sexual behavior to accomplish their developmental tasksof achieving independence and forming their adult identity may doso consciously or unconsciously. There is little empirical researchthat supports this point of view. Ascertaining adolescents'perspectives about their decision-making regarding sexual activityCHAPTER TWO25and contraception would enable adults to better understandadolescent behavior. More information about this area would beuseful for health care professionals planning interventions todecrease the number of teenagers who become pregnant.Decision-making about ContraceptionBarr and Monserrat (1986) have identified eight reasons whyteenagers get pregnant: (a) lack of knowledge in relation to theavailable methods of contraception and how to obtain them,(b) fear that the method will be discovered by a parent,(c) inconvenience in obtaining or inconsistent use of a method,(d) belief that using contraception will interfere with thespontaneity of sex, (e) belief that sexual pleasure will bediminished by using a contraceptive, (f) belief that use ofcontraception implies premeditated sex, (g) a need to engage inrisk-taking, and (h) a conscious or unconscious desire to getpregnant to prove one's masculinity/femininity, self worth, oradult status.Morrison (1985) examined the literature on adolescentcontraceptive behavior published in psychology, sociology,medicine, demographic, and family planning journals. Sheconcluded that adolescents are largely uninformed aboutreproductive physiology, and about the variety of contraceptivesavailable. Morrison linked adolescents' negative attitudes towardCHAPTER TWO26contraception, and its nonuse by sexually active adolescents totheir level of information, beliefs, and attitudes. Reviewing theliterature, she found relationships among contraceptive use anddesire to become pregnant, limited educational goals, and lowsocioeconomic status (Morrison, 1985). These factors relate to theenvironmental influences described earlier and indicate that limitedlife opportunities affect contraceptive use. She concluded thatadolescents do not like to use contraceptives, but the reason forthis is unclear. "The failure to find specific negative attributesof contraception that are reliable across studies lends support tothe hypothesis that some generalized negative affect towardsex-related topics is one component underlying adolescentsattitudes toward using contraceptives" (Morrison, 1985, p. 564).She cited a need for future research to address the relationshipamong cognitive, emotional, and developmental factors related tocontraceptive use.Strauss and Clarke (1992) proposed a framework thatexamined the maturity of decision-making patterns of adolescentsin relation to cognitive, social, and emotional issues. Theframework is derived from the theoretical literature and researchon adolescent development and problem solving. Threedecision-making patterns were identified: immature, transitional,and mature (Strauss & Clarke, 1992). Middle adolescents use atransitional model of decision-making characterized by what ElkindCHAPTER TWO27(1967) calls the imaginary audience and personal fable ("I didn'tthink it would happen to me"); they may not consider all thealternatives and their consequences when solving problems ofcontraception.Norris (1988) proposed an approach to contraceptivebehavior that draws on research and theory in the areas ofmemory and information processing. "The basic premise of thiscognitive model is that a woman's contraceptive behavior is afunction of the thoughts that are accessible at the time that sheis presented with an opportunity to engage in sexual intercourse"(Norris, 1988, p. 136). While this model is heavily influenced bythe social environment, it does take into account both adolescentand adult women's behaviors.Urberg (1982) used a problem-solving framework to examinecontraceptive behavior in both male and female teenagers.Contraceptive use by teens is determined by their self concept,cognitive skills, and knowledge; all of these influence theirmotivation. Motivation to use contraceptives is important but isalso related to the teen's locus of control, the value of pregnancy,and the teen's vulnerability. All these factors will influenceabilities to think about solutions to contraceptive problems, makedecisions, and choose a solution (Urberg, 1982). Urberg raised animportant point; different individuals may be contraceptiverisk-takers for different reasons.CHAPTER TWO28While the previous authors have focused on adolescentrisk-taking from a personal decision-making perspective, Furbyand Beyth-Marom (1992) suggested that the various aspects of thesocial-structural environment in which adolescents live may playan equally important role in decision-making competence. Theyanalyzed the literature on risk-taking, cognitive development, anddecision-making skills, and suggested that adolescents may be nogreater risk-takers than adults, and that risk-taking may bebeneficial for assisting adolescents to achieve their developmentaltasks (Furby & Beyth-Marom, 1992). This perspective offers adifferent approach for understanding adolescent risk-taking asnormal development, rather than a deviant behavior and suggeststhat adolescents' risk-taking in relation to contraceptive use maybe influenced by the environment in which they live.It is generally agreed that adolescents' development andtheir perceptions are dependent on a variety of psychological,social, and environmental factors (Alexander et al., 1991; Holt &Johnson, 1991; Mercer, 1979a; Shaw, 1991). Smith (1991) notedthere are differences in the adolescent's perspective, her family'sperspectives, and professional's perspectives. By focusing on"the deficits of adolescent mothers and the pathology of theirfamilies rather than on the possibilities and difficulties theyexperience in the midst of often formidable circumstances" (Smith,1991, p. 163), the professional fails to understand how anCHAPTER TWO29adolescent's environment may shape her experience of pregnancy.In addition, the research has indicated that the teen's socialenvironment also influences the decisions they make about beingsexually active and exposing themselves to the risk of pregnancy.In the next section, factors in the environment that influence ayoung woman's decision-making regarding risk of pregnancy willbe discussed.Environmental Factors Influencing Adolescent PregnancyHow a young woman deals with the risks of pregnancy isinfluenced by social and psychological factors in her environment.Flick (1986) has identified the following sociocultural forces thataffect the adolescent's risk for pregnancy: low socioeconomicstatus, metropolitan residence, and large family or single parenthousehold. Speraw (1987) studied the cultural beliefs ofCaucasian, African-American, Hispanic, and Pacific Asianadolescents and found that the adolescents' cultural backgroundsshaped their perceptions of pregnancy.This section discusses the research related to theenvironmental forces which increase the likelihood that anadolescent will be at risk for pregnancy under three headings:(a) poverty, (b) family, and (c) peers.CHAPTER TWO30PovertyLiving in poverty increases the likelihood of young womenbecoming pregnant. Zuckerman et al. (1984) noted that povertymay contribute to adolescent pregnancy "because economicdisadvantage increases the risk of parental depression and familydysfunction and decreases the opportunities for alternateadolescent accomplishments" (p. 860). Similarly, Flick (1986) notedthat adolescents who live in poverty may feel they lack controlover their destiny and opportunities to be successful; they seepregnancy as a way of achieving these in adult roles. Hayes(1987) also noted that poverty and poor employment opportunitiesare closely associated with nonmarital childbearing, and suggeststhat adolescents living in poverty may view pregnancy as a wayto be successful in their lives.Young women living in poverty are more likely to havesexual partners who are poor and have less education than theirpeers who delay childbearing (Marsiglio, 1987). As a consequence,both the young women and their partners face long-term socialand economic disadvantages. Hardy, Duggan, Masnyk, and Person(1989) when investigating the characteristics of men who hadfathered children by very young women in Baltimore, found thatthe fathers had low levels of schooling and poor employmenthistories. Indeed, several had criminal records, and one in fivehad at least one other child by another woman. These factorsCHAPTER TWO31suggest that young women living in poverty may be at greaterrisk for encountering irresponsible partners who have poorlydeveloped value systems and who have had more life experiences.While these studies all suggested that poverty increases thelikelihood that adolescents will be at risk for becoming pregnantand experiencing difficulty in their lives; they are fromprofessionals' perspectives. Research that addresses youngwomen's' perceptions of their socioeconomic status as a factorinfluencing their experience of pregnancy, would help health careprofessionals to understand young women's experiences.FamilyA great deal of research has been done to identify thefactors in the family environment that influence adolescentpregnancy. Wattleton's (1987) study of American teenagersidentified the following familial factors that influenced sexualactivity leading to pregnancy: (a) parent(s) with a lowsocioeconomic status, (b) parents who are unemployed, (c) singleparent families, (d) parents who are not college graduates and(e) families who do not value school attendance and making goodgrades. Because these factors are interrelated with the socialenvironment in which the family lives, specifically poverty, it ismisleading to suggest that these relationships are only attributedCHAPTER TWO32to the family itself as opposed to the family's interaction with thecommunity.Pete and DeSantis (1990) interviewed five 14-year-old,African-American pregnant adolescents, and found that certainfactors in the family unit intensified vulnerability, upset securityand belonging, and increased the likelihood that young womenwould become sexually active. These factors were identified as:(a) lack of planned activities, (b) unsupervised time,(c) incongruencies between mother's wishes and daughter'sbehaviors, (d) mothers who are ineffective authority figures, and(e) lack of communication between mother and daughter aboutinformation on sexuality (Pete & DeSantis, 1990). They suggestedthat when these factors are present in a family, the youngwoman's risk for pregnancy is increased (Pete & DeSantis, 1990).Not having a father figure present in their lives has beencited by several authors as a force that has increased thelikelihood of a young woman being at risk for pregnancy (Raines,1991; Robbins, Kaplan, & Martin, 1985). Robbins et al. noted thatfamily stress is positively related to pregnancies occurring inearly and middle adolescence. Testing multivariate models forpredicting adolescent pregnancy, they found that there arediffering psychosocial risk factors in early and late adolescence(Robbins et al., 1985). They also found a link between fatherabsence, low self-esteem, and increased feelings of powerlessnessCHAPTER TWO33in the daughter, all of which led to an increased risk ofadolescent pregnancy (Robbins et al., 1985). Raines reviewed theliterature and found that there is an increased probability thatfathers who are not involved in the lives of their adolescentchildren will have a daughter who experiences an unplannedpregnancy. She identified the following characteristics of fatherswho are not involved: the father is physically absent, emotionallyunavailable, or has a negative relationship with his daughter(Raines, 1991). The link between father absence and lowself-esteem needs to be explored further to understand better thefactors influencing this relationship.Hayes (1987) offered an alternate view, that the adolescents'self-perception, not self-esteem influenced their expectations andperceptions of the risks of pregnancy and childbearing. Theseself-perceptions are influenced by the family of origin. "Race,socioeconomic status, family structure, family size, and parents'education are strongly associated with attitudes about sexual andfertility behavior" (Hayes, 1987, p. 121).Alexander et al. (1991) cautioned that when genital sexualactivity with a partner occurs in early adolescence it is often outof a need to enhance self-esteem; at the same time, exploitation byan older partner needs to be ruled out. Often these youngadolescents come from families with multiple problems (Alexander etal., 1991). Alexander et al. suggested that young adolescentsCHAPTER TWO34involved in sexual intercourse need an opportunity to talk abouthow to build self-esteem in other ways, how they can gain copingskills to deal with their family problems, and how to be moreassertive. The link between low self-esteem and socialenvironment has been identified by health care professionals.This needs to be investigated from the adolescents' perspective inorder for professionals to more completely understand howself-esteem influences teens' decision-making about their sexuality.Another factor in adolescents' families is sexual abuse.Boyer and Fine (1992) examined the relationship between sexualabuse and adolescent pregnancy. Their findings indicated thatcoming from an abusive family (whether the abuse was physical,psychological, or sexual) is associated with having intercourse atan earlier age (Boyer & Fine, 1992). They suggested that physicalmaltreatment and sexual victimization (molestation, attempted rape,or rape) may disrupt adolescents' developmental processes andundermine their ability to make decisions about complex situations,putting them more at risk for pregnancy. Oz and Fine's (1988)findings also suggested that having lived in foster care, andhaving a father who was violent or an alcoholic increased theadolescent's risk for pregnancy.The social environment of adolescents is linked to theirfamily by culture. Hayes (1987) suggested that culture acted as aforce on adolescent sexuality by creating values, norms, andCHAPTER TWO35expectations about gender roles, sexual behavior, relationships,marriage, and parenting. For example, Faber's (1991) interviewsof African-American and Caucasian unmarried adolescents revealedthat family members influenced their decisions for pregnancyresolution. They also considered personal, familial, and religiousvalues in deciding to bear and keep their children.Warren and Johnson (1989) further investigated theinteraction between family environment, demographic measures, andthe decisions made by unintentionally pregnant 14 to 22 year oldsregarding postdelivery plans. Ambivalence about their plans forpregnancy resolution was found to be related to the followingfamily characteristics: nonsupportive and conflictual relationshipsamong family members, lack of respect and support for functioningindependently, lack of encouragement for expressing feelings, anda lack of interest in cultural and intellectual experiences (Warren& Johnson, 1989). The concept of ambivalence was not clearlydefined, consequently, it is difficult to understand what theadolescents were experiencing as ambivalent feelings. Theadolescents reported a low level of ambivalence (Warren &Johnson, 1989). Warren and Johnson noted : " . . . either theseadolescents were not very ambivalent about their postdeliveryplans or they were unwilling to report (or were unaware of) theirtrue level of [ambivalence] . . . factors, such as unconsciousdenial . . . may have distorted the measurement of ambivalence"CHAPTER TWO36(p. 516). This author believes the young women's denial of theirpregnancies may have influenced their perceptions of theambivalence they were experiencing, which may account for thelow level of ambivalence that Warren and Johnson measured. Theyoung women's denial may have also been related to their level ofcognitive development. The study results were biased towardadolescents who continue their pregnancies; no comparative datawere collected on those who chose abortion.Several authors have suggested that quantitative researchmethods, like questionnaires, do not allow the researcher to makeconnections between variables in the same way that qualitativemethods, like interviews do (Morrison, 1985; Warren & Johnson,1989). In an interview the researcher can record how individualsperceive their experiences and their links among the variables asthey describe them.PeersAnother factor in adolescents' social environments are theirpeers. The developmental literature noted that concern with peerapproval commonly affects sexual behavior in middle adolescence(Alexander, et al., 1991; Reedy, 1991). "Experimentation andrisk-taking behavior, both in sexual behavior and in otherhealth-related areas, are common at this stage and usually ariseout of the developmental task of defining oneself socially"CHAPTER TWO37(Alexander, et al., 1991, p. 1277). Adolescents look to their peersfor recognition and acceptance of their behavior (Reedy, 1991).Although some teenagers in this age group have sexualintercourse out of curiosity, many have sexual intercourse out ofa need to prove to themselves that they are lovable and acceptedby their peers (Alexander et al., 1991). Generally, the literaturehas ascribed teenage pregnancy to teens' efforts to fulfill theirneeds for feeling loved or having someone to love (Steane & Heald,1987). This perspective excludes the adolescent's own perspectiveof her experience.The attitudes and behavior of peers are frequently cited asa factor influencing adolescent sexual behavior. Rogers and Rowe(1990) found that the behavior of siblings and best friendsinfluenced adolescents' sexual behavior. Billy and Udry (1985)studied junior high school students to determine whetheradolescents' best same-sex and best opposite-sex friends wouldinfluence their intercourse behavior. They found that thelikelihood that respondents who were virgins would have sexualintercourse within two years increased if their friends weresexually experienced (Billy & Udry, 1985). While there appears tobe a correlation between the adolescent and their friends'behaviors, it is unclear how individual adolescents are affected bytheir peers (Hardy & Zabin, 1991; Hayes, 1987).CHAPTER TWO38Rather than seeking peer approval, late adolescents aremore interested in forming an intimate relationship (Mercer, 1979a).In late adolescence, teens are also more cognitively mature. Ifpregnancy occurs, teens are better able to imagine their optionsand the consequences of their actions for their futures.Choices for Pregnancy Resolution: Abortion, Adoption, or Keeping"Adolescents who become pregnant have difficultyenvisioning alternatives, evaluating alternatives via propositionallogic, engaging in perspective-taking, and reasoning about chanceand probability" (Gordon, 1990, p. 354). The adolescent uses aconcrete form of decision-making to consider options associatedwith her pregnancy (Reedy, 1991). Some teenagers have reportedthat before they became pregnant they felt bored and saw fewoptions for their futures; these teenagers hoped to find directionand purpose for their lives through their pregnancies and babies(Holt & Johnson, 1991).Hatcher (1973) studied young women who had abortions, andsuggested the experience of pregnancy and abortion is heavilydetermined by the stage-specific developmental conflicts of early,middle, and late adolescence. She found that young women whohad abortions, experienced a variety of conflicts that wereconsistent with their developmental stage. In early adolescence,conflicts revolved around concern with body image as aCHAPTER TWO39consequence of body changes (Hatcher, 1973). In middleadolescence, conflicts were centered around issues ofindependence. The adolescent was self absorbed in relationshipswith peers of both sexes (Hatcher, 1973). In late adolescence, theconflicts were centered around career goals and integration of aself-identity. These were issues for middle class adolescents withpregnancies ranging from 7 to 13 weeks (Hatcher, 1973). Theinterpretation of the findings from the study focused on thepsychological development of the participants. This study did nottake into account socioenvironmental influences affecting theteens' experience. Because the young women had made a decisionto terminate their pregnancies they may have had a differentperception of the experience than a teen who would decide tocontinue the pregnancy.Zabin, Hirsch, and Emerson (1989) noted that approximately40 percent of teenagers who get pregnant elect to terminate theirpregnancies, but very little research has examined the effects ofabortion compared to the effects of adolescent childbearing.Findings from their study indicated that the young women in theabortion group did not experience changes for the worsepsychologically, in fact, they experienced fewer negative feelingsthan the other teenagers who chose to keep their babies (Zabin etal., 1989). Further research examining whether pregnantteenagers considered abortion as an option and exploringCHAPTER TWO40decision-making by those who keep their babies may assist inilluminating these issues.In a study of young women who choose not to abort,McLaughlin, Manninen, and Winges (1988) studied adolescentsserved by an agency with an open adoption policy. They foundthat adolescents from stable families with a higher socioeconomicstatus, and who felt they had more to lose by childbearing weremore likely to place a child for adoption (McLaughlin et al., 1988).Because a teenager is still dependent on her parents forsome of her needs, she often experiences a conflict when shedecides to continue her pregnancy, and keep her child. At timesthe conflict between the teen's needs and those of her fetus areintense. This conflict begins during pregnancy and continuesafter delivery. Sadler and Catrone (1983) presented a frameworkof observable adolescent behaviors that illustrate the conflictsbetween the teen's needs and those of her expected child. Sevendevelopmental parallels of adolescence and parenthood wereidentified: (a) narcissism versus empathy with child;(b) egocentrism versus mutuality between mother and child;(c) identity formation versus maternal identification; (d) roleexperimentation versus maternal role definition; (e) formation of asexual identity versus body-image changes associated withpregnancy; (f) emancipation from family versus reassignment offamily role; and (g) transition from concrete to formal operationsCHAPTER TWO41versus problem solving and future planning skills necessary forchild-rearing (Sadler & Catrone, 1983). The parallels were basedon the author's clinical experience with adolescents living in aninner city neighborhood in the United States. Although, nomention is made of how the information was validated by theteens, the phenomena described are related to poverty and urbanlife, as well as the developmental tasks of adolescence andparenthood.A developmental approach to adolescent parenthoodhighlights the practitioner's need to address the social, emotional,and cognitive issues that relate to the teenage mother'sadjustment to the role of parent. Sadler and Catrone (1983)suggested that further research should be done to isolate thesevariables and to examine how they relate to the adolescent'sadjustment to the role of parent. The adolescent's perception ofherself as a parent begins during pregnancy. Researchers mustfocus, however, on the adolescent's perceptions of the earlydevelopment of her maternal identity as a point which occursduring pregnancy. In the next section the responses of thehealth care system to adolescent pregnancy will be discussed.Responses of the Health Care SystemConcerns about early pregnancy and unintendedchild-bearing revolve around the immediate and long term impactCHAPTER TWO42of the situation on the young woman, the child, the father, andother family members, as well as on society as a whole(Rothenberg & Sedhom, 1991). The impact of this phenomenon hasbeen studied in terms of physical health issues, economicdeprivation, marital instability, interrupted education, lowsocioeconomic status, child neglect and abuse, and implications forsocial policy (Moore & Burt, 1982; Rothenberg & Sedhom, 1991).Questions have been raised about whether current social andhealth care approaches to adolescent pregnancy are adequate.The current health care system approaches adolescentpregnancy from three areas: prevention of pregnancy througheducation and contraceptive awareness, care of the pregnantadolescent, and interventions directed at decreasing repeatpregnancies in adolescence (Hayes, 1987). Each of theseapproaches have been evaluated for adequacy or inadequacy. Theresults of these evaluations and issues that affect health caredelivery are discussed next.education and Contraceptive AwarenessEvaluation of preventative education programs has revealedthat the reasons for teenage pregnancy are dependent on anumber of interrelated variables (Hayes, 1987). Thomas et al.(1992) conducted an education program with 11 to 16 year olds inschools in Hamilton, Ontario. It was based on aCHAPTER TWO43cognitive-behavioral model for preventing adolescent pregnancy.Evaluation of the 3,290 male and female participants revealed that"the program had no effect on rates of self-reported sexualintercourse, consistent use of birth control, or pregnancy"(Thomas et al., 1992, p. 49). But, the results did indicate that anumber of different variables affected the sexual behavior ofadolescent males and females (Thomas et al., 1992). The resultsindicated that education programs that do not address all thevariables will not affect the rate of self reported intercourse andconsistent use of birth control.When medical care was added to an education program, adifferent result was found. Zabin (1992) evaluated a program thatoffered education, counseling, and medical services to 3,944 juniorand senior high school students using a quasi-experimentaldesign. A social worker and a nurse-midwife or nursepractitioner offered reproductive health education in the school inthe morning, and contraceptive services in a nearby clinic in theafternoon (Zabin, 1992). The program was evaluated by surveyquestionnaires that compared students in other nontreated schoolswith students who had received combined education, counseling,and medical care. Records kept in the clinic were also used as asource of data. The results indicated that adolescents using theprogram postponed the onset of sexual intercourse, increased theirCHAPTER TWO44use of effective contraception, and reduced their rates ofunintended pregnancy (Zabin, 1992).Miller and Paikoff (1992) compared adolescent pregnancyprevention programs, and suggested that the difficultiesexperienced with designing and implementing programs to changebehavior are similar to the difficulties experienced when trying todraw conclusions about the effects of the programs. In order tomeasure the effects of adolescent pregnancy programs, valid andreliable measures of sexual behavior, contraceptive use, andpregnancy resolution are required. Three of the most commonproblems with collection of this data are: parents who refuse toallow their teens to participate, nonvoluntary sexual experiences,and confusion about the wording of questions (Miller & Paikoff,1992). Evidence to date indicates that modest reductions in thenumber of adolescent pregnancies can be achieved by preventionprograms. There is still a gap in knowledge about howadolescents' socialization and cognitive growth affects their socialskills (e. g., assertiveness and responsibility) and sexual activity.At present, the health care system's response to adolescentpregnancy has decreased the number of late adolescents whobecome pregnant, but the number of early adolescents who becomepregnant has increased (Flick, 1991; Hayes, 1987). This indicatesthat health care professionals may not adequately understand theperceptions of early adolescents who get pregnant.CHAPTER TWO45Care of Pregnant AdolescentsAnother area of health care service is the prenatal care ofpregnant adolescents. Prenatal care has been evaluated byseveral researchers (Gale et al., 1989; Piechnik & Corbett, 1985;Smoke & Grace, 1988;). Piechnik and Corbett found that lowbirthweight can be ameliorated by a program that addresses thesocial, psychologic, and nutritional needs, and specific healthproblems of young pregnant women. Smoke and Grace's researchprovided further support for the premise that specialized prenatalcare for pregnant adolescents has a positive influence on theoutcome of the pregnancy for mother and infant. Gale et al.suggest that age is not a risk factor for teenage pregnancy,rather social and economic variables influenced the outcome formother and infant.Although many program interventions have been developedand implemented, few have been rigorously evaluated to identifyoutcomes and effectiveness. Hayes (1987) identified the lack ofclearly defined objectives for measuring outcomes, and the failureto distinguish direct and indirect outcomes as the reason whyevaluation data is missing. While comprehensive care programshave the potential to effectively help adolescents with theexperiences of pregnancy, birth, and the first months ofparenthood, there is no evaluative data that indicates the effectsare long lasting (Hayes, 1987). The literature does not addressCHAPTER TWO46how variables in the adolescents' environments influence theirperceptions of the pregnancy experience. More research isrequired to better understand how programs can address theproblems young people experience in their lives while they arepregnant. Research indicates, young women who seek prenatalcare early, can experience improved outcomes for themselves andtheir infants. Some adolescents, however, do not seek care untillate in their pregnancies. AU of the reasons why young women donot seek early prenatal care remain unclear and need to befurther explored.interventions for Decreasing Repeat PregnanciesYoung women who begin having intercourse at an early ageare at risk for repeat pregnancies in their teens, because they donot use, or ineffectively use contraceptives and have more yearsof sexual activity (Bassolone, 1989; Flick, 1986). Considering thatteens under the age of 15 have a higher rate of abortions thanbirths, research is needed to look at the issue of repeatedpregnancies and not just those teens experiencing repeated births(Bassolone, 1989). Understanding adolescents' perceptions ofpregnancy could provide information about why adolescents haverepeated pregnancies in their teen years, which could assisthealth professionals to better understand this phenomena.CHAPTER TWO47Issues that Need to be AddressedThe literature has identified the following issues that needto be addressed: barriers to successful program implementation,and variations in program utilization. Rothenberg and Sedhom(1990) identified the following barriers to successful programimplementation: poor coordination, insufficient resources,inadequate access, and incomplete program information. Nichols(1991) also noted that with the exception of prenatal health careprograms, prevention programs have been inadequately evaluatedin relation to effectiveness and costs. Despite the voluminousamount of research on adolescent pregnancy, there is relativelylittle information on how the negative effects of adolescentpregnancy and childbearing can be minimized (Nichols, 1991).Without this information, there is not a firm scientific base fordeveloping programs for prevention of adolescent pregnancy(Nichols, 1991).The World Health Organization (1989) attributed a lack ofinvolvement by young people in existing programs to thewidespread lack of effective policies and programmes in relation toadolescent reproductive health care. Rothenberg and Sedhom(1991) acknowledged that nurses must be knowledgeable aboutpolicies relating to teenage pregnancy if they are to effectivelyuse resources and participate in developing social policy andprograms. Two priorities identified for nurses were:CHAPTER TWO48(a) assistance with child care so that the young parents cancontinue their education or seek employment, and (b) outreachservices to reduce early pregnancies (Rothenberg & Sedhom, 1991).Programs for pregnant adolescents need to incorporate five goals.First, early prenatal care must be provided to monitorcomplications for both mother and fetus. Second, nutritionalcounseling and supplements must be provided to reduce theeffects of poverty. Third, educational and employment counselingis needed to enhance or optimize adolescent development. Fourth,support network building should be included with professionals,family, and friends. And fifth, the abilities of young women tocare for their babies should be maximized (Rothenberg & Sedhom,1991). Rothenberg and Sedhom acknowledged that in view ofconstantly changing societal values, policies and programs need tobe evaluated frequently.The literature also addresses the limited participation ofpregnant adolescents in programs developed by professionals(Bergman, 1988; Wells, McDiarmid, & Bayatpour 1990). Researchersevaluating programs have found that some programs have beenbased on unsubstantiated assumptions about teenagers' actions,such as lack of sex education or access to birth control, or a lowself esteem (Miaoulis, 1989; Stafford, 1987). These assumptionshave not been based on research which addressed the adolescent'sperspective. Burke and Mensah (1985), also noted there is a lackCHAPTER TWO49of coordinated planning of health programs designed for pregnantadolescents, which results in a lack of program size, scope, andflexibility to meet the complex needs of these young women.If prenatal care programs are designed to meet adultwomen's needs, young women will not participate. Young womenhave different prenatal care needs than older women. This hasbeen explicated by Kelen, Hunt, Sibeko-Stones, and Varga (1991)who identified the following complex needs of young women:physical and emotional isolation, lower educational levels,restrictions on individual choices, and limited financial resources.Therefore, adolescents need special services. Brown and Urback(1989) have suggested that high risk teens need services thatinclude: counseling, medical care, prenatal groups, school,parenting groups, nursery, housing, clothing, and respite care.Bergman (1988) reported that issues of accessibility, stigma,and informal networks of support are factors that explain thevariations in program utilization by pregnant teens. Many of thepregnant adolescents in her study were receiving informal supportfrom family, boyfriends and friends. They reported they did notneed or want special services designed for them (Bergman, 1988).Bergman noted the importance of investigating the needs anddesires of adolescents as they perceive them, so that futureprogram planning can incorporate these. Adolescent clinics willnot be used if teens are not aware of them, feel they will beCHAPTER TWO50labeled as deviants, or are too embarrassed to ask about services.Bergman suggested that the traditional perception of the doctor asthe sole caregiver must change to include appropriate nonmedicalservice programs as well.Mercer (1979c) pointed out that whether adolescents utilize ahealth care facility is dependent on factors, such as what the teenperceives as a health care need, accessibility, and whether thesystem's characteristics are congruent with the developmentaltasks of adolescence. Adolescents seeking health care serviceswant their privacy and issues of confidentiality respected. Forexample, a 15-year-old requesting the birth control pill will wantto know if the health care provider will respect her wishes by notinforming her mother that she is taking the pill. Middleadolescents are concerned about how they appear to others andwant to know that others are truly concerned about them aspersons (Mercer, 1979c). As adolescents strive to achieveindependence they want to make their own choices and may rebelagainst parents or health care professionals who try to imposechoices on them (Mercer, 1979c; Morgan & Barden, 1985).Elster, Lamb, Tavare, and Ralston (1987) studied the medicaland psychosocial effects on adolescents in a program whichprovided a comprehensive adolescent pregnancy and parenthoodprogram. They found that factors that were present prior toconception influenced a teen's ability to cope with the reality ofCHAPTER TWO51pregnancy, and her ability to adjust to parenthood. These factorsincluded: socioeconomic status of the teen's parents, whether theteen received Medicaid, whether the teen was in school or workingat the time of conception, maternal age, the week prenatal carewas started, and the teen's relationship with the baby's father(Elster et al., 1987).Limited data collected on teens' perceptions and theirrelationship to underutilization of programs supports the criticismthat a discrepancy exists between teens' and health care workers'perceptions of the experience. Further research is required toexplore teens' perceptions of their experience of pregnancy.SummaryIn this chapter, literature relevant to adolescent sexualityand pregnancy was reviewed. Initially, the literature onadolescent growth and development was described. The tasks ofadolescent growth and development have been identified as:gaining comfort and acceptance with body image, internalizing asexual identity role, developing a personal value system, preparingfor productive citizenship, striving to achieve independence fromparents, and developing an adult identity (Mercer, 1979a; Johnson,1986). The literature indicated that adolescents experience sexualmaturity and cognitive development at different rates which canlead to conflicts (Mercer, 1979a; Reedy, 1991). The researchCHAPTER TWO52identified discrepancies between biological and psychosocialdevelopment that influence adolescents' decision-making aboutsexuality and which can result in pregnancy (Alexander et al.,1991; Mercer, 1979a; Reedy, 1991). The event of pregnancy hasbeen characterized by four tasks: pregnancy validation, acceptingthe baby as part of their body, acknowledging the baby is anindividual, and becoming a care-giving mother (Barr & Monserrat,1986; Rubin, 1975). The literature on pregnancy in anenvironmental context was reviewed. The environmental factors ofpoverty, family, and peers were examined. The coping behaviorsused by adolescents during pregnancy were related to theirmaturational stage. Behaviors were influenced by their beliefs,and the social situation and circumstances in which they live.Lastly, the types of responses of the health care system, theadequacy or inadequacy of existing programs were assessed, andthe current understanding of the issues that need to beaddressed were critiqued.In summary, despite the abundant research relating topregnant teenagers, there is relatively little understanding abouthow the adolescent female perceives her pregnancy experience.There is a paucity of nursing literature describing theadolescent's perspective. Therefore, the study of the femaleadolescent's experience of pregnancy can provide informationCHAPTER TWO53necessary to better enable health care professionals to planprograms and provide care appropriate to their needs.Chapter Three will describe the research method whichenabled the researcher to investigate the female adolescent'sexperience of pregnancy.CHAPTER THREEMETHODSIntroductionAdolescent females who become pregnant have an experiencethat differs from adult pregnant females. They experience twodevelopmental events simultaneously: adolescence and pregnancy.Although special programs have been developed by health careprofessionals to attempt to meet their needs, concern remains asto the appropriateness and effectiveness of these programs.Obtaining information about the meaning of adolescents' experienceof pregnancy can provide information so that health care can beevaluated and changed.The question addressed in this study was: What is theexperience of pregnancy from the female adolescent's perspective?The research question is posed at the descriptive level, andrequires a description of a specific phenomenon of humanexperience from the client's perspective. Phenomenology is aninductive, descriptive method that allows the researcher toinvestigate human experience as it is lived (Ornery, 1983).Therefore phenomenology was the appropriate method to addressthis study's research question. Phenomenology enabled theresearcher to provide a rich detailed description of the femaleadolescents' experience of pregnancy.54CHAPTER THREE55This chapter briefly outlines phenomenology as a methodand describes the process employed in the study design, includingsample selection and criteria, ethical considerations, data collectionand analysis, and issues of scientific rigor for qualitativeresearch. The chapter concludes with a summary of thecharacteristics of the participants.The Phenomenological PerspectiveThe origins of phenomenology are in philosophy, it firstappeared in the writings of Brentano in the last half of the 19thcentury (Ray, 1990). In the early 20th century phenomenologywas further developed as a method by the German philosopherEdmund Husserl, who related phenomenology to the question ofknowing (Ray, 1990). Merleau-Ponty, a French philosopher furtherexpanded the method to focus on the perception of livedexperiences (Oiler, 1986). Field and Morse (1985) have identifiedthe goal of phenomenology to be the accurate description of theexperience of the phenomenon under study, as opposed to thegeneration of theories or models, or the development of generalexplanations. The phenomenological research orientation differsfrom empirical research, in that it generates hypotheses, ratherthan testing hypothesis (Knaak, 1984). Oiler (1982) acknowledgedthat the nursing profession is concerned with the client's qualityof life and the quality of the nurse-client relationship.CHAPTER THREE56Phenomenology is consistent with a collaborative nurse-clienteffort that supports the individual's right to exercise control overhis or her own health care (Oiler, 1982). The value of thephenomenological method lies in its holistic approach; thatapproach can effectively assist nurses in their goal to understandthe experience from the individual's perspective who is living it.Selection Criteria and Sample SelectionThe sample was selected to be consistent with therequirements of the phenomenological method. Becauseresearchers interested in phenomenology want to describe themeaning an experience has for those who are living it, theychoose informants who have specific characteristics or knowledgethat enhances the researcher's understanding of the experience(Field & Morse, 1985). The purpose of this study was to describethe experience of pregnancy from the adolescent's perspective.Initially, the plan was to interview young women, from a varietyof social backgrounds who were experiencing pregnancy for thefirst time and were willing to talk about their experiences. Thisselection process sought the maximum illumination of the richnessof individual experiences. In reality, there were few pregnantadolescents who met the study criteria and chose to carry theirpregnancy to term. Thus, the study population ultimatelyconsisted of a similar group of young women who were carrying aCHAPTER THREE57pregnancy to term for the first time, and who were willing to talkabout their experience.Selection CriteriaCriteria for selection of study participants were determinedprior to recruitment. To meet the study criteria, adolescentswere:1. in their last trimester of pregnancy (i. e., 33 to 40 weeksgestation),2. able to read English,3. 13 to 16 years of age,4. not married, and5. currently planning to keep the baby.It was decided to interview young women who were in theirlast trimester of pregnancy, because they would have had achance to have worked through their acceptance of thepregnancy. Therefore, they would be able to describe theirperceptions of the experience more fully than if interviewedearlier. Young women were excluded from the study if they hadalready delivered their babies. One young woman who met thestudy criteria was not interviewed because she had delivered herbaby the previous week.CHAPTER THREE58Sample SelectionThe sample of pregnant adolescents was drawn from anoutpatient clinic of a tertiary facility and from three programs inthe Vancouver Lower Mainland that offer services specifically topregnant teens. Agency and program personnel recruited theyoung women for the study. Prior to the recruitment of theyoung women, the researcher met with the nurses in theoutpatient clinic and provided information about the study. ALetter to Agency Personnel (Appendix A) was distributed to thenursing staff. This contact with the staff enabled the researcherto enlist the assistance of the staff and to involve them in theselection of the participants. A synopsis of the research proposaland copies of all consent forms and the trigger questions, as wellas a list of the sampling criteria were left with the nurses in theclinic. A Letter to the Attending Physician (Appendix B) was alsoprovided to be placed on the client's hospital chart so that thedoctor would be apprised of the client's involvement in theresearch project.The researcher also met with the program leaders of theselected programs to clarify their involvement in the selection ofthe participants. A Letter to Agency Personnel (Appendix A) wasdistributed to each program leader. In addition, a synopsis of theresearch proposal, copies of all consent forms and of the triggerquestions, and a list of the criteria for recruitment of the youngCHAPTER THREE59women, were provided. At weekly intervals, the facilities werecontacted to determine if any young women who met the studycriteria were available for the study.The clinic staff and program leaders were instructed to givethe introductory letter to those clients who met the study criteria.Then, the nurses and program leaders were to describe the studybriefly for the young woman, to provide her with a copy of theLetter to the Participant (Appendix C), and to determine if theyoung woman was interested in participating in the study. Eachyoung woman then contacted the researcher or gave consent forthe researcher to contact her.The investigator followed up the initial contact bycontacting each young woman to explain the study further and toobtain consent prior to each first interview (Appendix D). Theresearcher clarified her purpose: to interview the client and notto provide treatment. If a young woman was living at home,parental consent was obtained (Appendix E). Recruitment ofparticipants for the study was complicated by the fact that someyoung women were "wards of the court", in which case consent ofa young woman's social worker had to be obtained.Recruitment of the young women and completion of the firstinterviews took place over six months. In retrospect the longrecruitment period is not surprising, considering the difficultyaccessing a small target population.CHAPTER THREE60The sample size remained small, but that is consistent withthe method. By coincidence, six of the young women had lived onthe street in the previous year. This is a group who normallyare not readily accessible nor involved in research.It was difficult to predetermine the number of subjectsrequired to describe the phenomenon of interest. Initially eightto twelve subjects were viewed to be adequate. For this study,eight female adolescents were interviewed. The sample size wasdetermined by the number of informants necessary to describe thephenomenon that was being investigated. Guba and Lincoln (1981)noted that data collection can be ended when redundancy occursor when only a small amount of new information is acquired with asubstantial effort; they referred to this as saturation. Saturationof the data in relation to the phenomenon occurred when the sameinformation was repeated in the interviews. The researcher notedafter interviewing the sixth participant, that themes were startingto recur in the data. The data were beginning to reachsaturation, but interviews continued to include an eighthparticipant.The adolescents in this study were an especially difficultgroup to access and retain; they came from problem families andmoved frequently. In addition some young women were notinterviewed a second time, because they could not be located.Mercer (1991) acknowledges that attrition of subjects is a criticalCHAPTER THREE61problem for researchers studying pregnant adolescents and theirfamilies.Procedures for the Protection of Human ParticipantsThe issue of protection of human participants was addressedby following the guidelines established by The University ofBritish Columbia Behavioural Sciences Screening Committee forResearch and Other Studies Involving Human Subjects (1989).Approval to conduct the study was obtained from The Universityof British Columbia Behavioural Sciences Screening Committee andfrom the Research Coordinating Committee of the hospital in whichthe outpatient clinic was located.The young women were informed their participation in thestudy was voluntary and they were free to withdraw from it atany time. They were reassured that refusal to participate, adecision to withdraw from the study, or refusal to answer anyquestions would not jeopardize their health care. One youngwoman requested that specific information she had talked aboutwith the researcher be removed from the tape; the researchererased that section from the tape prior to transcription.During the interviews, the researcher was cognizant thatthe young women might be upset by discussing their experiences,in which case a referral to an outside agency would be necessary.In reality, the young women had available resources in the formCHAPTER THREE62of supportive program leaders and social workers, and noreferrals were made.The interviews were conducted at mutually agreeablelocations. A copy of the consent form was given to each youngwoman (Appendix D). There were no known risks to theparticipants associated with the proposed research. On thecontrary, the young women indicated that they benefited fromtheir participation in the research and appreciated talking abouttheir experiences with the nurse researcher. The young womendedicated between two and three hours of their time for theinterviews. There was no monetary compensation.Only the researcher and the thesis advisors had access tothe data to maintain confidentiality. No personally identifiableinformation was included in the transcripts; the identity of theparticipants was coded, so that their true identity would only beknown by the researcher. All data were kept in a locked file.Following completion of the study, the tapes and transcripts weredestroyed by the researcher.Data Collection and AnalysisIn the subsequent sections data collection and analysis arediscussed. The phenomenological method requires that datacollection and analysis occur concurrently.CHAPTER THREE63Data CollectionData were acquired in two sets of interviews set up by theresearcher. Interviews were conducted in a mutually agreed uponinterview location, usually at a young woman's place of residence.The purpose of the first interviews was to develop rapport and toelicit the young women's descriptions of their experiences. Toavoid jeopardizing rapport, sensitive questions about demographicinformation (Appendix F) were asked of each young woman at theend of the first interview. To elicit a young woman's viewpoint,the investigator used trigger questions (Appendix G). "The typesof questions included are meant to be [a] provocative and creativemeans of getting informants to talk about their experience of thephenomenon" (Swanson-Kauffman & Schonwald, 1988, p. 100). Theopen-ended trigger questions were used to initiate conversationabout a topic or to stimulate further exploration of thephenomenon. Reflective statements and requests for clarificationwere used to collect more "rich" data. For example, "When wetalked before you were concerned about telling the baby, aftershe grows up, that you were a teenager when you hadher--why?" "Tell me more about your feelings about this." Fieldnotes were used to record the researcher's observations of theyoung woman, the environment, and the interview. The interviewsranged in length from approximately 40 minutes to 75 minutes.First interviews were done with eight young women. Two youngCHAPTER THREE64women moved away and were not available for a second interview.One young woman's baby required major surgery one monthpostpartum, and she declined a second interview. Five youngwomen were interviewed a second time, with 5 to 16 weeksbetween the first and second interviews.During data collection the researcher addressed the issue ofthe reluctant informant. One young woman was uncomfortable withtalking at length about her experience of pregnancy; to facilitatethis interview, the researcher found it helpful to ask more directquestions, such as: "How did that make you feel?" "Can you tellme more about^?" "In what way do you see that?" "What was's reaction?" "Why did you feel sad?" Field and Morse (1985)compared the bias of the reluctant informant to that of the"non-response rate". In qualitative research, some lack ofresponse is to be expected and may be accepted as falling within"normal" limits. A clear description of those who refused toparticipate in the study can lend credibility to the study. Theresearcher did not encounter any young women who refused toparticipate in the study, but on one occasion a social workerrefused consent for a 15-year-old female who was a "ward of thecourt" because she felt the young woman was too vulnerable toparticipate in the study.The quality of the data in qualitative research reflects theparticipants' ability to articulate their experiences clearly and theCHAPTER THREE65researcher's ability to gather the data relevant to the researchquestion accurately and exhaustively. The young women wereinitially shy, but as each interview progressed they became morecomfortable with the researcher and talked more freely about theirexperiences.Initially, the researcher found it difficult to listen to theyoung women without interrupting with questions, but withpractice, the researcher was able to listen to the young womenand ask reflective questions that got at the deeper meaning theexperience had for them. The investigator found that if too manyquestions were asked at once, the young women became confusedand had difficulty responding. To remedy this situation theresearcher repeated the questions one at a time or rewordedquestions in a less complex manner. For example, the firstinterview was started with: "So I'm basically interested in thingslike what is it like for you to be pregnant, what are yourexpectations about your pregnancy, how your pregnancy haschanged your life, how you see it will affect you later on." Theyoung woman had difficulty responding, so the questions wereasked one at a time."Empathic and intuitive awareness" can be intentionally usedby the researcher to enhance data collection (Oiler, 1982, p. 179).Allowing close relationships to develop between the researcher andthe young women, resulted in the young women feeling theCHAPTER THREE66researcher was truly interested in what they had to say, and ineach expressing her concerns without fear of being judged. Anexample of an empathetic response occurred when one youngwoman shared how she had been rejected by her boyfriendfollowing confirmation of her pregnancy. The researchercommunicated that she understood that it was a difficult time forthe young woman, but did not persist with questions when theyoung woman indicated she did not want to discuss it further.Because she was cognizant that the young women mightreveal certain information in one social context but not in another,the researcher chose interview locations and settings that wouldallow for privacy. For example, on one occasion, a young womanmet the researcher in a restaurant, but this was a public placewhere the conversation could be overheard. Therefore, under thecircumstances, the researcher suggested that the interview couldbe conducted in her car to maintain privacy and to allow theyoung woman to talk freely about her experience without fear ofbeing overheard. The researcher was cognizant of thevulnerability of the adolescents when conducting the interviews.If the young women stated they did not want to discuss a topicor answer a question, their wishes were respected.The interview transcripts were typed verbatim, by theresearcher, using suggestions from Field and Morse (1985), andReinman (1986). Typing the transcripts enabled the researcher toCHAPTER THREE67become very familiar with the data of each interview. Allexclamations, such as expletives and laughter were included.Pauses were denoted by dashes, and a series of dots indicatedprolonged pauses or gaps. The interviews were typedsingle-spaced with a blank line between the researcher andparticipant, on sequential pages. Wide margins were left on theleft side of the page for coding and on the right side forcomments.Field notes documented information about the interviewsetting, the young women's nonverbal communication, and theresearcher's impressions. For example, nonverbal communicationincluded one young woman rubbing her abdomen when she wastalking about plans that she was making for herself and the baby,indicating acknowledgement of the fetus. On another occasion, thefield notes identified who was present during the interview;specifically, because a foster mother was present the young womanwas reluctant to talk about her relationship with her naturalmother. Such notes were made immediately following theinterview, because it was found to be distracting to the youngwoman if information was recorded during the interviews.Following the first interview, the questions that were askedwere reviewed by a thesis advisor and suggestions for improvingthe approach to questioning were incorporated in subsequentinterviews. For example, a thesis advisor suggested theCHAPTER THREE68researcher needed to ask deeper questions in order to access thedata, so that the meaning the young women gave to theirexperiences could be more fully understood. So that: "Do youthink that your family influences how you think about how youwant to live after you have had the baby?" became: "Why do youthink your childhood might have an effect on how you will motheryour baby?" "What about your childhood makes you feel unsureabout having a baby on your own?".Data collected during the first interviews formed a tentativepicture of what it was like to be an adolescent and pregnant. Forexample, it was a shock for the young women to find out theywere pregnant. They were both scared and excited when theysuspected they were pregnant. Prior experiences influenced howthey felt about their pregnancies. They indicated they wereunsure if they would be able to be all that was expected of amother, but felt becoming pregnant gave their life new meaning.In the second interviews, questions refined the data so thatfurther abstraction of the data could occur and so that themeaning of the experience began to emerge. The researcher askedthe young women to explain further their feelings andperceptions. Interpretations made by the researcher werevalidated with the young women. For example, the researcherasked a young woman how becoming pregnant had changed herlife to a more positive course. The young woman was able toCHAPTER THREE69respond to this theme by stating that it had allowed her to goback to school and make plans for her future rather thanpartying. "It gives you a reason to live for . . . Before I hadhim the biggest thing was going out and partying, being with myfriends. And school wasn't one of those things, and not beingresponsible. And now that I have him I can get my education, atleast I can do it, it's just with him it will take longer."Because time elapsed between the first and secondinterviews, and the young women had delivered, the pregnancyexperience blended into the adjustment to the parenting role. Inthe second interviews the young women also wanted to talk abouthow the baby was affecting their lives at present.Concurrent Data AnalysisField and Morse (1985) described the purpose of dataanalysis as twofold: (a) coding of the data so that categories canbe recognized, and (b) developing a flexible data filing systemthat allows data to be retrieved from storage. In this study, thedata were coded according to meaning units based on thesignificant statements, using Giorgi's (1985) method of dataanalysis.Giorgi 's (1985) method of data analysis was chosen becauseit allowed the researcher to collect a naive description of aphenomenon from an individual via an interview (Ornery, 1983).CHAPTER THREE70Giorgi's method was used to develop a framework of themes fromthe interviews. This framework began by extracting significantstatements, which were later transformed to meaning units. Thesesignificant statements were complied into lists for storage of thedata. For example, the young women talked about family andfriends who were supportive and nonsupportive. Supportivefamily was a heading for the following significant statements:"My mom and step-dad really supported me a lot.""[my mom] she was just there once I told her.""My mom was the most support I had there.""My mother was really understanding.""My brother has actually been very understanding about it."The meaning units were then clustered together to formsubconcepts or phases that expressed explicit or implicit meaning.The subconcepts clustered as concepts, and the concepts weresynthesized into broad themes that captured the essence of theparticipants' total experience. Each step of the analysis wasguided by two concerns: (a) to characterize the essential meaningof the participants' descriptions of adolescent pregnancy, and(b) to remain as faithful as possible to the participant's originaldescription (Reinman, 1986). The four steps of Giorgi's (1985)method of data analysis were followed: (a) the entire descriptionof the experience was read to get a sense of the whole; (b) thedescription was read again to identify units of meaning in theCHAPTER THREE71experience and to eliminate redundancies; (c) the subject'sexpressions were transformed into scientific language; and (d) theinsights were integrated and synthesized into a descriptivestructure to be communicated to other researchers (Giorgi, 1985).First, to be able to read the entire description, theresearcher had to transcribe the audio-tape recorded interviews.Transcription also provided an opportunity to become familiar withthe data of each interview. Field notes were consulted to recallthe atmosphere of the interview and impressions of the researcherat the time of the interview. After these activities, the researcherread the entire transcript while listening to the audio-tape to geta sense of the whole interview. The transcripts usually requiredthree readings. Giorgi (1985) acknowledged that transcribedinterviews may take several readings to get a sense of the whole.The general sense that was grasped from the reading of thewhole provided a basis for the next step: discrimination of themeaning units. The meaning units were discerned by reading andrereading each transcript and noting significant statements andthen reflecting on the meaning of the significant statements foreach young woman. Therefore the meaning units were derivedfrom significant statements--phrases or sentences that could beextracted from the transcriptions--that exemplified the phenomenonbeing studied. The meaning units were listed in a column to theleft of the data on the transcript. To the right of the data,CHAPTER THREE72points for clarification in the second interview were noted on thetranscript.Points for clarification were used to make a list of newquestions. These new questions were about specific concerns theyoung woman had discussed. New questions, in one case,concerned one young woman's relationship with her mother. "I'dlike to know more about what it was like for you to live with yourmother--the privacy and independence you felt." As well, generalquestions about the emerging meaning units and themes wereasked of all the young women. In the second interviews, theyoung women were asked to validate whether or not the themeswere similar to their experiences. If a theme did not seemrelevant to data collected from a young woman previously, she wasasked about the validity of the theme. Questions were also usedto formulate meanings identified in specific statements. Forexample, "What about being pregnant was scary for you?" wasused to assist in formulating meaning from her statement that shewas scared about the pregnancy.After the meaning units were explicated more clearly fromsignificant statements and further questions, they were clusteredto form subconcepts or phrases that expressed meaning. Thesubconcepts then clustered to form concepts. For example,although one young woman stated that being pregnant hadchanged her life, because she had to grow up quicker, andCHAPTER THREE73although she had questions about her future, her description didnot approach the complexity described by concepts such asexperiencing a changed life. Subconcepts included experiencinghope, caring for the infant, caring for herself, changing livingarrangements, and coping with the maternal role. The explicatedmeanings emerged during analysis from each young woman'sdescription of her experience of pregnancy. These were validatedin the data. In the first step, the language of the young womanhad remained unaltered, but the meaning units moved beyond thesignificant statements. With subsequent analysis, the explicit orimplicit meanings were explicated further; for example, living withthe bodily changes included: "breasts got different, like totallydifferent shapes", and "I'm always hot", and "I'm not used tocarrying around all that extra weight".This process became more complicated as the interviewsprogressed. The researcher compared one young woman's accountto another young woman's account in order to identify and extractthe common meaning units from each, and to ensure that theanalysis was consistent for all the interviews. Then the extractedmeaning units were compared to the transcripts. For example, themeaning unit of supportive friends included significant statementssuch as: "all my friends really supported me". Another youngwoman's account revealed similar significant statements: "and myCHAPTER THREE74friends just listening, no one really judging . . . that is whathelped me".In step three, the young women's everyday expressionswere transformed into language that provided a generaldescription of the phenomenon being investigated. The researcherused both reflection and imaginative variation to transform theexperience from the everyday language of the young woman to thepsychological language of the researcher (Giorgi, 1985). Theresearcher interpreted what the young women had said abouttheir experiences. It was both difficult and time-consuming toreflect on each meaning unit and to consider how each meaningunit could be explicated by concepts at a higher level ofabstraction. For example, the young women's descriptions of whatit was like to be pregnant--accepting the pregnancy, living withthe bodily changes, forming a self-identity, thinking aboutpregnancy and parenting, dealing with support and lack ofsupport, dealing with social and environmental influences--weretransformed into living the reality of the pregnancy.During step three discrepancies between extracted meaningunits were also noted. For example, some young women felt theirpregnancies had made them mature. One young woman disagreedthat she had matured as a result of her pregnancy; instead, shestated she still wanted to be a teenager rather than an adult.Discrepancies were included as they addressed typical andCHAPTER THREE75atypical elements of the data, and thus ensured that thedescription would be representative of a variety of experiencesrather than a single experience. The discrepancies also helpedthe researcher by increasing insight into ambivalence becausethese feelings captured the tension between coping with adultresponsibilities and remaining a teenager. Once the researcherhad incorporated the discrepancies, then themes were extracted toprovide a general description of the phenomena.Second interviews were conducted to validate informationcompared across interviews and to clarify the description. Forexample, "From doing interviews with other young women of yourage I understand that it was a shock for them to find out theywere pregnant. Does this sound like your experience? How wasyour experience the same or different?" During this stage thedata were refined and the accuracy of the language used todescribe the phenomenon was increased. The meaning unitsclustered into subconcepts, the subconcepts clustered intoconcepts, and these clustered into themes. For example, notexpecting the pregnancy to occur, and initially denying thepregnancy emerged as subconcepts. The subconcepts clustered toform the concept of suspecting the pregnancy. The conceptsevolved into phases, which linked the concepts together andrepresented the dynamic qualities of the young women'sdescriptions. The phases identified were entitled: suspecting theCHAPTER THREE76pregnancy, confirming the pregnancy, making decisions about thepregnancy, living the reality of the pregnancy, and experiencing achanged life. These concepts were synthesized into the themes ofambivalence and adolescent pregnancy as a life change event,which captured the adolescents' total experiences. The youngwomen reflected on how pregnancy had changed their lives inpart by describing their plans for the future. They felt positiveabout their pregnancies and stated that their lives would beimproved by having a baby, at the same time they often feltambivalent about the changes happening in their lives.An important step in the analysis that allowed thedescription to evolve was the researcher's ability to synthesizethemes from the participant's perceptions and intentions (Giorgi,1985). The theme of ambivalence interwoven with the five phasesof adolescent pregnancy as a life change event described theessence of the experience for pregnant adolescent females. Thetheme of ambivalence was integral to pregnancy as a life changeevent, and varied from high to low during the five phases ofadolescent pregnancy, as the adolescents struggled with theoverlapping tasks of adolescence and pregnancy. The phasesindicated that the experience was progressive for the youngwomen. The two themes that captured the participants' totalexperiences (ambivalence throughout adolescent pregnancy as alife change event) subsumed the concepts and subconcepts andCHAPTER THREE77were validated in the data. The researcher then created adiagram which illustrated the themes and concepts. Theinterwoven nature of the themes is represented, as well as theconflict the young women experienced between their tasks ofadolescence and pregnancy.Finally in step four, the researcher explicated the structureof the phenomenon by writing the description. The descriptionincorporated the themes, concepts, and subconcepts identified fromall the data. Swanson-Kauffman and Schonwald (1988) haveacknowledged that transforming the data of multiple informants'accounts into a theoretical model of a phenomenon is an intuitiveprocess. They liken this process to trying to say how you knowsomething and when you first recognized you knew it. "Intuitingconcepts of the final model is an exercise that involves continuouscritical reflection and discussion of the concepts as they emergefrom the researcher's experience of the multiple informants'reality" (Swanson-Kauffman & Schonwald, 1988).The researcher found that it was necessary to return to theinterview transcripts to maintain clarity and validity, so that thethemes represented their lives as the young women had describedthem. The researcher bracketed her personal perspectivesthroughout the analysis to decrease the potential for researcherbias. The emerging themes and the connections between theCHAPTER THREE78themes became more obvious after the rereading, intuiting, andreflection.One pitfall that can arise during the data analysis is datashuffling; that is, the researcher may shuffle the data fromconcept to concept if the data do not create a "total picture"representing the experience of the participants. Ammon-Gabersonand Piantanida (1988) note that qualitative data, unlikequantitative data, which lend themselves to clear-cut classificationin mutually exclusive categories, often have more than one salientcharacteristic that could potentially fit into several differentcategories. To move beyond data shuffling, the researcher soughtassistance from her thesis advisors in relation to phenomenologicaldata analysis to ensure that the analysis was being performedcorrectly. Field and Morse (1985) noted that, during analysis byrepeatedly comparing the interview data, the investigator canidentify when categories are saturated and no new information isbeing identified After the interview of the eighth participant,the researcher noted that no new information was emerging.Presentation of phenomenological research data decrees thatthe "rich" data from the interview subjects be communicated in away that the reader is able to identify with the description of theindividual lived experience. Knafl and Howard (1984) stated:"Presenting and discussing specific results in the context of theirtheoretical relevance demonstrates how conceptual formulations areCHAPTER THREE79grounded in the data" (p. 23). The researcher synthesized anintegrated picture from the data by organizing aggregateformulated meanings into clusters of themes and linking these to abody of literature that yielded a construct useful to a professionalaudience (Ammon-Gaberson & Piantanida, 1988). The findings fromthis study will present an overall picture of the experience of anadolescent female who becomes pregnant.Scientific Rigor in Qualitative ResearchFour areas for measuring rigor in scientific inquiry,whether it is quantitative or qualitative, have been identified as:(a) truth value, (b) applicability, (c) consistency, and(d) neutrality (Guba & Lincoln, 1981; Sandelowski, 1986). Forquantitative research, truth value refers to internal validity,applicability to generalizability, consistency to reliability, andneutrality to objectivity (Guba & Lincoln, 1981). For qualitativeresearch Guba and Lincoln, and Sandelowski have identified fourspecific factors: (a) credibility, (b) fittingness, (c) auditability,and (d) confirmability. These factors maintain an analogousposition: credibility refers to truth value, fittingness toapplicability, auditability to consistency, and confirmability toneutrality. The strategies used to achieve these four factors inthis study are described.CHAPTER THREE80CredibilityCredibility refers to the truth value of the study, that isthe explication of subjects' perceptions of their experiences ratherthan the researcher's perceptions of them (Giorgi, 1985;Sandelowski, 1986). Credibility is established when participants orothers who are experiencing the phenomenon immediately recognizedescriptions and interpretations as capturing their experiences.The researcher asked the young women in the second interviewswhether examples taken from the collected data and interpretationssounded like their own experiences. In general, the young womenagreed that the description was similar to their experiences, andfurther explicated their feelings. One young woman described howreflecting on her future with her new baby was intertwined withambivalence: "I'm just scared that this will not work out, that Iwill end up ruining his life and my life. That is my biggestworry, that I will some how not be able to do it, but that is whyI wanted lots of support--emotional, financial—when I startedout."Knaack (1984) has noted that researchers need to makeexplicit their assumptions, preconceptions, and presuppositionsabout the research topic in writing to avoid misunderstanding thephenomenon as it exists for the individual--a process known asbracketing. Bracketing was accomplished when the researcherwrote notes on her thoughts about working with adolescents andCHAPTER THREE81adolescent pregnancy, prior to beginning the interviews andafterwards. For example, the researcher did not think that alladolescents viewed their pregnancy as a negative experience, andthought that adolescents were sensitive to how others viewedthem, and were, thus, wary of approaching health careprofessionals for help with their concerns. She believed that itwas important to communicate interest in and acceptance of theteenagers' concerns. She recorded and bracketed her thoughts sothat any indications of these perceptions reflected the adolescents'own lived experiences. For example, during the interviews theresearcher wondered about the meaning of the young women'srelationships with their older boyfriends--whether they weremeeting different emotional needs. The researcher felt stronglythat the young women had different emotional needs than theirboyfriends; bracketing was used to allow the researcher toconcentrate on what the young women were saying about theirexperiences, as opposed to the researcher's own concerns.The researcher also recorded impressions during theinterviews and data analysis. For example, the researcher notedthat during the first interview she did not ask the young womanhow old her boyfriend was. Because the researcher had priorexperience working with young people who lived on the street,she was careful not to ask too many probing questions, whichCHAPTER THREE82have had the effect of increasing the youth's distrust andinterfering with rapport.A threat to the credibility of a study is "going native".Going native, refers to the researcher becoming so enmeshed withthe participants that he/she has difficulty separating his/her ownexperience from that of his/her participants (Sandelowski, 1986).The researcher avoided going native by maintaining some distancefrom the participants and by carefully recording and reflecting onher feelings when conducting interviews and data analysis. Forexample, after completing several interviews the researcher notedthat she was struck by the young women's resiliency, despite thedifficulties they had experienced in their lives, and noted this inher field notes.FittinanessFittingness refers to the degree to which findings from astudy can fit into other persons' experiences outside of thecontext of the study situation (Guba St Lincoln, 1981). To achievefittingness, the researcher needed to avoid two major threatsidentified by Sandelowski (1986): holistic fallacy, and elite bias.Holistic fallacy refers to conclusions that do not contain all thedata, but report the data as if they did (Sandelowski, 1986). Toavoid holistic fallacy, the researcher was careful to include typicaland atypical data in the data analysis. The researcher alsoCHAPTER THREE83avoided elite bias. Elite bias refers to over weighting thecontributions of the most articulate, accessible, or high-statusmembers of their group so that all the stories are not placed inthe proper perspective (Sandelowski, 1986). The researcheravoided elite bias by giving all the adolescents' descriptions equalweight and by including quotes from all the young women whoparticipated in the study. The findings presented in ChapterFour demonstrate the fit between the findings of the study andthe data from which they were derived.The five strategies identified by Sandelowski (1986) wereused to manage threats to credibility and fittingness. Theresearcher checked the representativeness of the data as a whole,the coding categories, and the examples that were used to reduceand to present the data with the original transcripts. In addition,data sources (field notes and interviews) were triangulated todetermine the congruency of the findings.The researcher also included typical and atypical elementsof the data in the descriptions, themes, and concepts; anddeliberately tried to disprove a conclusion drawn from the data.To try and disprove a conclusion from the data, the theme offeeling overwhelmed was compared with the original transcript andalso asked of the young women. The researcher discoveredfeeling overwhelmed was not supported by all of the originaltranscripts and received this response from one young woman:CHAPTER THREE84"Not really overwhelmed. Just having problems and havingsomeone else trying to help you out".Finally, the researcher had the participants validate theinformation. During the second interviews, themes were validatedwith the young women. For example: "From talking with theyoung women I have interviewed, I got the impression thatbecoming pregnant helped them turn their lives around, that is, itgave them "new meaning" or a purpose to live for that they didnot have before. Does this sound like your experience?" Theyoung woman replied:"Me getting pregnant with her is the best thing thatcould have ever happened to me it gave me a secondchance to make it better. There was a time before Ifound out I was pregnant that I was on the road tohell. Yeah it did I had never cared about myself atall and now I do."AuditabilityAuditability refers to the ease with which anotherresearcher can follow the decision trail used by a researcher in astudy. The second researcher is able to understand the logic ofthe data analysis by following the "decision trail" and identifyingsimilar conclusions given the same data, perspective, and situation(Cuba & Lincoln, 1981; Sandelowski, 1986). To achieve auditability,the researcher requested that experienced researchers--the thesisadvisors--assist with data analysis and review the data analysisCHAPTER THREE85for clarity. The way in which the data were organized wasdiscussed in meetings with the advisors. The advisors verifiedthe themes--ambivalence and adolescent pregnancy as a lifechange event.ConfirmabilityConfirmability of the research findings occurs whenadherence to credibility, fittingness, and auditability are accepted(Guba & Lincoln, 1981; Sandelowski, 1986). Confirmability "refersto the findings themselves, not to the subjective or objectivestance of the researcher" (Sandelowski, 1986, p. 34). Theresearcher achieved confirmability by valuing the young women'sperspective, and by focusing on the subjective meaning they gaveto their experiences of pregnancy, rather than the researcher'sobjective professional perspective.Throughout the data collection and analysis procedures theresearcher sought the assistance of thesis committee advisors toprovide guidance in the form of feedback during participantrecruitment, data collection and analysis. By reviewing thetrigger questions, an interview transcript, and the researcher'songoing analysis of the data, the thesis advisors helped theresearcher to develop questions to access further data importantto the experience, and to reflect on and abstract the data to aCHAPTER THREE86higher level of analysis. This guidance was invaluable inassisting the researcher to perform the phenomenological method.Characteristics of ParticipantsIn this section, the demographic characteristics of the studyparticipants will be described. This information was collectedusing the guide in Appendix F. The eight young women ranged inage from 14 to 17, with a mean age of 15. The ethnicbackgrounds of the adolescents included one North AmericanAboriginal and seven of mixed European descent. The youngwomen were between 29 and 39 weeks gestation for the firstinterview. When the second interviews were conducted, they allhad delivered their babies. The adolescents had acquired a gradeeight to grade ten education. Five of the young women statedthey had not attended school in the past year. They all hadexperienced problems in their family unit. Three young womencited a parent with a problem with alcohol. Six of the adolescentshad run away from home and had lived on their own for severalmonths in the past year. Six teenagers had parents who wereseparated. Two young women were wards of the court.The socioeconomic status of the young women was measuredby using their parents' occupations. One 16-year-old's parentswere semi-professionals. Five of the young women came fromhouseholds utilizing social assistance. The remaining two hadCHAPTER THREE87parents who were employed in skilled occupations. After becomingpregnant, two young women had moved back home with theirparents. All participants were planning to keep and to raise theirbabies, except one who decided to give the baby up for adoptionat two weeks post-partum.SummaryPhenomenology was used to study the female adolescents'experience of pregnancy. Trigger questions were used togenerate data. The researcher collected the data throughaudio-tape recorded interviews with the young women. A total of13 interviews were conducted. The sample size (eight adolescents)yielded significant data. The ethics of consideration for humanparticipants to participate in nursing research applied to thisstudy. Despite the difficult and numerous decisions they werefaced with at the time, all the young women willingly shared theirexperiences with the researcher.The procedure for data analysis involved four steps. First,reading the entire description to get a general sense of the wholeand then reading the description again to identify units ofmeaning in the experience. Secondly, eliminating redundancies inthe units, and clarifying the meaning of the remaining units.Third, transforming the units from the language of the youngwomen into scientific language. Fourthly, integrating andCHAPTER THREE88synthesizing the units into a description of the female adolescent'sexperience of pregnancy to be communicated to other researchers(Giorgi, 1985). The major themes that emerged are intertwinedand are explicated as ambivalence and a life change event inChapter Four.In Chapter Four, the themes, concepts, and subconceptswhich have been validated in the adolescent's descriptions will bediscussed in depth. The findings from this study will be linkedto the literature.CHAPTER FOURPRESENTATION OF FINDINGSIntroductionUse of the phenomenological method, as discussed in ChapterThree, produced the findings presented here. These findingsrepresent an interpretation of the young women's perceptions,their "story" of what it was like to be a teenager and pregnant,and experiencing two maturational events simultaneously. The useof open-ended questions elicited the "story" of each youngwoman's pregnancy from the point of suspecting she was pregnantto after the birth of the child. As part of that story, each youngwoman discussed her perceptions of factors related to gettingpregnant, and her family's, peer's, and partner's responses to herpregnancy.The young women in this study spoke with feelings ofdetermination and hope. In their accounts, they discussed thefactors that influenced their lives as they strove to achieve thedevelopmental tasks of adolescence simultaneously with thedevelopmental tasks of pregnancy.Organization of this chapter reflects the themes thatemerged during data analysis. The over-riding phenomenon ofadolescent growth and development shaped the young women'sexperiences of pregnancy. The young women were experiencing89CHAPTER FOUR90the developmental tasks of pregnancy layered over thedevelopmental tasks of adolescence.Two interrelated themes emerged from the data, ambivalenceand adolescent pregnancy as a life change event. As the youngwomen strove to achieve the simultaneous maturational events ofadolescence and pregnancy, they experienced ambivalence.Ambivalence occurred throughout adolescent pregnancy as a lifechange event, which was characterized by what this researcherhas chosen to call phases: (a) suspecting the pregnancy,(b) confirming the pregnancy, (c) making decisions about thepregnancy, (d) living the reality of the pregnancy, and(e) experiencing a changed life (see Figure 1).Ambivalence and Pregnancy as a Life Change EventAmbivalence, or feeling ambivalent, was characterized by theyoung women as experiencing conflicting thoughts and emotions.All the young women experienced ambivalence, which wasassociated with uncertainty and change at a challenging time intheir lives. They described their ambivalent emotions asexcitement interspersed with shock, worry, and fear. The youngwomen experienced ambivalent feelings from the time theysuspected they were pregnant until after their deliveries. Theywere ambivalent about the effects of pregnancy on their lives,their relationships, and their futures, because they wereAdolescentTasks PregnancyTasksHighAmbivalenceLowFigure 1: Phases of Adolescent Pregnancy as a Life Change Event.91--CHAPTER FOUR92struggling with the developmental tasks of adolescence.Ambivalence took different forms, and varied in intensity.Ambivalence explicated the emotional impact of experiencingadolescence and pregnancy simultaneously. The young women'sprogression through the phases of pregnancy as a life changeevent was influenced by their ambivalence. Their feelingsincreased with strains and conflicts, and then, slowed theirmovement through the process. Thus, the young women'sambivalent feelings were cyclic, with high and low ambivalencecharacterizing aspects of each of the phases (see Figure 1).Flagler and Nicoll (1990) acknowledged that, when pregnancyis viewed as a hurdle to overcome, research has often beenfocused on a single variable such as ambivalence about pregnancy.As a result, it "denies the complexity of the pregnancyexperience" (p. 268). In this study, both ambivalence and themultiple physiological, psychological, and social changes associatedwith pregnancy, influenced the coping behaviors the young womenused to manage the developmental tasks of adolescence andpregnancy; thus reflecting the complexity of the experience.Because pregnancy changed the lives of these adolescents,they were forced to make decisions about responsibilities that areusually ascribed to adults. The researcher believed theadolescent females' experience was different than adult women.The young women's stories in this study suggest that there was aCHAPTER FOUR93process through which they coped as they experienced the phasesof their pregnancies.The phases of pregnancy as a life change event can becompared to the ripples that result when tossing a stone into apond, an ever widening circle--a progression toward becoming amother. While the young women progressed through these phasesin an orderly fashion, their processes were individual. Somesubconcepts experienced were of greater importance to oneteenager than another. Also, the young women varied in theircompletion time of each phase, depending on their struggles withthe ambivalence created by the conflicts of the developmentaltasks of adolescence and pregnancy. Each of the phases ofadolescent pregnancy changed their lives. The concepts andsubconcepts that influenced the young women's experience arepresented in Table 1. The concepts will be described andsupported by direct quotes from the interviews with the youngwomen, and then compared and contrasted with relevant literature.Phase One: Suspecting the PregnancyThe following subconcepts were apparent in this phase:(a) not expecting the pregnancy to occur, and (b) initiallydenying the pregnancy.CHAPTER FOUR94Table 1Subconcepts Influencing each Phase of Adolescent Pregnancy.1. Suspecting the Pregnancy.- not expecting pregnancy to occur.- initially denying the pregnancy.2. Confirming the Pregnancy.- seeking confirmation.- self-questioning.- telling others about the pregnancy.3. Making Decisions About the Pregnancy.- prior life experiences influencing decisions.- reviewing the options.- discussing their decisions.4. Living the Reality of the Pregnancy.- accepting the pregnancy.- living with the bodily changes.- forming a self-identity.- thinking about me as an adolescent.- fantasizing about being a mother.- thinking about parenting.- concern about ability to parent.- influence of their families.- influence on the rate of maturation.dealing with supportive and nonsupportive relationships.- the supporting role of families.- coping with other's reactions.- dealing with social and environmental influences.5. Experiencing a Changed Life.- changed thinking.experiencing a sense of hope for the future.- caring for the infant.caring for oneself.- influence of previous life experiences.- thinking about future roles.- thinking about contraception.- changing relationships.- family.- boyfriends.- coping with the maternal role.CHAPTER FOUR95Not Expecting the Pregnancy to OccurWhen the young women in this study described theirexperiences, they indicated they had not made a consciousdecision to get pregnant. They had participated in sexual activitywithout consciously realizing the impact it would have on theirlives. The young women did not view their sexual activity asrisk-taking behavior, or they maintained a false sense of securityand believed pregnancy would not happen to them. For example,a 16-year-old stated:it was just that I never thought of that, because Ithought hey that couldn't happen to me. I'm nevergoing to get pregnant . . . . I was wrong . . . . Itwas something that never popped into my mind . . .this happened the first time we actually had sex, itwas just a spur of the moment thing . . . . it was thefirst and only time . . . We broke up just after that.It was like we never really discussed that.She could hardly admit her suspicion that she might be pregnant,because she had not perceived herself at risk for pregnancy.The notion of invulnerability has been identified in the literatureas playing a role in adolescent sexual decision-making in regardto the need for contraception (Ringdahl, 1992; Urberg, 1982).Tauer (1983) has identified this sense of invulnerability as being afactor that enables the teenager to think it will happen tosomeone else, but not to them.CHAPTER FOUR96The following comments from a 17-year-old illustrate howpast experience influenced one young woman's perception of herrisk for pregnancy:Well for some reason I never figured it [pregnancy]would happen . . . After my last abortion I washemorrhaging really badly. Something I believe wentwrong with the operation . . . I'd have periods thatwere like two weeks long . . . figured I couldn't getpregnant again . . . I figured they'd screwed up mybody good enough, now I wasn't ever gonna getpregnant again.Like the young woman above, a 16-year-old did not see herself atrisk in the context of her relationship. She was provided with afalse sense of security by her boyfriend.I wasn't planning to get pregnant again . . . I justdidn't take any precautions [laugh]. Cause the fathertold me he was infertile, cause he doesn't like usingcondoms, so it kind of stuck us both in a spot.These findings are supported by Pete and DeSantis (1990)who interviewed 14-year-olds about their initiation of sexualactivity and their decisions to continue with the pregnancy thatresulted. They also found that the young women did not feelvulnerable about becoming pregnant (Pete & DeSantis, 1990).Urberg (1982) has noted that if an adolescent female feelspregnancy will never happen to her, she will see little point intaking precautions to prevent pregnancy.CHAPTER FOUR97Initially Denying the PregnancyThe young women resisted feeling physically different orthey ignored their symptoms. The following comments from a17-year-old indicated that only after she experienced severalsymptoms did she stop ignoring them:I didn't eat. I couldn't sleep. I was very depressed. . . . I had one period that came it was justdischarge . . . . I was getting very lazy, I justwanted to stay at home and sleep, my jeans wouldn'tfit anymore, like around the stomach . . . . Me andmy girlfriend went out . . . . I couldn't get to sleep'til two or three in the morning . . . . the nextmorning when I did wake up I felt very ill . . . I wasjust green. Just all these things getting me to think.It took time to even consider the possibility of pregnancy,because denial was commonly used as a coping strategy. Thisstrategy permitted the adolescents to deny their feelings and todeny their suspected pregnancies. Although it allowed them timebefore they had to acknowledge being pregnant, the youngwomen's denial made them unable to acknowledge their suspicionsand to act on them, and thus, interfered with seeking safepassage for themselves and their children during the pregnancy(Rubin, 1984).The young women used denial until something or someonecompelled them to investigate their physical symptoms. A16-year-old was fairly certain she was pregnant but tried to hideit.CHAPTER FOURAfter I missed my first period I kind of knew . . . .^ 98I tried to hide it as much as possible.When at three months gestation, she was hospitalized with akidney infection she could no longer deny her pregnancy.A 14-year-old was so frightened that she denied herpregnancy for four months. Finally she told her aunt about hersuspicions.. . . I thought I was pregnant because I didn't getmy monthly [period]. But I didn't want to doanything about it. I was too scared to do something.She used denial to help her cope with her fear of tellingher family.Denial permitted the young women to continue the adolescentlifestyle that they were living. It appeared to the researcherthat, by denying they were pregnant, the young women did nothave to deal with acting on their suspicions regarding thepregnancy. However, denial also increased the young women'sambivalence during this phase. Only in the next phase,confirming the pregnancy, were the young women able toarticulate their ambivalent feelings about their pregnancies.Phase Two: Confirming the PregnancyThe following subconcepts were manifest when confirmingthe pregnancy: (a) seeking confirmation, (b) self-questioning,(c) and telling others about the pregnancy.CHAPTER FOUR99Seeking ConfirmationBy acknowledging the possibility of pregnancy and seekingconfirmation, the young women acknowledged their flood ofambivalent emotions. One young woman articulated theambivalence she was experiencing when she confirmed herpregnancy particularly well in the following comments:Actually it was a shock to find out that I waspregnant. But it was kind of like at the time I wasyes, no, I can't do this, yes, right on type of thing.Although she mostly described excitement about being pregnant,she was also frightened, partly because she was worried aboutwhether she could do what was required at this stage in herdevelopment.Some young women sought immediate confirmation ratherthan denying their reality. They admitted they might be pregnantand proceeded to confirm it. They sought confirmation in avariety of ways. One 15-year-old suspected she was pregnantafter she missed her period and sought medical assistance.. . . eight weeks when I found out . . . . I . . .thought . . . I was pregnant before I went in to getchecked out . . .Another young woman began to question why her periodshad changed, and performed a home pregnancy test.CHAPTER FOURI had one period that came it was just discharge^ 100. . . . I had a period the next month that was twodays long the same thing and I said . . . there issomething wrong here . . . can we go and get apregnancy test . . . . So I went and did it [a homepregnancy test] and it started turning purple[positive], I was going no. And that is how I knew.One young woman, who did not consciously realize that shewas pregnant, could not ignore unusual bleeding. She went tothe hospital to find out why she was bleeding.. . . the way that I found out that I was pregnantwas urn I went in for a threatening miscarriage to thehospital and I didn't know what it was or anythingand they told me it was a threatening miscarriage.And I stayed in the hospital for a couple of days andthey checked the baby and did an ultrasound andtold me I was seven weeks.The above descriptions illustrate that confirmation of apregnancy is a personal process that varied among individuals.These findings are supported by Faber (1991) who also found thatthe process of confirming a pregnancy varied among adolescentfemales. Once they confirmed they were pregnant, the youngwomen began a process of self-questioning.Self-questioning Ambivalence following confirmation of the pregnancy madethe young women question themselves. A 15-year-old related herambivalent feelings about what would happen to her now that shehad confirmed her pregnancy:CHAPTER FOURSo I could say I was basically really excited that I^ 101was having a baby. Then I was worried, urn, alsobecause ok what is going to happen to me . . .With the admission of pregnancy, the young women were uncertainabout what to do and what being pregnant would entail.I was excited . . . . I was kind of scared I didn'tknow what to do, what going through pregnancy waslike or anything.Both of these young women were experiencing pregnancy for thefirst time. They were worried about their personal safety, andtheir thoughts were egocentric. While egocentricity is normal foradolescents, in these cases, it did not allow the young women tofocus on their babies.Sometimes their questioning was expressed as a rollercoaster of excitement followed by uncertainty or doubt. For some,the feelings were associated with being pregnant outside thesafety of a relationship and of feeling alone, but at the same timewanting to claim her child as her own. This included a17-year-old, who had broken up with her boyfriend prior torealizing that she was pregnant.The father and I did want to have children together.And then before I found out I was pregnant he left. . . . it's been really weird since --- there will bedays when you feel absolutely great and doinganything that you feel like. Then, is it even worth it[I] think I should just get rid of it now kind of thing. . . then you sit down and think to yourself for fiveor ten minutes, and then you think no, it's . . . worthit I should keep it---it's life; it's beautiful.CHAPTER FOUR102The end of her relationship was associated with a high level ofambivalence about whether she wanted to be pregnant or not. Atthe same time she was working on developing a personal valuesystem.A 14-year-old questioned whether she was ready to be amother, and shared these feelings after confirming the reality ofthe pregnancy:. . . when I first found out I was pregnant I wantedto keep the baby, and after a couple of months Istarted thinking it's not fair to the baby maybe Ishouldn't.Her ambivalence about whether or not she should keep the babyreflected her ability to move beyond her egocentricity. Herawareness of the expectations to accept adult responsibilitiesassociated with a pregnancy indicated that she questioned theeffect of her development on raising a baby.The young women expressed ambivalence in relation toaccepting their pregnancies. They struggled with the reality ofbeing pregnant and yet still wanting to do what they wanted.For example, a young woman who was 15, described herambivalence this way:CHAPTER FOURLike in some ways my mind doesn't want to accept it^103yet. Like it will probably accept it two seconds afterthe baby is born . . . I don't know my mind stillwants to like, like I can still be a kid and everythingright, but it is still my mind just doesn't want to.Like there are some times that I just want to totallyforget that I am pregnant, and just go out and dothings, then the other half of my mind [says] noyou're pregnant you can't do that.Her emotions shifted between accepting being pregnant and notwanting to be pregnant. The young women discussed how tellingother people about the pregnancy also assisted theiracknowledgement of the reality of pregnancy.Telling Others About the Prean- cvTelling others enabled each young woman to acknowledgeher pregnancy and to confirm the existence of the baby. Tellingothers made the experience real. Consequently, they thoughtabout how others would react. After the young women confirmedtheir pregnancies, they related numerous questions that ranthrough their minds such as: What will everyone think? What willmy boyfriend say? Will he leave me? What am I going to tell myparents? How will I face them with the news?They were thinking about the response of important othersin their lives to the pregnancy; they wanted their acceptance.But the young women were not certain about how others wouldreact, hence, they felt ambivalent. They were experiencing aconflict between the adolescent's need to be accepted, and theirCHAPTER FOUR104fear of rejection because they were pregnant. A 15-year-old gavethe following account of her concern about other's perceptions:. . . at first I was concerned about what peoplethought about me, and then I have never been one toworry about what people thought. [I thought] Oh,great, everyone is going to think I am a slut . . .Then I thought why would they think I'm a slut,there's so many people that are having sex it couldhappen to any of them . . . another thing that isreally scary is telling my parents.Some of the young women felt ambivalent about their sexualactivity. Having sex was acceptable, but getting pregnant wasnot. Many felt that they had been labelled "slut" by their schoolmates and friends, even when others did not overtly give thatmessage. Like the young woman who gave the above account, a16-year-old avoided telling her friends, because she hadanticipated they would label her as a "slut". By avoiding themshe did not have to confront their reactions.I don't associate with any of my friends anymore.Urn, not that they don't want to, it's me that doesn'twant to. They're wanting to get involved all the timebut I don't want to see them. It's kind ofembarrassing . . . . Cause they all know I have beenpregnant before and I'm afraid, not really afraid ofthem but I don't want them to see me [laugh] they allknow. But I don't really want to associate with them     The literature supports that there are two conflictingmessages in the adolescent's peer group: one, is where they areconsidered stupid for getting pregnant, as in the above account,CHAPTER FOUR105and the other, is that it is acceptable not to use contraceptivesand to get pregnant (Wilkerson, 1991b).Although the young women wanted to tell others their news,they were ambivalent about how their families and boyfriendswould react. Even though they felt compelled to share their newsof pregnancy, they also hoped others would be accepting of them.The need to complete the maternal task of acceptance bysignificant others, overcame their fears and discomfort aboutpregnancy being out of synchronism with their developmentalstage (Rubin, 1984). For example, a 15-year-old gave the followingaccount of telling her father the "news":Well, my Dad, it's just like all my sisters in my familygot pregnant at the age 15, 16, 17 . . . he was, youknow, he kind of took it lighter than all the restcause he knew that it is probably going to happen.He though it is going to happen. I never thought itwould. I thought well I'm going to be a goody,goody, and not. But then he took it nicely. And hewent along with me, with what my decisions were.Even though she was uncertain about what her father's reactionwould be to her news, she needed to tell him. When his reactionwas supportive, she was relieved and her ambivalence decreased.One young woman received mixed reactions when she toldpeople. These mixed reactions had the effect of increasing herambivalence. She recalled telling others about her pregnancy asbeing a scary experience. She was scared because she expectedher family to reject her, which was in conflict with her hope thatCHAPTER FOUR106her family would support her in her decision to continue with thepregnancy. She gave the following account:. . . another thing that is really scary is telling myparents . . . Actually my foster parents took it reallygood . . . my social workers took it pretty good, andmy Mom urn she didn't even want to talk to me or seeme . . . my Dad was pretty understanding about it.This young woman's feelings of high ambivalence were specificallyrelated to her mother's reaction, one of rejection of herpregnancy. This interfered with the maternal task of seekingacceptance from significant others (Rubin, 1984).In addition to being scared of their families' rejection ofthem, the young women were upset about their families' hurt anddisappointment. For example, a 16-year-old, who had parents whowere divorced, stated:. . . I didn't tell my mom 'til I was five and a halfmonths, because I was scared of what she would say. . . . I cried . . . all I could think about was how Iwas going to tell my Mom . . . and what she'd say, Ifigured she would be really disappointed in me ---and that she just wouldn't want to be there anymore.The young women revealed that all their mothers reactedwith feelings of shock and disappointment when their daughtersconfided their pregnancies to them. For example, a 14-year-oldgave the following account of telling her mother of her pregnancy:. . . it's just as soon as I got pregnant all hopeswere shattered type of thing. My mother was ateenage mother and said I was gonna end up in hersame situation.CHAPTER FOUR107Another 14-year-old was upset by her mother's reaction to herpregnancy, she shared the following feelings:My . . . Mom was hurt, cause she didn't expect it fromme . . . . I felt bad because I hurt her.Having their mothers react with disappointment to news of theirpregnancy, particularly increased the young women's feelings ofambivalence. Their mothers were very significant people in theirlives. This finding is consistent with Smith's (1975) description ofthe initial reaction of the mother to her adolescent daughter'spregnancy as being one of shock, anger, self-questioning (whatdid I do wrong?), and sadness that her daughter was losing heradolescent years of freedom.A 14-year-old was so concerned about her families' responsethat she was scared to confirm her pregnancy.My family, I didn't know . . . [whether] my familywould disown me or something, so I didn't want to doanything.The young women indicated acceptance of them by theirfamilies was important, because it allowed them to confirm thereality of their pregnancies, and to feel valued as individualpersons. They were particularly afraid that family members woulddesert them and they would be without support.Another young woman talked about how her boyfriend'sacceptance of the pregnancy influenced her own feelings.But he didn't leave me so that makes me feel better[laugh]. He's excited about it [the pregnancy] now.CHAPTER FOUR108Her boyfriend's acceptance was interpreted, by this young woman,not only as acceptance of her pregnancy, but also as acceptanceof her as a person. Consequently, sharing her news made herfeel good about herself and confirmed her pregnancy in a positiveway. The link between seeking acceptance of significant others,and positive feelings about self is consistent with the adolescentdevelopmental task of self-identity formation (Mercer, 1979a).Acceptance increased the young women's self-esteem when theyhad been doubting themselves. In the next section the youngwomen's decision-making about their pregnancies will bedescribed.Phase Three: Making Decisions About the PregnancyThe following subconcepts comprised making decisions aboutthe pregnancy: (a) prior life experiences influencing decisions,(b) reviewing the options, and (c) discussing their decisions.Many of the young women were faced with numerousdecisions, beginning with what they should do about beingpregnant. One 15-year-old, discussed how she considered herdecisions for pregnancy resolution in the following excerpt:. . . there is so many decisions and things that youhave to think about . . . like keeping it or not . . .or the first issue should I have an abortion . . . orfacing the future and having those kind of heavydecisions laid on you. It makes you really think.CHAPTER FOUR109The above description indicated that the young women suddenlyhad many things to consider all at once, including both immediateand long-term consequences of their decision. Once thepregnancy was confirmed they realized that this was happening tothem and not someone else, and that they needed to makedecisions.Their decision-making was influenced by prior lifeexperiences, the options available to them, and discussions withtheir families and boyfriends. Their responses also influenced theyoung women's feelings of ambivalence.Prior Life Experiences Influencing DecisionsPrior life experiences influenced the young women'sdecisions about continuing with their pregnancies. For example, a15-year-old shared the following comments about a prior abortion:I knew I didn't want to go through that [abortion]again . . . the other one still bothers me.When asked how having a prior abortion influenced her decisionabout having the baby and keeping it, a 17-year-old replied:. . . it was like I don't need this now, kind of thing,right, then I thought about it and I've had twoabortions already . . . and to me that is not a form ofbirth control. You know, I believe to each his ownopinion but it is still not a form of birth control . . .and with this one I figured I was ready.The logic this young woman used showed an inability to projectconsequences; she was operating from an orientation in theCHAPTER FOUR110present rather than the future. However, this young woman wasstruggling with developing a personal value system andexpressing a belief in her ability to cope with this pregnancy.Even though she denied trying to get pregnant this time, a14-year-old's feelings were influenced by a previous pregnancythat had ended in miscarriage. Her positive feelings wereindicative of her acceptance of the pregnancy because she wasready to change her life.The first time I got pregnant I really didn't want ababy, to be pregnant. I was young I still wanted togo out and party and not be tied down with a littlebaby. And when I lost the baby I thought, you know,that if I had cared about the baby more I wouldn'thave --- lost it . . . . but with this one I was happy     Some of young women reflected on the current effect oftheir families' input during past decisions. A 17-year-oldreflected on her lack of input into the previous decision to havean abortion:For one thing I didn't have the choice before . . . Idid not have a choice as far as [being] 14 [years-old].I was under my mother's roof and law. [She said]'Sorry you have to get rid of it.' And I didn't wantto but . . . in a way it did influence my decision [thistime] . . .This young woman was trying to establish her own identity andindependence, and part of doing that was refusing to considerabortion as an option again.CHAPTER FOUR111There are differing opinions in the research literature as tothe consequences of abortion among adolescents. Most studiesexamine the effects of abortion on psychological outcome orsubsequent fertility (Zabin et al., 1989). No research articles werefound that explored the influence of previous abortions on futuredecisions to carry subsequent pregnancies to term. The literaturedoes indicate that prior life experiences influence adolescents'decisions for continuing on with their pregnancies (Hayes, 1987).In this study, experience with a prior abortion was identified as astrong influencing factor for making a specific decision aboutpregnancy resolution--to keep this baby. The influence of atraumatic former life event on decision-making should not beoverlooked and may merit further study.Reviewing the OptionsIn addition to reflecting on past experience while makingdecisions about the pregnancy, the young women reviewed theiravailable options. Some of the young women had never thoughtseriously about their attitudes toward abortion, adoption, orkeeping the baby. Their attitudes were not well formulated, andconsequently, their decisions were difficult. A 14-year-old sharedthese feelings about her decision-making for pregnancy resolution:CHAPTER FOURI decided . . . that I wanted to keep the baby and if ^112I didn't want to I would have had an abortion . . .because I was ready to be pregnant . . . yeah it wasa hard decision to make.A 15-year-old had considered the pros and cons in relationto her options. She had obviously been tempted to have an earlyabortion so that she would not have to be public about herpregnancy, but reconsidered because of worrying about her guiltover an abortion.. . . but I am against abortion in some ways . . . . Alot of hard times. A lot of tears. Just too much, feltlike your head was going to explode . . . . withadoption I was thinking, like urn, well at least givesomebody who can't have a child a chance. Then withabortion I was thinking nobody would have to knowbut then I would probably feel bad and so I decidedagainst that. Like I never thought about it seriously.Some of the young women felt abortion was morally orethically wrong and rejected it as an option in theirdecision-making. For example, one young woman shared thefollowing thoughts:I chose to have the baby instead of having anabortion . . . . to me it is another life inside of me. . . some people don't think it is, [but] to me it islife, and it [abortion] is murder. And I won't do it.A 15-year-old felt frightened by taking the responsibility to end alife and described an element of retribution for making mistakes.CHAPTER FOURsome people did tell me that, oh, the baby's heart is^113already beating and it is already developing. Andthen when I started reading things about abortionand it just scared me, you know. I am taking lifeand killing it . . . . it just scared me . . . I decidednot to . . . . I went and got pregnant myself, right,I did it myself. So I should be the one to sufferinstead of the baby.Ambivalent feelings were also evident in making decisionsabout keeping the baby. One young woman thought about what itwould be like to have a baby. She openly discussed her feelingsin the following comments:Well I am still kind of confused about whether to keepit or not. I want to.Further comments demonstrate that she had clearly considered anumber of factors and was uncertain about the best course totake.Ok, for giving it up I keep thinking about it nothaving a father and I'm so young I'm like [not] totallyemotionally stable. And I think in some ways thebaby would have a better chance with more matureparents. But then I want to keep it because I love itso much already, I mean it is just like it is a part ofme, it's there. And at first I wanted it to go awaybut now if it just went away I would be really upsetbecause I've formed a bond with it, and so that iswhy I'm confused.She showed insight into long term decision-making as well:you have ten days after you have the baby whereyou, before you are allowed to sign anything. I thinkin those ten days I'll really make my decision with thechild. Cause I am planning on keeping it with meduring that time. That is probably when my realdecision will get made no matter what I say now.CHAPTER FOUR114Her comments illustrated her realization that she would notappreciate what carrying on with the pregnancy would mean interms of child-rearing and how challenging the maternal rolewould be until after the baby was born. This young womandemonstrated insight by her ability to project what her futurewould be like. These are qualities not expected of someone of herchronological age.None of the young women initially chose to adopt out theirbabies. The literature suggests adoption as a choice forpregnancy resolution by adolescents is a rare event (Herr, 1989;Nichols, 1991).The decisions were difficult for all the young women. Manyof the young women described it as a painful time when they hadshed many tears. For example, a 15-year-old, described heremotional turmoil when confronted with options she had neverexperienced:Yeah I did. It took me quite awhile because I readthe adoption book. And . . . the day before I wassupposed to go for the abortion I said no. I startedcrying . . . and I cried a lot, it wasn't the thing todo, it wasn't that easy . . . it took me a while to makemy decision up [zing].A 15-year-old, who had looked after her sister's baby triedto take her baby's interests into account during herdecision-making. She gave the following account:CHAPTER FOURI was going to give it up for adoption, then I decided ^115to keep it . . . . I just thought no. It is going to behard for the baby too. And I decided I could give ita good life, and I think I can.Discussing Their DecisionsDuring the making decisions phase, the young women useddiscussion with their friends, or family members, for example, amother, an aunt, or a sister to consider their options. A15-year-old talked to her sisters who had been pregnant asadolescents themselves, and she had this to say about thediscussions:. . . nobody [] else made my decision I made itmyself . . . they are the ones that told me I shouldgive it up for adoption or I should have an abortionand I didn't feel right . . . I didn't go.Even though the young women wanted input from others, andtalked over their decisions with them, they still made thedecisions themselves. Family members affected the young women'slevels of ambivalence. The young women's ambivalence decreasedif family members were accepting and offered support, theirambivalence increased if family members rejected their decisions.Some of the young women used supportive boyfriends todiscuss their decisions. For example, a 15-year-old described herdiscussions with her boyfriend:CHAPTER FOUR. . . and then for a while we talked about adoption^ 116and that, I'm against abortion in some ways . . . Ithought that because I am healthy enough to have itat least then if I can't look after it, give it tosomebody else who can't have a child a chance.Not everyone had a supportive boyfriend. Another young womanrelated quite a different experience:. . . he . . . said you gotta get an abortion or giveup the child, cause I don't want anything to do withit and [laugh] I don't want my parents to find out.Consequently, this young woman experienced feelings of highambivalence related to rejection by her boyfriend. His rejectionnegatively affected her coping and made her feel uncertain aboutthe pregnancy.Faber's (1991) research with Caucasian and African-Americanadolescents revealed that family members were an importantinfluence in the young women's decision-making related topregnancy resolution. This is consistent with the findings in thisstudy.During decision-making the young women had to consider anumber of factors such as, previous experience with abortion, theyoung women's desire to become a mother, a belief in the sanctityof life, acceptance of the consequences of their actions, and whatthey perceived to be the best interests of their babies. Theimportance of these factors varied amongst the young women. Bydiscussing their decisions with others they clarified their thinkingand made their decisions.CHAPTER FOUR117Reedy (1991) suggested that young adolescents do not havethe cognitive skills to cope with the maturational event ofpregnancy. Negative sociocultural factors can increase theconflict the young woman is experiencing between her tasks ofadolescence and tasks of pregnancy, particularly around issues ofindependence (Reedy, 1991). There is some evidence in this studythat negative sociocultural factors had increased the youngwomen's maturity in relation to decision-making, before and duringtheir pregnancy experiences. Rich (1990) reported similar findingswhen studying homeless pregnant adolescents.The young women in this study all stated that making thisdecision was a difficult process for them. Unlike adult women whocan draw on their life experiences for making decisions, the youngwomen had limited life experiences, and also had yet to achieveabstract thinking. Despite this some of the young womendemonstrated remarkable insight as they described theirperspectives, and how they made their decisions for pregnancyresolution. As they moved from the making decisions phase to theliving the reality of the pregnancy phase, the young women'semerging sense of self-identity became evident. Pregnancyproduced multiple effects in their lives.CHAPTER FOUR118Phase Four: Living the Reality of the PreanancvIn the living the reality of the pregnancy phase, the youngwomen thought about what motherhood and it's attendantresponsibilities would mean to them. These adolescents had notpreviously carried a pregnancy to term and parented. It wasdifficult for the young women to anticipate what it would be liketo become a mother. This was compounded by their immaturecognitive and value systems development and a need forindependence and self-identity. In living the reality of thepregnancy the following subconcepts were evident: (a) acceptingthe pregnancy, (b) living with the bodily changes, (c) forming aself-identity, (d) thinking about parenting, (e) dealing withsupportive and nonsupportive relationships, and (f) dealing withsocial and environmental influences.Accepting the PregnancyAlthough the young women had confirmed their pregnanciesand considered their options, they still had to accept the realityof living the role, and that the pregnancy would end with thebirth of a baby. Even though living the reality of the pregnancywas difficult, they saw the pregnancy and mothering as anopportunity to make their lives right, because they expected thattheir pregnancy experiences would end with the birth of a healthybaby. One 17-year-old reflected on the desired outcomes:CHAPTER FOURMy expectations of the pregnancy are pretty well just^119to have a healthy child. And do the best I can afterit is here.Some days it seemed like an easier task than others, as evidencedby the following excerpt, in response to a question on havingdoubts about her decision to continue with the pregnancy:. . . I think everybody does at one time or another.You know, you look at what is going on in your lifetime --- and you think, this moment if I had a choice.Like, I have days when . . . I wish I could take it output it into an incubator and leave it for the day. Oroften I used to do drugs and alcohol . . . I'll be thefirst to admit that, but there are days when you justwant to, when you wake up in the morning and you'refeeling great, and you're like, I'm going out to getpissed tonight. Um, you walk out of the house goingyeah, right. Yeah, you know, just a glass of Pepsiplease, sort of thing . . . . you know, some days youwant it to hurry up and be over with, other days youwish you hadn't even started it.Because the reality of their lives contrasted with the expectedoutcome, the ambivalence the young women felt about theirpregnancies was high. Their risk-taking behaviors and adolescentdevelopmental tasks of defining their self-identities were inconflict with the maternal tasks of binding-in to the unborn child,and seeking safe passage for themselves and their children(Rubin, 1984).Living with the Bodily ChangesThe adolescent is often self conscious and preoccupied withthe changes her body is undergoing during normal growth anddevelopment. Pregnancy brings more changes in the form ofCHAPTER FOUR120breast enlargement, skin changes, abdominal enlargement, weightgain, and discomforts like backache, and leg cramps. Everyonediscussed the changes in their bodies, in particular, the change inthe shape of their bodies.Some young women were aware of what the changes wouldbe and others were surprised by the body changes theyexperienced. For example, a 15-year-old described her bodychanges as:It is really weird because changes started happeningthat I didn't expect . . . and I just started freaking. . . Like my breasts got different, like totallydifferent shapes and that was something that I wasnot expecting. And I was like why is this happeningall that is supposed to happen is my stomach issupposed to get bigger . . . and I was supposed tomiss my period, that is all that is supposed tohappen.Her lack of knowledge of the bodily changes associated withpregnancy and lack of previous experience did not provide herwith realistic expectations, made her fearful, and increased herambivalence.A 16-year-old was concerned with different body changes,and stated:. . I'm always hot . . . you have more blood in yourbody and it doesn't travel around as fast, therefore itdoesn't cool down as fast. And your body is like onedegree in temperature higher . . . . All 380 pounds[gross exaggeration] of it [laugh] that is what it feelslike, it does, it feels like I am just a giant . . . Iknow I have only gained 15 pounds, but still it is likeit is 40 or 50 . . . because I am not used to carryingit around, that extra weight.CHAPTER FOUR121The bodily changes were often undesirable, particularly weightgain, and could place the young women in direct conflict withseeking safe passage for their babies if they tried to stay slim(Rubin, 1984).Several of the young women commented on howuncomfortable they were when they tried to sleep. For example:I try to find a position . . . then I have to change itand find another position . . . . It is mainly my back[that is uncomfortable] it's my stomach that is in theway, right.Another young woman had this to say about the discomforts shewas experiencing with her pregnancy:. . . I like being pregnant, of course, I don't like thebackaches and leg cramps, but I like knowing thebaby is there, and feeling it inside of me . . .As the young women grew more tolerant of the discomforts ofpregnancy, their pleasure about being pregnant increased.The bodily changes experienced by the young women madethe pregnancy more "real" to them, and heightened theirawareness of the growing fetus. Consequently, these feelingshelped them accept the bodily changes as part of pregnancy.They expressed excitement about the changes they wereexperiencing as the pregnancy progressed and the fetus grew.This enabled them to identify the baby as a distinct individual, adevelopmental task of pregnancy. For example:CHAPTER FOUR. . . there is something alive inside of me . . . just^ 122thrills me, I love it, like every time the baby kicks itamazes me. The other morning when I was having ashower I felt pressure on my stomach and I could seea little hand.Forming a Self-Identity Forming a sense of self-identity, a major task ofadolescence, refers to an individual's concept of who they are asa person. The young women's pregnancies influenced theiremerging self-identities. Forming their self-identities is the thirdarea of living the reality of pregnancy. The following factorsinfluenced their self-identity formation: thinking about me as anadolescent, and fantasizing about being a mother.Thinking about me as an adolescent. Prior to thepregnancy they were already experiencing role confusion. Theyspoke of experiencing a struggle between being concerned withwhat they appeared to be in the eyes of others as compared totheir own view of themselves. The literature suggests that someadolescents in role confusion, cling to an intimate relationship toassist them with integrating their identities (Holt & Johnson, 1991).Part of the way these young women defined their identitieswas by exploring intimate relationships with older men asboyfriends. At times, these relationships appeared to developwithout conscious planning but they became important to theyoung women's self-identities.CHAPTER FOUR. . . I was on [one of] my running away little trips^ 123and I just found him, and he was another person tolive with. I didn't think I was going to be stayingthere. But he was really good looking. [laugh] So I. . . ended up staying and got feelings for him andhe got feelings for me. But he thought I was18-years-old, I did a lot of lying to him.This young woman's description highlights her struggle with herindependence from her parents because she had run away fromhome to achieve this, and her struggles with development of aself-identity. She had to lie and misrepresent herself to staywith her boyfriend. This represented a difficult situation whenshe started to care for him.Once pregnancy occurred, the formation of a self-identitywas also tied to future plans. A 15-year-old shared the followingthoughts about her plans for the future:I have kind of decided what I want to be, but itcould change. I know I am not going to go throughyears of university or something. I am just planningon going to nursing school, to do something thatwon't take up too much time [laugh] . . . . I'm notgoing to be able to work, I want to get a job so bad. . . . It is a lot easier living here [at home] . . . Iwant to live here until I finish my high school. Itwill be another three years.Self-identities were confused during these experiences. Althoughconsidering the future and working towards career or vocationaldevelopment while anticipating motherhood increased the youngwomen's ambivalence, this young woman also suggested thatmaking plans for her future made her feel in control of her lifeand decreased her ambivalence. This was a complex situation.CHAPTER FOUR124Another young woman could not predict how the pregnancywould change her life in the future, or impinge on herdevelopmental tasks, consequently she felt a high level ofambivalence.I've though a lot about that and it could change in alot of different ways, but the only way I'll reallyknow is when I see it. When the baby is there and,you know, we have had a few years together.Because this young woman's age (14 years) and stage of cognitivedevelopment made her unable to visualize her future life, sheexperienced a high degree of ambivalence.Fantasizing about being a mother. Some of the youngwomen fantasized about what their lives would be like with ababy.I am always thinking what it is going to be like . . . .all I can really say is I want to give this baby a goodlife. Urn I want to finish my schooling, like I amgoing to do that, like I understand that I am givingup my whole life for this baby, and I feel . . . great,you know. I am really looking forward to it.Fantasizing allowed the young women to begin to preparethemselves for the birth of their children and the realities of thematernal role (Lederman, 1984). In their fantasies, the youngwomen saw the baby as promising excitement and challenge. Theyviewed "making a baby of my own" as an experience that wouldbring excitement into their own lives, but it was initially difficultfor them to think of the baby as a separate individual. Theyoung women's expectations were consistent with Brown andCHAPTER FOUR125Urback's (1989) report that adolescents describe unrealisticexpectations and fantasize that life with a baby is wonderful andthat parenting is easy. For example, the following comments froma 15-year-old:Yeah it's, it's the weirdest experience that somebodycould go through, I don't know how to say. It's likehaving something on the inside, that's alive, and youcan feel it kicking, and like your stomach startsgetting bigger, and bigger, and bigger. I don't lookvery big, but believe me in another month I'll be outto here [laugh] [gesturing with hands] But it's weirdbecause you're thinking wow this is a new life. Thisis actually going to be mine and no one can take itaway from me.Another 14-year-old enjoyed other people's excitement about herpregnancy:Everybody is excited about it, every time your bellygets a little bigger and the day comes a little closer. . . and when you go clothes shopping they say doyou want a boy or a girl, it's nice . . . I don't know,the baby is positive and I think people realize thateven if I am young . . . . the baby is something theycan be excited about . . . . it's good, right now thebaby in my eyes is perfect . . . . it just feels right.This adolescent viewed the expected baby as being perfect. Thismay be in contrast to an adult woman's view that encompasseshow much care a newborn requires, and how dependent they areon their mothers for their needs. This view might create highlevels of ambivalence when the experience does not meet theadolescent's expectations.On the other hand, the excitement the young women feltmade them feel positive about the pregnancy. This decreasedCHAPTER FOUR126some of the ambivalence they were feeling during the pregnancyand made them feel good about themselves, because they werecreating something.An adolescent forms her self-identity by interacting withothers and the peer group is an important source of validation forwhat is normal and acceptable. Peers became less important asthe individual teenager fantasized about her identity as a mother.To a large extent, that shift probably reflected the new realitiesthat pregnancy had created in the young women's lives, whichmade their issues very different from others in their age group.One young woman talked about how her pregnancy hadhelped her to appreciate herself as a person.I've had to do a lot of growing up myself and a lot oflearning [about] myself, and a lot of nurturing tomyself and this child before I can, you know. Asthey say, you have to be able to love yourself beforeyou can love somebody else. Well, I have never reallyloved myself . . . and I have in the last nine monthsbecome [] to love myself. So I want to . . .continue that before I go on to sharing it withanybody else.In learning to appreciate herself as a person she was defining herself-identity as a person and a mother.Because they had grown to love themselves, and had startedto understand themselves better, the young women felt betterabout who they were. A 17-year-old who had run away from homeat nine years of age, and lived in a series of group homes sharedthe following response:CHAPTER FOURYeah, very much so, I love myself more today than I^127have in the past seven years of my life.Because she felt like she had a purpose in life, something to livefor, pregnancy had increased her self-esteem.Another young woman did not believe that becomingpregnant had helped her to understand herself better:I liked myself before I was pregnant . . . and I stilldon't understand myself, I don't think people evertotally understand themselves.Perhaps for those young women who had a strong identitypregnancy did not increase their self-esteem. But, this youngwoman did acknowledge that becoming pregnant had given her lifea purpose and "settled" her down.It gives you a reason to live for . . . . It hasmellowed me out . . . . I used to do wild things,that's the main thing it got me to settle down.None of the young women in this study viewed pregnancyas a way to keep their boyfriends. Their exploration of thematernal role did not necessarily include the fathers of theirbabies. As a matter of fact, one young woman stated she turneddown her boyfriend's offer of marriage. She gave the followingreasons for her decision:He [her boyfriend] wanted to get married before itwas born but I said no. I didn't want to get marriedjust for this reason. Plus, I don't know if he is theright person.Steane and Heald (1987) suggested that many teenagers whobecome pregnant have a poor self-image and self-esteem and viewCHAPTER FOUR128having a baby as a way to improve their lives by having someonewho loves them. The young women in this study did not talk oftheir pregnancy as giving them someone who would love them, butrather as experiencing something positive that could help them tolove themselves.Holt and Johnson (1991) reported that teenagers, who seemotherhood as one of the only options available to them, hope tofind direction through their pregnancies and babies. The youngwomen in this study did talk about how their pregnancies hadhelped them to change the course of their lives to a more positivedirection. They hoped that motherhood would enable them tocontinue their lives in this positive direction.Thinking about Parenting A fourth area that comprised living the reality of thepregnancy was thinking about parenting. The young womenexpressed concerns regarding: (a) their ability to parent, (b) theinfluence of their families, and (c) how thinking about parentinginfluenced their rate of maturation.Concern regardina their ability to parent. One concern theyoung women expressed repeatedly was, whether they would begood mothers. This was part of establishing a maternal identitythrough comparing themselves--their actual self, to their image ofan ideal mother--their ideal self (Rubin, 1984). They expressedCHAPTER FOUR129concern as to whether or not they would be able to manage therole. In response to a question about feeling apprehensive inregards to her pregnancy, that is, things that she felt scared orunsure about, a 14-year-old shared the following comments:Urn, just how I am going to be a good mother or abad one.She stated she was unsure if she was going to consciously decidehow she would mother. Her comments reflect her uncertaintyabout her coping abilities for being a mother. It is difficult forteenagers to think about and plan for motherhood, because theyprobably have not had the life experiences to help them imaginewhat the maternal role involves. In addition, they may haveexperienced inadequate parenting and want to do better than theirparents. This is also a developmental task of pregnancy thatadult women struggle with--how to define themselves as a mother(Flagler & Nicoll, 1990).Increased knowledge assisted the young women to anticipatethe responsibilities of the parenting role. The young women alsoused their previous experiences to help them reflect aboutparenting. For example, a 17-year-old provided the followingdescription:I've always had that motherly instinct. I'vepractically raised my two brothers, or at least when Iwas younger I did. Urn, I've lived with a girlfriendwho didn't take care of her kids so I did.CHAPTER FOUR130Some of the young women were very clear about theirreadiness to be a mother. They wanted the baby, liked children,believed they had the necessary skills, and were looking forwardto becoming a mother. For example, a 15-year-old had thoughtabout becoming a mother and shared these thoughts:. . . I have always liked young kids . . . . I used tolook after my sister when she was a little baby .. . .I was feeding her and changing her diaper . . . . it islike I have always had like, I guess you could saymotherly instinct cause I have always been aroundlittle kids . . .However, it was difficult for some of the young women toenvision just how much their lives would be changed by becominga mother. A 15-year-old, who had spent time thinking about howher life would be changed by having a baby, shared the followingthoughts:Like well first of all I won't be able to, well I couldgo to a normal school, like regular high school, butthen I would have to pay all the money for a babysitter and whatever else. It is just really weird, likeit is something that you think would happen tosomeone else.Although she was beginning to acknowledge the limitations ofhaving a baby, she was still having trouble relating them toherself.Some young women carried their wondering about whetherthey would be able to fulfill the parenting role further andworried about whether they had made the right decision to carryon with their pregnancies. For example, a 15-year-old stated:CHAPTER FOURWill I be a good enough mother for the baby? . . . ^ 131will it grow up in an alright . . . environment? Will ithave proper nutrition? I think about all that stuff. . . . what is going to happen afterwards . . . that'sbasically what I worry about . . . just am I gonna' bealright, and how I'm going to be living with a newaddition to the family type of thing . . .Some of the young women who talked about wanting to be"good" mothers had a vision about what that would entail. A16-year-old shared the following thoughts:Spending lots of time with them . . . and loving themas much as you can, making your life better for them,I haven't decided how I am going to discipline her yet. . . . I don't want to spank her or hit her, maybe aslap on the hand sometimes . . . . My parents neverhit me or my sisters and other than me they haveturned out fine (laugh).Her comments reflect some feelings of lack of self-esteem. Shedefined being a good mother as spending time with the baby andproviding lots of love. She felt being a good mother anddiscipline were linked, but was unsure how. She also felt herown parents were good role models.Other young women were very certain that they wanted tomother, but worried about their timing:. . . it's great like in some ways I was always scaredthat I wouldn't be able to have children for somereason, like I don't know why I was just scared thatI wouldn't be [able]. And now I know I can, and Ihave always wanted a family, right, just not so early.Her ambivalent feelings about the pregnancy are evident in hercomments. Although pregnancy was an indicator of her fertility,she recognized conflict with her current stage of development andCHAPTER FOUR132readiness for pregnancy. The above narratives indicate that eachyoung woman thought about different variables in relation to herpregnancy and parenting. What was important to one youngwoman was not necessarily accorded the same importance byanother.influence of their families. A part of thinking aboutparenting was acknowledging the influence of their families. Someof the young women considered their behavior in comparison totheir parents, specifically in relation to teenage pregnancy.Parents' attitudes had an effect on the young women's attitudes.Two young women spoke of the cycle of teenage pregnancy beingrepeated. For example, a 14-year-old shared these thoughts onher situation:. . . My mother was a teenage mother and said I wasgonna' end up in her same situation . . . . I figurewe are two different people and we have lived ourlives two different ways so far . . . . And if I endup in the same place it's not because I got pregnantit's because of other choices I made and not because Igot pregnant.Either she did not have the life experience to enable her to judgewhat her life in the future would be like, or she may have beendenying reality in an attempt to establish her independence,believing that she would continue to have choices.A 15-year-old described her boyfriend's parents' experiencein the following excerpt:CHAPTER FOURThey were young when [boyfriend] was born . . . .^ 133And so it is really like I guess you could say it is acycle, because his dad was 17 when he was born, wellwhen he was conceived, and 18 when he was born.[boyfriend] was 17 when the baby was conceived, andhe'll be 18 when it is born . . . . Like they wentthrough all the same things we did . . .By doing this comparison she was able to normalize her ownsituation. She was also perhaps trying to place someresponsibility for the outcome on the parents' behaviors.Adolescent parenthood repeating in families is a phenomenonthat has been studied in recent years. Newcomer and Udry's(1984) study suggested a strong link between being a teenageparent and coming from a family in which the mother was sexuallyactive at a young age herself. This is in contrast to studies doneby Horwitz, Klerman, Kuo, and Jekel (1991) and Furstenberg,Levine and Brooks-Gunn (1990) which specifically investigated arelationship between the offspring of teenage mothers becomingadolescent parents themselves, and found that only a minority ofadolescents repeat the pattern of adolescent parenthood of theirparents. More importantly, Furstenberg et al. found that maternalexperience with social assistance increased the likelihood of thedaughters bearing children as adolescents. The reason for thislink remains unclear. They raised questions about whether thelink was related to family socialization, limited family resources,living in neighborhoods with high rates of early childbearing, or acombination of these three (Furstenberg et al., 1990). It wouldCHAPTER FOUR134appear that some of the young women in this study did repeat thepattern of teenage parenthood like their parents and step-parents.One young woman's mother had been a teenage parent on socialassistance.Influence on the rate of maturation The third part ofthinking about parenting was reflecting about how pregnancy andparenting had influenced their rate of maturation. Maturation wasaffected by their cognitive growth and their past life experiences.Living the reality of the pregnancy required the young women togrow towards adulthood. Some young women already sawthemselves as mature and no longer a teenager. Others sawthemselves as teenagers who were taking on the responsible roleof adult parents.A 16-year-old who had run away from home on severaloccasions in the past two years described how her perspective ofher parents had changed:I think I have matured a lot more . . . Well when Ilook at my sisters and how they act. I know I am alot more mature than my older sister. They'reterrible the way that they talk to my parents. Iguess I'm understanding what it is like to have kids[laugh]. And what my parents have gone through.Especially after . . . trying to live on my own.Her feelings about adolescents' appropriate behavior had changed.She was able to place herself in her parents' position because shewas contemplating her own parenting. Her values aboutCHAPTER FOUR135appropriate behavior used by adolescents for communicating withparents had changed, because she had changed her perspective.A 16-year-old who believed that becoming pregnant hadmade her more mature, shared the following analysis:Well I think I am more mature than I used to be. Ihave to say that because there is so many decisionsand things that you have to think about . . .For her being more mature meant having to be more responsiblefor making decisions and thinking about the future. Speraw(1987) also reported that young women perceive pregnancy asincreasing their level of maturity. Some of the young womenviewed pregnancy as a way to grow up, to become an adult.Viewing pregnancy as a way to become mature may makepregnancy appear a viable alternative for taking on an adultstatus thereby making their lives more positive. Walker (1991)noted that pregnancy is not a negative event for all adolescents,some view pregnancy as providing them with social and personalbenefits.Some young women denied becoming more mature duringpregnancy. A 14-year-old stated:I don't think so . . . No for me it didn't make megrow up faster but it made me feel more insecureabout every little thing I was thinking . . . I felt, Idon't know, more of a demand on what I was lookingat while I was shopping . . . it just wasn't the same.But I don't think it [pregnancy] makes you mature. . . if anything I'd say you still have to grow andstill be growing when your child is growing.CHAPTER FOUR136This young woman saw maturity as an outcome of adulthood, andacknowledged that although she was not an adult she wasgrowing. The next narrative indicates how another young womanviewed maturity differently. A 14-year-old thought she needed tomaintain her freedom to be an adolescent.Urn not really, because I'm not going to grow up fast.I'm not going to let myself grow up really fast. Whenthe baby comes I am still going to go out and doeverything I have to.This young woman's normal adolescent behaviors were in conflictwith her pregnancy tasks. Although she wanted to act like ateenager, that is, "hang out" with her friends, she realized thathaving a baby involved responsibility and would reduce herfreedom.Yeah . . . . [in what ways] The baby needs someoneand I'm always going to have to be there. Thatmeans that I am going to have to get it for the baby.To a further question about how she felt about the increasedresponsibility, she replied:Um --- I don't mind but then again I sort of dobecause I don't think I am going to be able to get iteverything when it needs something.Her comments indicate the ambivalence she was feeling because ofthe conflict between her adolescent task of forming an adultidentity, and the developmental task of pregnancy of learning togive of herself to her child. She was able to identify some of herresponsibilities as a parent. She also recognized that she mightCHAPTER FOUR137not be able to obtain all the resources her child needed. Thusshe was uncertain as to how she would cope and whether shecould accomplish the adult responsibilities of parenting.Another young woman linked maturity to the responsibilityof parenting. She anticipated maturity developing as she becameresponsible for parenting, but she also anticipated being able tostill enjoy children's pleasures.If anything I'd say you still have to grow and still begrowing when your child is growing. I've lived witha lady, who I was living with before the one I amnow, who had her first baby at 13 and her secondbaby at 14, and she said even with her second babyshe wasn't mature. I mean she was mature to knowthe responsibilities of the baby, she was good to thebaby. But she still went down and she played on theswings with her children, and she went to andenjoyed the amusement parks as much as her childrendid. And I don't think there is any reason why tohave to go out and mature like that just because youget pregnant. Just the responsibility part but Iunderstood that before I was pregnant.Even though this young woman realized the role of mother andparent involved a lot of responsibility, she felt that enjoyingchildlike behaviors was not incongruent with being responsible.Another 15-year-old shared the following analysis of her situation:CHAPTER FOURI can't really say I've gotten more mature since I^ 138have gotten pregnant, because I haven't, it is justlike I have always . . . liked young kids. Right, andI always babysat . . . . I have always been aroundlittle kids and always looked after them and that. SoI haven't matured any. Like I am sure I will once thebaby is born, like I will realize how much worst [morework] it is. Like I know a lot, like how much youhave to do (but). . . when you sit there and youwatch somebody do it doesn't seem like a lot of work,but it really is.Even though she had not been a mother before, this youngwoman compared the maternal role to an experience she knew,babysitting. By doing this comparison she was able to envisionthe maternal role as being "a lot of work". She was also able toproject and acknowledge that it would be different. She seemedto be operating at a cognitive level somewhat beyond herchronological age.The young women were anticipating what the new role ofmother and parent would be like in relation to their maturity.Mercer (1979b) observed that adolescents who assume parenting (amature role) experience a break in the continuity of theirdevelopment; they move from a dependent role of receiving care toan independent role of giving care. This results in a conflictbetween the adolescent developmental task of achievingindependence, and the pregnancy task of learning to give ofoneself. The experiences of the young women in this study areconsistent with this observation.CHAPTER FOUR139Dealing with Supportive and Nonsuppo 've RelationshipsAs part of living the reality of pregnancy, the young womendiscussed their perceptions of their need for support in thematernal role. During their pregnancies the young womendescribed how their relationships with others affected them; theyidentified supportive and nonsupportive relationships.Talking things over with other pregnant teenagers, programgroup leaders, family, boyfriends, and friends was viewed assupportive. This was a coping behavior that assisted in findingsolutions to problems, relieving stress and frustrations, andreceiving information. The young women felt that talking thingsover had a positive effect on their mental health. One youngwoman described how she used talking things over:And we [she and her boyfriend] thought [and talked]about if I was to keep it [the baby], like how wewould end up getting the money and stuff. And likehow we would support it, and like if we would be ableto look after it.This young woman was fortunate because she had a supportiveboyfriend who would talk about her decisions and plans with her.The supporting role of families. Some of the pregnantteenagers identified their families as sources of emotional supportand guidance for them. Parents were often more supportive thanthe teenagers thought they would be. For example, in response toa question about her parents' reaction to her pregnancy, a16-year-old shared the following thoughts:CHAPTER FOURActually she [my mother] was really understanding^ 140. . . I wasn't expecting her to be, like I was expectingher to freak out . . . but she has just beenunderstanding and she has helped me and supportedme.Not all the young women identified the same need forsupport. But, they consistently wanted their families involved intheir lives. This was a theme that occurred in all the interviews.As the young women anticipated the new role they were taking on,some very much wanted their mothers for emotional support andguidance for labor, and child-rearing activities. A 17-year-oldprovided the following comments:I didn't expect anything from my family I haven't forthe last couple of years but it amazed me that theywere there for me . . . . Yeah my Mom was the mostsupport that I had there [labor].Despite this young woman's past experiences with an unsupportivefamily, she found that her mother was more accepting of herpregnancy as the birth neared. Her mother was her main supportperson during a long, difficult labor. Consequently she felt closerto her mother, and less ambivalent. She did not have contactwith her natural father, and she had been physically abused byher stepfather so she did not want any contact with him.Poole, Smith, and Hoffman (1982) studied mothers ofadolescent mothers and found that the addition of a baby to thefamily may enhance the mother-daughter relationship, as was thecase for the young woman in the previous narrative. Smith (1975)identified the mother of the adolescent as being a significantCHAPTER FOUR141figure for role modeling and emotional support; she found that"the support a mother gives her daughter at this crucial time, hercaring and empathy can increase the younger woman's confidencein herself and her ability to become a mother" (p. 282). Theyoung women in this study were more confident of their ability tobecome mothers as a result of their mothers' support.Support from their fathers or step-parents was also needed.The young women were looking for approval and support fromboth of their parents.Yeah my mom and my step-dad they really supportedme a lot. [How] Well for one they both seemed reallyinterested . . . and excited about it like my step-dadhe just [laugh] he acted like a little kid . . . likeevery time I'd come home for a weekend he'd say let'ssee how big you have gotten . . . . he'd see itkicking all of a sudden you'd see his hand would goover, and that showed me they weren't mad . . . . Andmy mother was the same way . . . she cried with mewhen I felt like crying and she was just there once Itold her.This young woman was ensuring acceptance of herself and herbaby by significant family members, a developmental task ofpregnancy.The reaction of siblings was also of importance to some ofthe young women, because they provided emotional support andacceptance. The following comments from a 16-year-old illustratedthat although her brother's reaction was somewhat negative, sheviewed him as caring and supportive, because she saw hisbehavior as being protective of her.CHAPTER FOURHe [her brother] was really upset with the father. I^142mean really upset. I mean he threatened to go outand kill him a couple of times . . . . that is just theway my brother is with me. I'm his little sister andhe takes care of me . . . . he is scared for me, hedoesn't want me to have any pain . . . . My brotherhas actually been very understanding about it [thepregnancy] . . .Communication problems with parents increased the youngwomen's feelings of ambivalence about their pregnancies and theirself-esteem.a lot of parents think . . . well you shouldn't do thisI screwed up, you know, a lot of people want to learnby their own mistakes, not from somebody telling them. . . I did this and look at what happened . . . . Andmy Mom was always like yeah, look it I did this andlook at what happened, and I wanted to find out formyself. But she was really strict about everything.This young woman related that she did not want hermother's experience imposed on her life. Although her decisionsplaced her in major jeopardy, she wanted to make her ownmistakes and deal with the consequences herself. Shedemonstrated the adolescent developmental task of achievingindependence from parent(s). This young woman's experience isconfirmed by Cohen (1983) who suggested that sexual activity maybe a form of acting out used by some teens to achieveindependence in relationships with parents.Acknowledging the support of their families was only part ofthe experience of pregnancy for the young women. Others'reactions to their pregnancies were also of concern.CHAPTER FOUR143Coping with other's reactions. Under the second area ofcoping with supportive and nonsupportive relationships theadolescents described others' reactions to their pregnancies. Ayoung woman admitted that she talked to people, but did notalways follow their advice.Urn if . . . I didn't like what they had to say I justignored it. And mostly I just took it as advice, like Itook everything. If somebody said something that wassupportive that made sense, that was the kind ofthing that I wanted to hear. Even if it didn't makesense, [if] it was still supportive I still wanted tohear, [it] just didn't necessarily mean I listened.This young woman's comments indicated that when she was talkingthings over she was only prepared to listen to certain commentsthat she viewed as supportive. Although that decreased herambivalent feelings at the time, it also prevented her fromlistening to suggestions that might have interfered with herautonomy.The adolescent female who becomes pregnant often feels shehas done something wrong. There is an implicit social code thatconveys the message that pregnancy is not a socially acceptablebehavior for teenagers. However, many of these teenagersbelieved it would be acceptable to be pregnant, and could notunderstand what they had done wrong. A 15-year-old gave thefollowing account:CHAPTER FOUR154This young woman was thinking ahead about how her life wouldunfold as a mother indicating development toward formaloperational thinking.Experiencing a Sense of Hope for the FutureThe second aspect of experiencing a changed life wasexperiencing changes that gave life meaning and a sense of hopefor the future. The young women reflected on how theirpregnancies had changed their lives after they had given birth.Because, by the second interview, the young women had recentlygiven birth, their discussions vacillated between pregnancy andtheir current lives as new mothers. They believed becomingpregnant had given their lives hope, and "new meaning" or apurpose that they did not have before.The young women reflected on how becoming pregnant hadforced them to change their risk-taking behaviors. As a17-year-old stated:Yes it has changed my life a lot, I used to go out andparty with my friends all the time but I can't do thatanymore . . . . I had very mixed feelings at the time[when I found out]. Well at the time life wasn't goingso good, so it was kind of like urn it gave me newmeaning to life.After the baby's arrival she was relieved, and not disappointedthat her life had changed.I don't care, it might have been a shock, but I'm gladI kept her. I'm glad I got pregnant.CHAPTER FOURI feel uncomfortable at times . . . I don't know, it is ^144hard to explain how it feels . . . . I feel like I havedone something wrong and --- it's just my fault ---but I also realize that it isn't. And when some peoplewill look at you strange when they find out that youare a teenager and you're pregnant. And that makesme feel more insecure and scared to tell people.Feeling they were wrong and at fault created insecurity and fear,and increased the amount of ambivalence the young women felt.This may have been related in part to feeling different frompeers, and identifying difficulties in finding acceptance from theirpeers that they were normal.Teenagers' friends were also an important source ofsupport. A 15-year-old described feelings of low ambivalence.This was related to feeling others cared about her. Sheacknowledged that her friends supported her in her pregnancyexperience, their support helped to offset her feelings of beingout of step developmentally. Having their support enabled her tofeel part of her peer group, rather than rejected by her peers.. . . I still have contact with my friends. All myfriends really support me . . . and they care a lot. Itis like every time someone looks at me I have someoneto phone because they are all are waiting on me.She viewed the support of her friends as vital to herself-image, because she felt normal and part of the group. Thiswould fit with the middle adolescent task of trying to define theirself-identity by comparing themselves to their friends to see ifthey are normal. Support included affirmation from others,including peers, that they were normal. The following youngCHAPTER FOUR145woman was worried about being judged as abnormal by not livingup to the expectations of her parents (and peers) and wasrelieved to be supported instead:I'd have to say that one thing that was reallyimportant that was helpful was . . . my friends justlistening no one really judging, they'd listen and . . .everything would be ok to them. And that is whathelped me because if people had been judging me Iwould have been really hurt.While the young women saw themselves as different than theirpeers they neither viewed themselves as abnormal nor did theywant to be viewed that way.Speraw (1987) conducted an exploratory study to determineadolescents' perceptions of pregnancy and found that perceptionof pregnancy was influenced by: sources of emotional support,anticipating pregnancy and motherhood. Similarly, the youngwomen in this study also identified their families, boyfriends, andfriends as sources of emotional support. As well, they identifiedtheir positive anticipation of parenthood as influencing theirexperiences of pregnancy.The young women viewed pregnancy as a way to improvetheir lives and therefore, felt positive about their pregnancies.This decreased some of their ambivalence and enabled them tomake decisions about coping with the pregnancy. In addition totalking things over and looking to their families for support, anddealing with others' reactions to their pregnancies, the youngCHAPTER FOUR146women acknowledged that a variety of social and environmentalvariables influenced their thinking.De- ' g with Social and Environmental InfluencesLastly, the young women discussed social and environmentalvariables that were also influencing the reality of theirpregnancies such as: using social assistance, smoking cigarettesand marijuana, and drinking alcohol, having a dysfunctionalfamily, experiencing abusive relationships, and experiencinghomelessness.A young woman who had a mother who had been on socialassistance shared the following perspective about how herexperience with social assistance influenced her thinking:I will do everything in my power to not to have mychild on Welfare . . . My mother was on Welfare whenwe were really young, and it didn't bother me but itbothered my mother a lot. --- it was hard on her, soI figure I would never put myself in that position andmostly I want to be able to give my child, to be ableto afford little hockey lessons if it's a boy, or dancelessons if it is a girl. You can't do that if you areon Welfare . . . your child won't get a lot of thosethings that other children would and I don't think itis fair --- Or to have to wear second hand clothesand feel embarrassed. I never had to do that but alot of kids do . . . . you lose a lot of self respect. . . I mean you're having somebody else support you,you are not you know, you figure if you're on yourown you otta make it on your own and not have otherpeople support you.This young woman viewed social assistance as a negative influenceon self respect for herself and her child. it is an importantCHAPTER FOUR147perspective to acknowledge, because it may influence the wayadolescents access health services in the prenatal and postnatalperiods of their lives. In addition, their perspectives may offerinsight into how they feel about the bureaucracy of socialservices and collaborating with those professionals.Smoking cigarettes or marijuana, and drinking alcohol wereseen as coping behaviors the young women used. Quantity of usewas not explored. Alcohol and drug use appeared relevant to thesocial activities in which they participated.Smoking and use of street drugs have been associated withearlier sexual activity and risk for pregnancy (Zabin, Hardy,Smith, & Hirsh, 1986). Zabin et al. used a self-administeredquestionnaire to study the relationship between substance use andsexual knowledge, attitudes, and behaviors; and found that teenswho experienced early onset of sexual activity participated inother problem behaviors such as smoking, and use of street drugs(Zabin et al., 1986). These findings are consistent with the youngwomen's behaviors in this study.Additional variables the young women identified wereabusive relationships that had led to running away from home andrelated life experiences that placed them in more challengingsituations than their peers, but that may have led to theirpregnancies. A 16-year-old reflected on why she had run awayfrom home and lived in group homes. She described how she feltCHAPTER FOUR148betrayed by her mother when she suffered physical and emotionalabuse. As a result she continued to feel her mother would beunsupportive during her pregnancy.I was a mummy's little girl and then all of a suddenshe got together with a man who would beat her andbeat my brother and beat me . . . . and that is whenthings really started going wrong . . . . I wasbecoming more independent wanting to do things onmy own because my mother wasn't there for meanymore, I needed her.She did not indicate that she consciously became pregnant, butshe did acknowledge that the pregnancy had given her a chanceto make her life right. In the subsequent section on changed life,the way pregnancy and childbirth changed the young women'slives is explored in more depth.There is a paucity of literature that addresses the homeless,pregnant and parenting adolescent (Rich, 1991). The literatureacknowledges that the reasons for running away are multiple,including: parents who are physically abusive, parents with drugor alcohol abuse problems, physical and sexual abuse by theirmother's partner, foster care situations, and dysfunctionalrelationships with both parents. In describing Capable AdolescentMothers (CAM), a program in New Jersey for homeless pregnantand parenting adolescents, Rich (1991) noted that although theyoung women were homeless they were not totally cut off fromtheir families. However, Rich (1991) also noted that the family asa whole may have been dysfunctional to some degree prior to theCHAPTER FOUR149adolescent's pregnancy, which may further exacerbate familydysfunction. This observation supports the experience of some ofthe young women in this study. Although they did not live withtheir families of origin, they still had contact with their mothersand/or fathers, and their siblings.A unique characteristic of this sample was the number ofyoung women with a history of running away from home and/orliving on the street in the year prior to their pregnancies. Rich(1991) noted that homeless adolescents developed a coping mode of"running" to deal with their incredibly difficult life circumstances.Because of their experiences of running away from home andliving on the street, the young women in this study may have haddifferent emotional needs and attitudes than their peers who livedat home under less stressful situations. These factors may haveinfluenced their coping behaviors and explained why they viewedtheir pregnancies as a positive change in their lives.Because some of these young women had been exposed tofamily dysfunction, stress, and abusive situations, they felt theyhad sought out relationships and experiences that were beyondtheir chronological ages. Their social and environmental lifeexperiences may have also influenced their maturation and howthey viewed their pregnancies. A 17-year-old, provided thefollowing analysis of her life, which she described as differentfrom her peers:CHAPTER FOURI've done quite a bit of growing up in my lifetime and ^150I, you know, it is only because of my background thatI have, it has almost forced me to become older thanwhat I am. You know, sure I wish I had that perfect,you know, life going to school and going out with the16-year-old boyfriend. No I've gone out with20-year-olds or older, up to 30-year-olds, and youknow, sorry but I never had that so I've never, can'trelate to that. But this you know, in a way I havebeen forced into an adult world kind of thing and forme I want to give my child more than what I had,right.She recognized that her family situation and life experiencesdiffered from that of peers who lived in a two parent home wherethey felt loved and secure. She came from a broken home, hadbeen physically abused by her stepfather, and had spent timeliving in foster homes and on the street.Protinsky, Sporakowski, and Atkins (1982) found thatpregnant teenagers were significantly more untrusting of othersthan nonpregnant peers. Although a substantial number of thepregnant teenagers were from broken homes, they did not relatethis to the teenagers' lack of trust in others. Other authors like,Hartman, Burgess and McCormack (1987) have related runaways'lack of trust to their life experiences:In general, the longer runaways have been away from home,the more self-demoralizing experiences they have had. Suchexperiences impinge on their ability to trust, to be calm,and to feel connected and committed to both people andplaces (p. 298).CHAPTER FOUR151Although the young women in this study did not specifically talkabout trust, they did talk about not feeling connected andcommitted to people. A 17-year-old who had run away from home,and lived in foster homes shared the following comments:I had nothing to come home to like . . . it's the sameway with the abused child, who goes home and getsbeaten everyday, why are they gonna go home? Theyare not going to go home there is nothing there . . . .if they go home and they have a good loving family.Well they are going to be home everyday right afterschool.Her comments indicated that she did not feel connected to herfamily. This may have implications for how she copes in thefuture in the maternal role.The young women in this study indicated that their lifeexperiences influenced their rate of maturation, their ability totrust, and how they viewed their pregnancies. This researcherperceived a difference in the way the young women viewedpregnancy depending on their chronological age. Social andenvironmental influences also had a major impact on theirperceptions. The perception of Experiencing a Changed Life isphase five of pregnancy as a life change event.Phase Five: Experiencina a Changed LifeIn this section, the young women's descriptions of theirchanged lives as a consequence of the experience of adolescentpregnancy will be presented. Particularly, their reflections ofCHAPTER FOUR152pregnancy, and the births of their children will be discussed inrelation to the life change event. This phase is composed of thefollowing subconcepts: (a) changed thinking, (b) experiencing asense of hope for the future; (c) caring for the infant, (d) caringfor oneself, (e) changing relationships with families andboyfriends, and (f) coping with the maternal role.Changed Thinking,In the first interviews, some young women said that theywould not let being pregnant change their lives. In theinterviews after the births of their babies, they indicated thattheir lives had changed.A 14-year-old stated in her first interview, that she wouldnot allow having a baby to make a difference in her life.When the baby comes I am still going to go out anddo everything I have to.In a follow-up interview, after the birth of her baby she statedthat she had to get someone else to look after the baby when shewent out with her friends, and had realized how muchresponsibility motherhood entailed. In addition, she acknowledgedthat she spent a lot of her time caring for her baby. The conflictshe felt between wanting to remain an adolescent and taking onresponsibility had decreased. She was able to respond to how thebaby had changed her life and to the responsibilities ofCHAPTER FOUR153parenting. Consequently, she was able to think about plans forher future that included envisioning how different decisions wouldinfluence her future life, for example, making plans to continueliving with her parents, and to attend a school with a program foradolescent mothers.Other young women also recognized that their thinking hadundergone change over time. For example, in a follow-upinterview after the birth of her baby, a 16-year-old was excitedabout being a mother and did not want to be like a teenageranymore. She shared the following thoughts:I don't, I don't see myself as a teenager . . . I don'tthink I feel or think like a teenager . . . . [thatperiod of life is over]. I can't really do the teenagethings, I don't want to jump in the cars with theboys, or go get drunk, it doesn't appeal to meanymore at all . . . . It makes you grow up a lot whenyou have kids [laugh] I don't want to be a teenager Iwant to be an adult so far.She was striving to achieve an adult identity--a developmentaltask of adolescence. Having a baby increased her responsibilitiesand was causing her to think beyond her adolescent role to anadult mothering role.One young woman demonstrated a change from self-centeredthinking to concern for the infant.But you have to experience it to, urn, really know howit feels, because, like there are things you have toplan for thinking of the baby.CHAPTER FOUR155Others described having a baby as motivating them to changetheir behavior. For example, a 16-year-old stated:Um you try and be better for her, better yourself forthe baby . . . You want to make everything better,--- to give her the best there is, and I want her tohave so much [opportunities to experience differentsports, youth activities].Some of the young women reflected about how they started tochange to be a better role model for their children during theirpregnancies.. . . right after I found out I was pregnant with her.I tried to mold myself to Urn be what I want, to be abetter person . . . . Me getting pregnant with her isthe best thing that could have happened to me. Itgave me a second chance to make it better. Therewas a time before I found out I was pregnant that Iwas on the road to hell . . . . Yeah it did I hadnever cared about myself at all and now I do.The above comments conveyed a sense of hope and optimism. Theyoung women believed their lives would be better because theywere making opportunities for their babies. Their thinking movedfrom destructive egocentricity toward a more healthy caring foroneself. Rich (1990) suggested that homeless adolescent mothersneed help in balancing their own needs with those of their infantsbecause "enduring love, altruistic self-denial, and empathy . . .are maternal qualities that come in conflict with the adolescent'segocentric pursuits" (p. 208). These maternal qualities are alsodifficult to maintain during child-rearing. As the young women inCHAPTER FOUR156this study were just becoming mothers they were just beginningto experience these conflicts.Pregnancy also increased their self-esteem. Many of theyoung women acknowledged that because their lives had changed,they felt better about who they were. They saw a way to changetheir self-destructive behaviors and they wanted those changes.However, their changes could be influenced by barriers in theirsocial environments, which had a negative influence on theircoping behaviors.Carina for the InfantA third aspect of experiencing a changed life was caring fortheir infants. In addition to the young women discussing theirconcerns about whether they could care for the baby and go toschool or work, they also talked about how their previous lifeexperiences influenced their physical caring and their emotionalcaring.A 14-year-old described how she was adjusting to caringfor her infant.Every night I am up with him . . . I'm . . . here tofeed him, to change him, . . . . I enjoy being withhim.She also compared her present experience, of caring for herinfant, to that of her former experience as a baby-sitter.CHAPTER FOURit is a little different with your own [compared to^ 157babysitting], I guess you are really tired and he iscrying, but it is usually for a reason and you arepulling out your hair, so at least you love the kid. Ifyou didn't love the kid you'd have problems.As part of caring for their infants the young womendiscussed how important their babies were to them. The theme of"making a baby of my own" was part of claiming the infant (apregnancy task) and provided feelings of accomplishment. Forexample, in response to a question regarding why having the babywas exciting, a 17-year-old gave the following reply:. . . that she was born healthy, that I made her, Ilove her, you have to feel it to know . . . exactly howit feels . . . . I created her . . . I am proud of her.Some of the young women feared that their babies might beabnormal. This was a maternal task, they sought safe passage fortheir infants, and worried about whether their babies would benormal (Rubin, 1984). One young woman expressed her fears inthe following comment:. . . wondering if she was going to be ok . . . Ialways had a fear that something bad was going tohappen to her.This fear was resolved once a healthy baby was born. It madethe experience seem even more positive, and gave them a sense ofachievement; perhaps one of the first achievements they hadaccomplished.The 16-year-old who had contemplated adoption, made herdecision to place her baby after the birth. In response to aCHAPTER FOUR158question about what she had found helpful in making her decision,she shared the following comments:I found it really hard to keep up with everything sheneeded. And that showed me that I wasn't reallyready yet, and just thinking about everything that Iwould never be able to give her and what they [theadoptive parents] could, really helped.Being able to care for the baby after the birth helped her tounderstand what the mothering role involved. Consequently shedecided that she was not ready to be a mother yet. She hadplans for her future. She wanted to go on to college and get herbusiness degree. Because of her young age, few resources, andlimited life experiences, she felt it would be difficult to accomplishmaternal tasks as well as developing a vocation or career. Herideal image of what a mother should be and her ability to be amother did not fit together. Her caring was expressed in givingthe baby up.Caring for OneselfA fourth aspect of experiencing a changed life was caringfor oneself. Although the young women were thinking about theirinfants' needs they were also thinking about their own needs. Allthe young women considered schooling important, either they hadplans to return to school, or were continuing with their schoolingat the time. Many had even considered child-care arrangementswhile they were in school. They were using formal operationalCHAPTER FOUR159reasoning in making plans for the future. They discussed: (a) theinfluence of previous life experiences, (b) thinking about futureroles, and (c) contraception.Influence of previous life experiences. The young womenwho had run away from home had not experienced their teenyears in a way that is presented in textbooks on adolescentgrowth and development. Their former lives were very difficultand these experiences influenced their plans for parenting. Forexample, a 15-year-old gave the following account of her life:A lot of bad things have happened to me in my past.Like in my family and just being on the streets . . .like my family is mostly alcoholics. So I had a lot oftrouble with that during my life. I think that is whyI started drinking and everything . . . . I starteddrinking when I was eight . . . but I never reallyused to drink a lot when I was eight, but I starteddrinking more and more . . . . I started smokingwhen I was five . . . . I have quit that . . . . Ihave seen so many kids get abused like I got abusedwhen I was little . . . . I was always the odd onewhen I was little . . . . I wouldn't want to see anychild go through that, what I went through.Her comments illustrated the multiple problems she dealt with as achild, and her desire that her child not have the sameexperiences. As stated previously developing a self-identity wasdifficult for these adolescents because of their young age andlimited life experiences, but the adolescents who have experiencedabuse in their families of origin, found development of aself-identity and a maternal identity even more complicated.CHAPTER FOUR160Sander (1991) interviewed four black women who wereadolescent mothers. The women described the social, economic,and psychological struggles they faced as adolescent mothers.Their poverty, loss of their fathers, difficult relationships withtheir mothers, and battered sense of self-esteem affected theirability to achieve the maternal role. From the personal testimoniesof the women, Sander (1991) concluded that it takes tremendousresilience and personal resourcefulness for adolescent mothers toturn their lives around. Similarly, the young women in this studyrequired personal resourcefulness and resilience to deal with thedifficulties they experienced as pregnant teenagers who werebecoming mothers.The young women who had experienced homelessness talkedabout their need for assistance and support with the motheringrole.I'm just scared that this will not work out, that I willend up ruining his life and my life. That is mybiggest worry, that I will some how not be able to doit, but that is why I wanted lots of support, emotional[and] financial when I started out.This 14-year-old was making a transition to behaviors in thecontext of an experience of inadequate parenting. Her ability tothink about how her life had changed, and about the manychallenges that she still had to face, is more typical of lateadolescence or early adulthood than a middle adolescent. ByCHAPTER FOUR161voicing her doubts, she demonstrated her realistic appraisal ofher coping abilities, and identified her needs for support.Oz, Tani, and Fine (1992b) studied the psychologicalcharacteristics of teenage mothers who had experienced traumaticchildhoods and found that while teenager mothers feel good aboutthemselves and want to be good mothers, they recognize that theyare inexperienced with the role. They proposed that theteenagers' lack of education and job skills required them toremain dependent on social assistance, even though they wereassuming an adult role, causing them to feel powerless aboutchanging their lives.Many of the young women, in this study, who had run awayfrom home, associated their pregnancies with a chance to changethe pattern of their lives. Their life experiences had made someof these young women more mature than their years. This issupported in the literature by Oz, Tari, and Fine (1992a) whocompared the psychological characteristics of a group of teenagemothers to a group of nonmothers and found that the teenagemothers had more mature ego development. Traumatic experiences,such as growing up in a broken home, living in a foster home,and being sexually abused exerted an influence upon thematurational processes of young women (Oz et al., 1992a). Theysuggested that many adolescent females from foster care andabusive environments, who become mothers handle the conflictsCHAPTER FOUR162between life as it should be and life as it is by toleratingambiguity and appreciating life's complexity (Oz et al., 1992a). Inthis study, tolerance assisted the young women to cope with thedevelopmental tasks of adolescence, the developmental tasks ofpregnancy, and the maternal role. This observation is consistentwith the descriptions provided by the young women in this study.Thinkina about future roles. The young women wanted tofinish their schooling so they could get jobs and supportthemselves and their babies. This was a change from their pastexperiences. A 16-year-old had this to say:I want to finish my schooling and get a career so Ican support myself comfortably . . . . before I wasnot caring about school, now I know I have to goback.The following excerpt from a 14-year-old illustrated how thepregnancy and birth had changed her life and provided her withan opportunity to finish her schooling:If I hadn't had it [the baby] I probably would havebeen somewhere else. I would have just gotten drunkif I hadn't gotten pregnant. At least with him I canfinish my schooling or I am going to finish myschooling . . . it is like a different chance . . . Iwouldn't say it [having a baby this young] is unfair,having a baby is not unfair it is sort of a gift . . .It gives you a reason to live for . . . . Before I hadhim the biggest thing was going out and partyingbeing with my friends. And school wasn't one ofthose things, and not being responsible. And nowthat I have him I can get my education at least I cando it, it's just with him it will take longer.CHAPTER FOUR163This young woman acknowledged that pregnancy and birth hadprovided her with a reason to live her life differently. She hadmoved from living her life from day to day for pleasure toplanning ahead to finish school and to make career or job plansfor her future. She was learning to give of herself to herchild--a maternal task (Rubin, 1984). At the same time she wasdeveloping a personal value system, formulating her self-identity,and choosing a vocation or a career--tasks of adolescence.Thinking about contraception. With their lives changing asa consequence of pregnancy and giving birth, came the realizationof what the maternal role entailed. As a result some of the youngwomen mentioned that they did not want to get pregnant again fora long while. They wanted to wait until they had had a chance toaccomplish some of the other things that they wanted to do withtheir lives. For example, a 14-year-old provided the followingassessment of her situation:. . . after this baby --- no babies for a long time so--- one more reason I don't need a relationship withthe baby's father . . . . the only sure way abstinence[laugh]. What I should have done in the beginning sothat way you don't have to worry about gettinganything, which I was always paranoid about before.This young woman planned for abstinence as a coping behavior toavoid another pregnancy. Her young age may have contributed toher not considering other viable options.CHAPTER FOUR164A 16-year-old communicated that she would give seriousthought to her actions in the future:. . . I am never going to let this happen again, we'retalking two condoms, and the pill, and everything elseyou can think of. Cause I'm scared, I don't want itto happen again, I will be on the pill for sure nexttime. [If] I do have a boyfriend that this may happenagain with, it is like I will be prepared [laugh]. (5.1)The reality of having a baby forced these young women todevelop coping behaviors (some more realistic than others) and tothink about their needs for contraception. In this study, theyoung women assumed the responsibilities for their pregnanciesand future needs for contraception. These findings are supportedby Meyer (1991) who reviewed the literature on adolescentpregnancy and found that men did not take responsibility forcontraception and pregnancy.Changing RelationshipsA fifth aspect of experiencing a changed life encompassedliving arrangements and relationships with families and boyfriends,which had changed. For some of the young women who had livedon the street or in group homes, becoming pregnant had enabledthem to be in a stable home environment for the first time, butliving arrangements changed over the course of the pregnancy.Their relationships with families and boyfriends also changed aftertheir infants' arrivals.CHAPTER FOUR165Families. Many of the young women were assisted by theirfamilies. Family support allowed them to learn mothering skills,and enabled them to feel that they could cope with the motheringrole. Family support was expressed in various ways consistentwith the literature.Smith (1983) studied the developmental tasks that must besuccessfully negotiated in the family life cycle when an adolescentdaughter becomes pregnant. She used grounded theory toanalyze the specific developmental tasks and process involvedwhen a family incorporates a young mother and her child into thehousehold. Three patterns of incorporating the young mother andher infant into the household were identified: role sharing, roleblocking, and role binding. She defined role sharing as "theshared performance of acts that in their sum represent theperformance of the maternal role" (Smith, 1983, p. 51). The rolesharing pattern provides the young mother with opportunities tolearn mothering skills, whereas in role blocking--the adolescent'sown mother assumes many of the "mothering" responsibilities andin role binding--the adolescent assumes all responsibilities formothering herself.One 16-year-old appreciated her family's support.they are always taking her from me and letting me gotake naps and so on. Even my Dad has come to help,when she was first here, like at three o'clock in themorning he was rocking her to sleep for me . . . .They have been really helpful.CHAPTER FOUR166Because this young woman lived at home, her family was able toassist her in meeting the 24-hour responsibilities of child care,consistent with Smith's (1983) definition of role sharing.Having their mothers' praise and approval for doing a goodjob was important to several of the young women. For example, a16-year-old provided the following account:My mom is still mothering of course she still tries totake over, but I just tell her, but she says I amdoing a good job.A 14-year-old identified the following reasons why her mother'sencouragement was important to her:I've got my mother mostly for emotional support whenI am ready to pull my hair out or have a question,she will answer the question or just say that shethinks I am doing fine . . . with the baby , which is abig help. For financial support I have social services,if I need to take a shower or just need to sit downfor a minute I've got my foster mother . . . I haveactually got a lot of support . . . it is nice to have. . . . the little things like having someone say yeahyou're doing good makes a big difference.Both her mother and foster mother offered her advice andassistance with child care. She especially valued the emotionalsupport her mother provided to her.Flaherty, Facteau, and Garver (1987) in a study of 19African-American grandmothers (adolescents' mothers) who hadengaged in the care of their adolescent daughters' infants,identified seven grandmother functions: managing, nurturing,caretaking, coaching, assessing, assigning, and patrolling. TheseCHAPTER FOUR167functions are also applicable to grandmothers from other culturalgroups. In this study, the researcher found the young womenvalued the role their mothers played in nurturing them during thelater half of their pregnancies, coaching and supporting themduring labor, and in providing information related to caretakingand assessing their infant's needs. Mercer (1980) also found thatadolescents identified their mothers as a source of support fortaking on tha mothering rola,Living with families could create difficulties with siblings.A 16-year-old who was experiencing difficulty with her littlesister's acceptance of her in the maternal role shared thefollowing comments:My little sister is having a hard time trying to acceptit . . . like watching me go through everything I'vegone through so she is kind of mad at me. So Iguess she is taking it out by calling me names andstuff, or saying she doesn't care about the baby, butthen she will turn around and say oh can I hold hershe's so cute and things.This young woman's description of her relationship with her sisteris consistent with the literature. Rich (1991) suggested that therelationship between adolescent mothers and their siblings ischaracterized by tension, and feelings of competiveness, whichconsequently increase rivalry feelings and behaviors.Boyfriends. Three of the young women had partners whowere their age or two to three years older. This presents its ownset of problems. Hardy and Duggan (1988) stated:CHAPTER FOUR168Many of the studies of young fathers have shown that they,like teenage mothers, tend to be from among the poorer andless educated groups in society, and that they may faceserious and long-term social and economic disadvantages,when compared with young men who postpone parentinguntil a later date (p. 159).None of the partners of the young women in this study wereinterviewed, so data on their backgrounds is incomplete. Oneyoung man chose to offer emotional support to a young woman,but the other young men were no longer involved in relationshipswith the young women.Four of the young women had "older" boyfriends that theyhad left as their pregnancies progressed or shortly after thebirth of their babies. Some of the young women had differentneeds than their boyfriends as evidenced by the followingstatement:He's got his job and his house, he's got everythingset up and for him it's a good time to start [a family],and for me it's just a little early.The "older" father and the young women were both trying to meettheir emotional needs for being special and having a caringintimate relationship with another person, but their needs werenot always compatible.CHAPTER FOUR169A 14-year-old who did not want a permanent relationshipwith the 24-year-old father of her child shared the followingperception of their relationship:I don't want to put myself in a position where . . . ifI were to live with him he'd have custody of me untilI was 18. You don't have . . . a spouse or a partnerhaving custody of you [and your child] . . . If thereare any problems that puts you in a bad situation. . . . I don't want to put myself in the positionwhere the baby can be stuck in a bad relationshipwhen people are young they usually don't --- we aremore like good friends too, more like good friendsthan actual --- mummy and daddy figures.Her thinking shows concerns for independence and autonomy thatis more typical of an adult than a middle adolescent.Even though the young women viewed their pregnancies aspositive, they expressed ambivalence about maintainingrelationships with their infants' fathers, and the impact of theirrelationships on their infants. For example:I don't want any contact with him for myself but forthe baby I would like for him to know who his fatherwas. If he wants to be a father and see him, he canbut I'm not going to make it easier for him.A 14-year-old was no longer interested in a relationship with her"older" boyfriend. She provided the following comments:I'm not so much worried or if I am at all interested ina relationship with him for myself, but for the babyI'd like for him to be involved. He wants custody andI'm not going to let him have custody. I don't thinkhe'll go to court for it, I'm hoping he won't. --- justvisiting I'd like that actually.CHAPTER FOUR170These quotes indicated the conflicts the young women wereexperiencing about their relationships. They wanted theirboyfriends' involvement with their babies, but they wantedautonomy for themselves. They also did not want to lose custodyof their children.Some of these young women were in vulnerable positions forabuse and with the birth of their babies they recognized theyneeded to monitor their own and their infants' safety needs. Forexample, a 16-year-old related the following account:He hit me when I was pregnant. When I was sevenmonths pregnant, and I did a stupid thing stayingwith him. He went through the birth and everythingwith me but now he's talking about wanting fullcustody and stuff. I won't go over to his housealone. Because I am scared of what he might do.When I did before he grabbed her from me andwouldn't let me back in the house to see her andstuff. And I tried to get up to go and phone thepolice but he wouldn't let me go. So I told him if hewants to see her he has to come here [her parentshome]. But now . . . he doesn't want to see her atall, until I finish breast-feeding. So he doesn't haveto see me.Similar to the experience of the young woman in the previousnarrative, Parker and McFarlane (1991) acknowledged thatpregnant teens reported that their abuse began or increased oncetheir partners were informed about their pregnancies. Parker andMcFarlane also noted that pregnant adolescents report batteringmore frequently than pregnant adult women.CHAPTER FOUR171Ending a relationship was complicated by the men's threatsto pursue custody of their children. It was not explored in thisstudy, but some of the young women discussed that they did notwant to leave their babies in day-care facilities. This may havebeen related to threats by the fathers to apply for custody oftheir children. The two young women who stated they did notwant to have their children looked after in day-care centers wereboth no longer in relationships with their babies' fathers. Mercerand Flick (1991) have also expressed concern about the emotionalupset young women experience when the fathers of their childrenthreaten to sue for custody.Only in recent years has the literature discussed thedifferences in age of the fathers and the adolescents who becomepregnant by them. Five of the eight young women that wereinterviewed had partners who were 6 to 12 years older thanthemselves. Hardy and Zabin (1991) raised an important issueconcerning the male role in adolescent pregnancy, whether thereis sexual abuse or coercion of the young women to haveintercourse with older men. Reedy (1991) also suggested that it isunlikely that young female adolescents are sexually active for sexitself. "She may be sexually active as a result of abuse/incest bythe older male object of her adolescent crush, or, if the homesituation is unstable, she may be trading sex for food and/orlodging" (Reedy, 1991, p. 222).CHAPTER FOUR172Two of the young women in this study started living withtheir "boyfriends" because they offered a place to live, prior tobeginning their relationships. The issue of sexual abuse was notaddressed in this study, but it raised questions for theresearcher as to the nature of the young women's relationshipsparticularly when the fathers of their children were much olderthan themselves. A young to middle adolescent is concerned withdifferent developmental tasks than a young adult. For example, inresponse to a question about her boyfriend knowing her age, ayoung woman who was 14, had this to say about her 24-year-oldboyfriend:Urn --- I didn't lie or tell him otherwise but he neverasked not until I was living with him and he asked meand I told him and he kind of backed away for a bit,and then I figured it didn't matter. When I first gotpregnant it scared him he was wondering if he couldbe charged or you know anything like that. Andwhen he found out he was safe he just kind of, hewas ok with it again . . .She needed to maintain a place to stay, her boyfriend's acceptanceof her meant she would continue to have lodging. It also soundedas though her boyfriend was seeking an intimate relationship.Coping with the Maternal RoleThe sixth aspect of experiencing a changed life was copingwith the maternal role. These young women were interviewed inthe immediate postpartum period, and the maternal role was veryCHAPTER FOUR173new to them. Even though some of the young women hadexperience with babysitting and caring for siblings, they did nothave experience with the 24-hour responsibilities of mothering.Consequently they found it was hard. They were still pleased,however, that the pregnancy had provided them with a chance tochange their lives. A 15-year-old stated:I have thought about it [the baby] a lot . . . . but Istill think, you know, that there are lots of things Ican do. And, it is not taking my whole life away, itwill still bring more joys to it . . . . I am gladactually because it took me away from the drugs andalcohol and . . . a lot of those things, bad things thatI used to do.Even though pregnancy and the birth had changed theyoung women's lives, they still had to deal with issues from theirpast. One young woman discussed how taking responsibility forstress and anger came down to some very specific copingbehaviors:You see if I am stressed out then she is stressed ---by findings ways to vent my anger, to vent myfrustration. Other than in the same room as her, Idon't do it anymore. As I've said I have yelled threetimes around her. That was enough to worry me . .Just because anger can lead to other things . . . Andthat is why I started feeling I was on the road thento being a danger to my own daughter. And Icouldn't allow that, and so for me trying to be abetter mother [involves] going and talking, I amtrying to get . . . referred to a counsellor so I canspend an hour with somebody talking over myproblems . . . . problems from the past that I haven'tsolved.CHAPTER FOUR174These young women acknowledged their coping behaviorswere limited and that their past had put them at risk for hurtingtheir children. Some were able to acknowledge their difficultiesand seek help to deal with their concerns.It is unclear if adolescents abuse or neglect their childrenbecause of their young maternal age, the environment of socialdisadvantage in which adolescent pregnancy often occurs, or acombination of these factors (Hardy & Zabin, 1991). Hardy andZabin found that parenting education was effective in preventingaccidents and child abuse/neglect of children born to adolescents.The literature indicates that adolescents who have social supportavailable for developing mothering behaviors are more likely tofeel competent in the mother role (vonWindeguth Urbano, 1989).As the young women began to project ahead, they sawparenting as a responsible role. They realized being a singleparent would not be easy:. . . I want her to have a dad. I thought I wantedto raise her on my own but I don't want to do thatnow. But I think It would be too hard and I thinkshe needs a guy around . . . . so I could have somehelp with decisions and stuff about her. Cause I maynot be right all the time [laugh]. But it would benice to have some input from somebody else aboutwhat is right for her.They were also concerned about finding a partner.I am really worried about finding a husband [laugh]. . . I think it will happen.CHAPTER FOUR175Worrying about supplying a father figure and concernsabout being a single parent complicated the numerousresponsibilities involved with mothering. Some of the youngwomen also thought about how a baby would affect establishingrelationships with young men. For example:. . . finding a guy that will accept me and my childand not be put off by the fact that I have one.Because there is a lot of guys . . . that would bescared away by that.The young women were projecting their needs for intimacy andsupport but, because of their young ages, they were assumingthat males in their peer group would not want to deal with aninfant.After their children were born, the young women consideredall the challenges they were facing and acknowledged the realityof years of work and responsibility that was ahead.but yet now that I have her and know theresponsibilities . . . . once you have the baby out inyour arms it is a hell of a lot of hard work it is.The difference between carrying the baby during pregnancy andcaring for a separate individual echoed their earlier comments.Even for adult women it is often difficult to understand how muchtheir lives will be changed by the birth of a baby.The findings of the study were explored in the context ofthe current literature from nursing, medicine, social work,psychology, and sociology. By examining their stories, thisCHAPTER FOUR176chapter has explored how the young women perceived andmanaged their pregnancies. In Chapter Five, a summary of thestudy findings and conclusions that arise from the study arepresented, as well as implications for nursing practice, education,research, and social policy.CHAPTER FIVESUMMARY, CONCLUSIONS, AND IMPLICATIONS FOR NURSINGIntroductionThis chapter presents a summary of the findings andimportant conclusions arising from the study. In addition,implications are proposed for nursing practice, education,research, and public policy.Summary of FindingsThe study explored and described the female adolescent'sperspective of what it was like to be pregnant. Chapter Fourpresented the young women's stories which were elicited duringthe interviews. These accounts were candid and rich in detail.Because the perceptions and experiences of the young women werehighly individual and related to both their personal and socialenvironments, their management of their pregnancies was alsoindividual. The phenomenological analysis resulted in adescription of this unique group of female adolescents' experiencesof pregnancy.The maturational event of pregnancy was superimposed onthe young women's developmental tasks of adolescence. The themeof ambivalence was interwoven with the theme of adolescentpregnancy as a life change event. The ambivalence the young177CHAPTER FIVE178women experienced took many forms and varied in intensity. Theywere ambivalent about changes in their lives, their relationships,and their futures.The description that emerged from the data analysis processhas been characterized, by this researcher, as phases ofadolescent pregnancy as a life change event. These phases wereentitled: (a) suspecting the pregnancy, (b) confirming thepregnancy, (c) making decisions about the pregnancy, (d) livingthe reality of the pregnancy, and (e) experiencing a changed life.Concepts and subconcepts that influenced how the young womenmanaged their pregnancies were identified under each phase.During the data analysis, it became evident that a numberof factors influenced the adolescent females' experiences ofpregnancy and their coping behaviors. Throughout thenarratives, the young women talked of the role others playedwhile they struggled to cope with the simultaneous developmentaltasks of adolescence and pregnancy. In particular, mothers'acceptance was important and mothers were identified as valuablesources of support. The social environment in which the youngwomen lived, and interactions with their significant others, alsoacted as factors which influenced their coping behaviors andconsequently their experiences of pregnancy.While coping with pregnancy, the young women continued tolearn about themselves. Data from this study suggested thatCHAPTER FIVE179these adolescents perceived their pregnancies as a positive lifechanging event.ConclusionsQualitative research findings "are important in and ofthemselves since it is the richness and detail of the data thatgive[s] the reader an understanding of the . . . [participant's]social world" (Knafl & Howard, 1984, p. 18). The findings of thisstudy cannot be generalized to all pregnant female adolescents.These findings are descriptive of an unique group of middleadolescents who have had a history of unstable family and livingarrangements. Many had run away from home. Some had lived onthe street from time to time. Some were living with foster familiesor boyfriends. None were attending school when the interviewswere conducted. All the young women were vulnerable becausethey were uncertain about the level of family commitment tothemselves, and later to their infants. The findings of this studyprovide nurses, who work with pregnant adolescents, with insightabout adolescents' pregnancy experiences. Such perspectives canenable nurses to respond to pregnant female adolescents' healthcare needs in a manner that supports and enhances adolescents'coping abilities.The following are the major conclusions from this study:CHAPTER FIVE1801. The experience of pregnancy, and the expected childprovided the young women with meaning, purpose and a sense ofhope for their lives. This meaning and purpose provided themwith motivation to change their previous self-destructivebehaviors. The hope and optimism they felt about theirpregnancies, and later their healthy babies, provided them with asense of achievement and increased their self-esteem.2. All of these young women were vulnerable. Some of themwere escaping from abusive situations and seeking shelterelsewhere, and as a result, they were at increased risk forpregnancy. Also, they had a poor understanding about the risksof pregnancy associated with sexual activity, or falsely believedthey were not at risk. The lower the chronological age and stageof cognitive development the less developed were the youngwomen's abilities to use realistic future thinking and to examinepossible outcomes of their actions.3. Because they were unsure about their abilities to providea safe environment during their pregnancies and following theirbirths, they wanted assistance from their families and varioussocial programs. At the same time they were uncomfortable withbeing dependent on social assistance or their families.4. Ambivalence characterized the young women's responsesto pregnancy. Initial ambivalence caused the young women todeny their pregnancies and prevented them from seeking earlyCHAPTER FIVE181prenatal care. Denial was associated with ambivalence and enabledthe young women to cope when they first suspected they werepregnant. However, denial also permitted them to continuerisk-taking behaviors at the most critical time in theirpregnancies. Some young women denied their pregnancies at firstbecause they were ambivalent about their parents' or other'sreactions. These actions also prevented them from seeking earlyprenatal care.5. When the young women did tell others about theirpregnancies and were rejected, their ambivalence increased.Rejection by families decreased adolescents' feelings of trust andreduced their receptiveness to help from others including healthcare professionals. The findings in this study indicated howimportant even dysfunctional families were to adolescents' views oftheir pregnancies and feelings of self-worth.6. Higher feelings of ambivalence were associated withfeeling unsure about themselves and had a negative impact ontheir self-esteem. High ambivalence prevented them from feelingin control of their lives and from achieving their pregnancy tasks.Also, the more limited their life experiences, the more ambivalentthe young women felt about pregnancy and parenting.7. The young women identified their mothers as importantsources of support during their pregnancies, labors, and after thebirths. Although the young women wanted to be in control ofCHAPTER FIVE182their lives, they also wanted their mothers to be emotionallysupportive and available for guidance.8. These young women did not consider abortion a feasibleoption for pregnancy resolution. Previous experience withabortions reduced some of the young women's willingness to usethat form of pregnancy resolution again during this pregnancyexperience. This was especially true, when the young women'sparents had controlled previous decisions about abortion. Inaddition, some held beliefs that abortion was not acceptable.9. The young women's thinking and decision-making becamemore mature during their pregnancies. They thought more abouthow their pregnancies would affect their future lives. However,the previous life experiences of the young women had alsoincreased their maturity in relation to decision-making.10. The young women's relationships with families andpartners were often dysfunctional and put some of them at riskfor abuse. Five of the eight young women had older partners andtheir perceptions of their male partners changed as theirpregnancies progressed. Some young women wanted lessinvolvement with their partners and choose to bear and raisetheir children on their own. However, some of the young women'spartners threatened to apply for custody of their children whentheir relationships ended. The climate of fear and coercionCHAPTER FIVE183created by their relationships made the young women fearfulabout their own and their infants' safety.11. The young women's abilities to accept help weredependent on their perceptions of being supported. Theyindicated that when they talked to others about their pregnanciesthey were only prepared to listen to comments that weresupportive. Thus, they valued persons who were seen asempathic and supportive. While this decreased their ambivalence,because they blocked out comments that would interfere with theirautonomy, their resistance to necessary positive changes may havebeen increased.12. Peer relationships were affected by the pregnancy. Theyoung women had different experiences than their peers. Someyoung women were not interested in relationships with their peersbecause they felt they no longer had things in common. Othersindicated that their friends' support continued to be important tothem, because they did not see their pregnancies as abnormal.13. The young women made associations among socialassistance and negative influences on their self-image; theirchildren's self-image; and their loss of independence.14. This was the first time for the young women to carry apregnancy to term. They had difficulty anticipating what themothering role entailed, however, they expressed a strong desireCHAPTER FIVE184to be good mothers and wanted recognition for their abilities withthe role.15. The young women stated that they were not overwhelmedby the information they were given throughout their pregnancies.They may have found it difficult to acknowledge that they wereoverwhelmed, or perhaps, they found the information decreasedtheir ambivalence and made them feel they could cope with thepregnancy.16. The young women became more interested in educationand career or vocational planning following confirmation of theirpregnancies. However, some of them wished to maintain teenbehaviors.17. All the young women were participating in supportprograms for pregnant and parenting adolescents, which theyindicated helped them to adjust to their pregnancies, prepare forlabor, and care for their babies after the delivery.18. In the early postpartum period, the young women statedthat they wanted to postpone future pregnancies until they hadfinished their schooling and career plans. Consequently, theydiscussed their readiness to practice contraception. However,their history of dysfunctional relationships influenced theirabilities to be assertive about their own needs.These conclusions provide implications for nursing practice,education, research, and public policy.CHAPTER FIVE185Implications for _NursingPracticeNursing interventions that are derived from anunderstanding of the female adolescent's perceptions of pregnancyare likely to be more effective than those derived only fromprofessionals' speculations of what is important to these youngwomen. The data from this study provide direction for nursinginterventions aimed at assisting pregnant adolescents to cope withtheir pregnancies.The five descriptive phases of adolescent pregnancyidentified in this study can provide a framework for nurses touse in exploring young women's experiences of pregnancy. Theframework would assist nurses to focus simultaneously onadolescents' developmental tasks and the tasks associated witheach phase of pregnancy as a life change event. The frameworkprovides the nurse with direction to assess a young woman'sexperiences and expectations related to her pregnancy, and toidentify her ambivalent feelings.The young women in this study felt that their experiencesof pregnancy and their expected babies provided them withmeaning, purpose and a sense of hope for their lives. The hopeand optimism they felt about their pregnancies, and later theirhealthy babies, increased their self-esteem and provided them withCHAPTER FIVE186a sense of achievement. These positive feelings should besupported and enhanced by nurses so that the young women'sambivalence would be decreased and their motivation to change tohealthier behaviors would be facilitated. Recognizing the youngwomen's strengths would enhance their coping skills forpregnancy and parenting.A striking characteristic of all the young women in thisstudy was their vulnerability. Many of them came from families oflow socioeconomic status. Their mothers were single parents, orthey identified problems in their family unit. They were notattending school during their pregnancies, and did not have majorsupport groups like churches or youth groups in their lives priorto their pregnancies. The young women talked about wanting tochange their lives for the better, and reducing self-destructivebehaviors.Nurses, who are designing programs for high risk youth,need to be aware of young women's vulnerability in relation topregnancy risk and inadequate living situations during pregnancy.Interventions need to address the social factors that are presentin young women's lives prior to as well as during theirpregnancies. Nurses need to refer pregnant adolescents tosuitable housing and programs that provide financial and emotionalsupport to young women. This could lessen their vulnerabilityand assist them to become more effective mothers. TheseCHAPTER FIVE187programs must be designed to move them towards increasingindependence in order to build self-esteem and address concernsabout dependency on social assistance.Since the young women's living situations and false beliefsor poor understanding of risks for pregnancy contributed to theirvulnerability, nurses in practice settings such as youth clinics orschools must assist young women to realistically assess their risksfor pregnancy. As well, nurses should help young women toassess their safety concerns when they are in abusiverelationships. Nurses could address these concerns in individualcounseling sessions or small group discussions.The young women wanted help to provide safe environmentsfor their babies. They asked for assistance from their familiesand social programs. Nurses should make referrals for teenagersto adolescent pregnancy programs. Nurses should also work withsocial workers to ensure that young women's and their children'sneeds for safe living situations are addressed, this may includesafety in their own homes.High levels of ambivalence when suspecting pregnancy andsubsequent denial challenges nurses to acknowledge young womenwho deny their pregnancies. This finding is supported by Harveyand Faber (1993) who found that a significant barrier to obtainingprenatal care was a woman's ambivalent feelings about herpregnancy. Nurses need to assist young women to confirm theirCHAPTER FIVE188pregnancies by acknowledging their symptoms and by encouragingthem to access prenatal programs and services.Since the young women's ambivalence increased when theyfelt rejected, nurses also need to provide young women withassistance to tell their families, boyfriends, or friends that theyare pregnant. It would be helpful for nurses to review strategiesfor telling others with pregnant teenagers, perhaps throughrole-playing. Nurses should also help pregnant adolescents togain skills for decision-making for pregnancy resolution.Because the young women identified families and especiallytheir own mothers as important sources of emotional support,nurses need to look at ways these relationships can be supportedand enhanced. Lederman (1991) has suggested that group therapythat includes both adolescent females and their mothers iseffective in preventing unplanned pregnancies. Family counselingor support groups could also be used to offer support to familiesso that optimal family relationships could be facilitated. Thesupport to the families should address concerns of individualmembers and the family as a unit, as well as effectivecommunication patterns.Smith (1991) suggested clinical interventions that impose adifferent model for mothering than adolescents' families' beliefsmay undermine the resources and skills of adolescents' families forsupporting their daughters in the role of mother. Nurses need toCHAPTER FIVE189collect data about the family's perceptions about mothering, andvalidate their impressions with families. Clinical interventions thatare consistent with the family's beliefs are more likely to be seenas supportive and accepted. As well, Wilkerson (1991b) noted thatadolescents learn patterns of communication for meeting theirneeds in their families of origin. These patterns of communicationcan either assist or hinder the adolescent in meeting her needs.Nurses could be involved in sensitively offering interventions thatbuild on the current communication skills of adolescents' and/orfamilies' to make them more effective.Some of the young women in this study mentioned that theirdecisions to carry the pregnancy to term were influenced by theirbeliefs that abortion was not an option, or by a prior abortion.Some of their families had made decisions for them to have anabortion during a previous pregnancy. Nurses must recognizethat, if adolescents are not allowed to make decisions forpregnancy resolution (i. e., a parent tells them what to do), asubsequent pregnancy resolution experience will not be addressedwith the necessary decision-making skills. As well, subsequentexperiences may be influenced by unresolved feelings, or negativeperceptions from a previous experience.Nurses can assist young women in developingdecision-making skills by working with them and their parents.The parents' concerns for the best interests of their daughtersCHAPTER FIVE190needs to be recognized. But, parents must also understand theimportance of their daughters being allowed to participate in thedecision so that they gain decision-making skills and takeresponsibility for decisions for contraception and pregnancyresolution.Some of the young women in this study felt that thepregnancy experience had allowed their thinking anddecision-making to mature. Viewing the pregnancy experience asa way to become mature may make pregnancy appear a viablealternative for changing a young woman's life to a more positivecourse. This concept is important for nurses who work withadolescents at risk for pregnancy and pregnant adolescents.Nurses often assume this is a negative experience, and thesefindings provide direction as to how these young women can besupported. Where an adolescent expresses a desire to change,interventions need to work specifically toward achievingdevelopmental tasks that will prepare her to develop skills forparenting. Interventions that are aimed at helping young womenwho are pregnant develop as adolescents, will simultaneouslysupport their abilities and confidence to take on the maternal role.Some young women also indicated that their pregnancies didnot make them adults; they still wanted to engage in adolescentbehaviors, for example, hanging out with their friends. Animportant consideration for nurses working with adolescents isCHAPTER FIVE191identification of conflict between their desire to maintainadolescent behaviors and accepting adult parentingresponsibilities. Acknowledging their conflicts might assist youngwomen to deal with their ambivalence.Because of their dysfunctional families and having spenttime living on the street or with their boyfriends, these youngwomen were living in less than ideal situations. Consequentlytheir choices were affected. The challenge for nurses is toempower these young women to develop healthy behaviors in thecontext of their own living situations. These young womenrequired ongoing support during their pregnancies and parenting.Support over a long period of time with consistent caregivers canenhance young women's abilities to be effective, confident mothers.Stevens and Hall (1992) pointed out that people living in"health damaging" conditions (unsafe physical surroundings,economic impoverishment, and oppressive social arrangements) mayidentify different priorities than community health nurses. "It isnot nurses' responsibility to think for others or to mandate theiractions. We must let go of 'ideal' notions of health that are notrelevant to people's everyday lives" (Stevens & Hall, 1992, p. 5).Young women should be involved in identifying their own needs.This would reinforce the nurses' respect for young women andconsequently encourage them to be more open to care and advice.In such an environment of care-giving, nurses would be moreCHAPTER FIVE192likely to note what the young women's interests were and whenthey were ready to learn.The findings indicated that the young women valuedinteractions with others who were caring, and who offeredencouragement and support. Some of the young women indicatedthat they wanted to hear advice that was supportive, but ifothers offered advice that was not supportive they would ignoreit. The young women viewed their pregnancies as a positiveinfluence in their lives, and were optimistic about their futures.In order to help these adolescents, nurses can gain their trust.Hardy and Zabin (1991) noted that staff who offered services toteens needed to build relationships of caring, confidence, andtrust so they could help young people gain the skills they needfor their futures.It is important that health professionals respect a youngwoman's beliefs and values and avoid imposing their own values ifinterventions are to be successful. These young women hadengaged in many risk-taking behaviors (e. g., use of street drugsand alcohol, and unprotected sexual intercourse). Practitionerswho examine their own beliefs and values, especially when workingwith adolescents living in disadvantaged situations, will be moreeffective. Mercer (1991) noted that health professionals mustrespect a young woman's and her family's values if interventionsare to be successful, but at the same time nurses need to offerCHAPTER FIVE193support and facilitate healthy behaviors. This may create someethical dilemmas for nurses.The young women who were interviewed initially wantedtheir boyfriends involved in their pregnancy experiences. Theywanted them to attend their prenatal classes, and to support themduring labor. There is a need to involve the male partner morein the pregnancy experience. Involving men in the prenatal careof their partners would enable them to gain skills for supportingtheir partners and preparation for parenting. Support of thisidea is found in the literature by Wilkerson (1991a) who states:"Nurses should assess the nature of the pregnant adolescent'srelationship with the father of her infant. Attempts should bemade to incorporate his support into her plan of care wheneverappropriate" (p. 127).Many young women in this study had partners who weremuch older than themselves; they chose not to remain in theirrelationships, but to bear and raise their children alone. Hardyet al. (1989) found that men who father children of youngadolescents are in poor financial situations themselves, and couldnot provide a stable, independent home, even if they wanted to.Nurses must acknowledge the possibility of sexual abuse beingassociated with older partners. Butler and Burton (1990)conducted an exploratory study with young rural mothers who hadbeen pregnant as teenagers and found that childhood sexual abuseCHAPTER FIVE194was linked to some adolescent pregnancies. Childhood sexualabuse was not explored with the young women in this study, butnurses need to be cognizant that childhood sexual abuse may be afactor in some adolescents' pregnancies.Although none of the young women mentioned sexual abusein their relationships, one young woman did mention that she wasphysically abused by her boyfriend as the pregnancy progressed.Nurses need to be aware of the potential for abuse with thisvulnerable population and refer to agencies for battered women.Nurses can also assist young women in evaluating the positive andnegative aspects of their relationships. Parker and McFarlane(1991) suggested that nurses should assist women to gainproblem-solving and decision-making skills so that they can leavea relationship, or to recognize imminent danger to their own ortheir child's safety.The young women in this study wanted to be respected fortheir knowledge and skills, and to be able to find out things forthemselves. The phases of adolescent pregnancy as a life changeevent indicated that the young women's ambivalence decreasedwhen they felt supported, thus, enabling them to learn new thingsabout pregnancy and parenting. Consequently, nurses whodemonstrate respect and support for adolescent's existingknowledge and skills will offer opportunities to learn based on theyoung women's individual learning needs. Positive parentingCHAPTER FIVE195behaviors can be modeled by nurses. Contact with a consistentcaregiver would allow the young woman to develop a relationshipwhere she would feel comfortable asking for advice, and the nursewould be able to observe changes in behavior, consistent withpositive parenting, over time.Many of these young women had spent time living on thestreet, nurses need to offer services in clinics that are accessibleand in locations frequented by adolescents. Storefront clinicsthat offer contraception, sexually transmitted disease treatment,and prenatal care have advantages because they are accessible toadolescents whether or not they attend school.Nurses can recognize that adolescents' interactions withtheir peers may change during their pregnancies. Although theirpeers' approval was important to the young women in this studyprior to their pregnancies, as their pregnancies progressed theyoung women only maintained contact if they felt their friendswere supportive. After the birth of their babies, they placed lessemphasis on their peers' approval. By recognizing how responsesto peers could change, nurses could assist adolescents to buildsupportive networks. This information assists nurses to use peerinteraction judiciously to assist young women to meet their needsfor approval and belonging.Nurses need to recognize that if young women associatesocial assistance with a negative influence in their lives, they mayCHAPTER FIVE196not be willing to use social assistance until they have exploredother options. This negative perception of social assistance maycause young women to delay seeking health care services.It was difficult for the young women to imagine what itwould be like to become a mother and what responsibilities eachphase of adolescent pregnancy entailed. The framework ofadolescent pregnancy as a life change event provides the nursewith direction to collect data in relation to a young woman's homeenvironment, relationships, life experiences, and their cognitiveabilities. As well, it provides some anticipatory guidance aboutthe phases of the process and coping strategies.The young women expressed desires to be good mothers,and wanted help as they took on the mothering role.Acknowledging the young women's strong desires to be goodmothers and their prior experience with child care would providethe young women with recognition and increased self-worth whiledecreasing their ambivalence. In addition, young women might bemore receptive to specific information about pregnancy andmothering.The young women in this study did not think they wereoverwhelmed by the information that was given to them aboutpregnancy. They may have been unwilling to admit they wereoverwhelmed, or the information that was given to them may havedecreased their ambivalence. This has implications for designingCHAPTER FIVE197programs that capture the interest of pregnant adolescents andthat can decrease their ambivalence and support them asknowledgeable capable parents.These young women indicated a greater interest in pursuingeducation following confirmation of their pregnancies. Programsthat enable young women to finish their schooling even thoughthey become pregnant can increase their self-esteem and allowthem to achieve vocational training or a career. Both factors areimportant for decreasing pregnant and parenting adolescent'srisks for poverty and dependence on social assistance.The young women in this study were participating inprograms for pregnant teenagers. They found the programshelped them adjust to their bodily changes, prepare for labor, andto care for their babies after their deliveries.Programs that begin in pregnancy and continue after thebirth can incorporate role modeling that would assist young womento meet both their adolescent and maternal developmental tasks.At the same time, these programs can offer adolescents asupportive environment for dealing with their conflicts betweenadolescent and pregnancy developmental tasks. Fleming, Munton,Clarke, and Strauss (1993) noted that by recognizing adolescentmothers' needs for respect and recognition of their positiveparenting behaviors, nurses can foster parental and childdevelopment.CHAPTER FIVE198Emphasis needs to be given to working collaboratively withother health care professionals and social agencies in thecommunity to support pregnant adolescents in their changedlifestyles. Reedy (1991) acknowledged that social workers canassist with home evaluations and investigations of abuse, as wellas connecting young women with community agencies. Mercer(1991) taking a broader view of adolescent pregnancy in thecommunity, proposed that a multidisciplinary team approach,supportive networks in the community, and funding are necessaryif changes are to be effected. Nurses can make referrals toprograms that address adolescents' learning needs for pregnancyand parenting. As well, there are numerous settings in whichnurses can participate as members of multidisciplinary teamsoffering services to adolescents.The young women in this study mentioned they did not wantto get pregnant again for a long time. They wanted to achievesome of their other developmental tasks such as education andcareer or vocational goals. They planned to use contraception orabstinence. Abstinence may be an unrealistic method to prevent afuture pregnancy if a young woman is still in a relationship orunder pressure to resume one. Early in the postpartum periodwould be a prime time to explore the use of contraceptive methodswith young women, because of their receptive attitudes. Thenurse could offer information about several methods, andCHAPTER FIVE199encourage the young women to verbalize their own feelings aboutthe different methods. Discussing contraceptive options wouldprovide young women with an opportunity to clarify their values.It is important to recognize that young teens often need supportin using a method, whether it be review of how to use themethod, or possibly an offer to try something different. Byfollowing up at regular intervals, the nurse is able to answerquestions and offer emotional support.This study also found that the young women assumedresponsibility for contraception in their relationships. Nursesneed to acknowledge that reality when they counsel young women.The counseling should include how to talk with, and involvepartners in the responsibility for preventing pregnancy. This isparticularly challenging area for nurses to facilitate youngwomen's assertive behaviors, because recent research indicatesthat young men who have been responsible for a previouspregnancy report it enhanced their male self-esteem, and wereless likely to use effective contraception (Marsiglio, 1993).Furthermore, vulnerable young women are often not assertivewhen discussing contraception with their boyfriends.The findings of this study add to the research basedknowledge for planning nursing care of pregnant adolescents.Implications for nursing education follow from this discussion.CHAPTER FIVE200EducationNursing educators teaching about adolescent pregnancy aredirected to use an eclectic model that integrates knowledge from avariety of fields. The findings indicated numerous socioculturaland familial factors influenced the young women's risks forpregnancy and their decisions to keep and raise their children.These factors included: the reactions of their families to theirpregnancies, living in single parent families, prior life experiencessuch as having been abused or running away from home andliving on the street, problems with street drugs and alcohol,having older men for boyfriends, and the support or lack ofsupport they received for coping with pregnancy and parenting.Nursing educators and their students need to be aware thatsome young women have dysfunctional families, and these youngwomen view their pregnancies as a positive life changing eventthat gives them a sense of hope and optimism. Hope and optimismare usually conspicuously absent from discussions aboutadolescent pregnancy.Ambivalence is a concept that is not often discussed inrelation to adolescent pregnancy and parenting. Ambivalenceinfluenced the young women's coping strategies by delaying theirseeking of prenatal care, allowing continued risk-taking behaviorsin the early prenatal period, and preventing them informingothers. In addition, levels of ambivalence increased whenCHAPTER FIVE201rejection from family, boyfriends, or friends occurred.Ambivalence was linked to decreases in self-esteem and theserelationships should be explored with students. The relationshipbetween limited life experiences and increased ambivalence aboutpregnancy and parenting must be appreciated by educators andtheir students. Particularly, this relationship must be explored inlight of strong desires to be good mothers and to valueinteractions with others who were caring and supportive.Students can be made aware of adolescents' needs to remain ateenager and to maintain their teen behaviors with peers. Inaddition, there is a possibility that relationships with peers mayvary and some young women may not want contact with peers whoare not supportive of their pregnancy, or parenting after thebirth. These concepts provide educators and students with amore complete understanding of adolescent pregnancy.Some young women can have older men for partners, whichcan make them vulnerable to abuse. Students can relate youngwomen leaving their partners and deciding to gestate and raisetheir children alone, to their needs for safety. They are also,however, at risk for living in poverty. Case studies would be aneffective educational tool, as they would allow students to gain anunderstanding of the multiple factors that influence a youngwoman's experience of pregnancy.CHAPTER FIVE202Also of importance to educators is preparing nurses atadvanced levels who understand public policy so that they areable to work with community leaders to develop services andprograms for pregnant and parenting teens. Norr (1991) urgednurse educators to prepare nurses who understand the importanceof community-based nursing and know how to work withcommunity leaders to develop programs that address the needs ofpregnant adolescents.Agencies that employ nurses to work with adolescents couldoffer specific orientation programs. Such programs could addresstopics such as adolescent decision-making, counseling skills forworking with adolescents and their parents, and services to whichreferrals can be made for adolescents who need support duringpregnancy and parenting, or who have experienced abuse. Aswell, staff nurses could be encouraged to attend workshops andinservice programs to up-date their knowledge base, includinginformation reflective of the findings of this study. This idea issupported in the literature by O'Sullivan (1991) who recommendedthat nurses who work with pregnant and parenting adolescentsshould attend conferences to keep themselves professionally up todate and abreast of new developments.Since nurses that practice community health are in keypositions to advocate for community support and the developmentof programs for adolescents during pregnancy and parenting,CHAPTER FIVE203attention needs to be given to these nurses' preparation.Considering, that this study found the young women's socialenvironments influenced both their risks for and experiences ofpregnancy, it behooves nurses to understand how the environmentinfluences adolescents' decisions affecting sexuality andpregnancy. Morgan and Barden (1985) suggested that communityhealth nurses delivering care to adolescents need an orientationthat provides information on: adolescent growth and development,antepartal and postpartal care, environmental influences on health,and community referral sources for problems that are beyond thenurses' immediate scope.Nurses in educational settings are in key positions to carryout research on adolescent pregnancy and to influence nurses whowork directly with adolescents. The next section discussesimplications for nursing research.ResearchThe phenomenological method has been useful for developingknowledge about the perspective of pregnant teens fromdysfunctional families. It is important to realize the difficultiesfor researchers working with this group. Mercer (1991) notedthat attrition of subjects is a problem when studying adolescentpregnancy: "we need to develop more critical ways of capturingthose incidents and situations that contribute to attrition" (p.CHAPTER FIVE204273). In this study, the researcher found the young women weredifficult to access due to their age and problems with obtainingconsent, and they moved frequently during the study.By coincidence, several of the young women had run awayfrom home and spent time living on the streets. Furtherqualitative research with young women who have lived in unsafeenvironments needs to be done to expand understanding of theirexperiences. What are their needs? How do they access services?How can their needs be met?It would appear from this study's findings thatdisadvantaged adolescents view themselves differently from sameage teenagers because of their life experiences. As well, furtherlongitudinal research should be done with adolescents fromdysfunctional families or unsafe living conditions who are mothers.Does their hope and optimism continue? If so, how does it enablethem to be capable parents? What other factors are necessary?The young women talked about how their relationships withtheir mothers changed as their pregnancies progressed. This wasa relationship that they valued, because it provided them withemotional support, decreased their ambivalence, and increasedtheir self-esteem. Further research needs to examine how themother-daughter relationship can be supported and enhanced.How do pregnant adolescents and their mothers perceive theirCHAPTER FIVE205relationships? What interactions are effective in helping them tomeet their needs? How can these interactions be enhanced?The young women valued the support significant othersoffered to them during their pregnandea and in the immediatepostpartum period. How are supportive relationships within thefamily, such as with fathers, foster parents, siblings, andextended family members like grandparents and aunts used by theyoung women? Anderson (1991) and Smith (1991) also called forfurther research on family relationships. Anderson (1991)suggested that more research is needed in order to understandthe role of the family in adolescent pregnancy, because the familymay contribute to both the problem and the solution. Smith (1991)suggested that health professionals who lack an understanding ofthe supportive relationships within the family sometimes devaluethe caring practices of the family; practices which could supportthe adolescent taking on the role of mother.The young women's perceptions of their relationships withboyfriends changed as their pregnancies progressed. Furtherresearch with young women could assist nurses to identifypregnant adolescents who will require support with maintaining orterminating these relationships. What are pregnant adolescents'perceptions of relationships that end during pregnancy? Whattypes of relationships do parenting adolescents seek?CHAPTER FIVE206This study identified some of the young women's partnersas older men. More research is needed to understand thispopulation. What are the characteristics of this population? Whatare their attitudes towards adolescent pregnancy? This researchwill require innovative approaches as Hardy et al. (1989) notedthat this is a difficult group to access.Although the concept of intimacy was not explored in-depthin this study, it is an area that needs to be studied to identify ifthe young women and their partners were seeking intimacy forthe same reasons. Some of the young women in this study becameinvolved in relationships with older men when they ran away fromhome and the men offered them a place to live. Oz and Fine(1988) made a similar observation: "The family problems of theteen mothers, apparently having lead to school problems andassociation with troubled males, may have allowed the emergenceof a lifestyle facilitating more frequent sexual encounters"(p. 259). How do disadvantaged young women meet their needsfor intimacy? Do these intimacy needs get incorporated underneeds for safety and shelter?Research also needs to explore intimacy in young women'srelationships with parents, and the association of intimacy withrisk for pregnancy. Some of the young women indicated that theyfelt a lack of caring in their relationships with their parents. Ozet al. (1992b) suggest that pregnant female adolescents who areCHAPTER FIVE207trying to work on the developmental tasks of autonomy andindependence in relationships with males of their own age, ratherthan parents, may have difficulty developing healthy intimaterelationships. Therefore exploration of intimacy between youngwomen and young men is important. How do young women andyoung men define their needs for intimacy? Are their needs thesame? If different, how are they different? This informationcould be used to assist both young women and men in decisionsregarding sexual activity, contraception, and pregnancy resolution.Perceptions of intimacy, also have implications foridentifying young women who are at risk for sexual coercion orabuse. Boyer and Fine (1992) found that physical maltreatmentand sexual victimization influence the adolescent's developmentalprocesses, and consequently their decision-making forcontraception and pregnancy. They suggest that many youngwomen who become sexually active and pregnant before theirpeers, despite the options for contraception available to them,have not been adequately understood (Boyer & Fine, 1992).Further research with vulnerable adolescents in relation toachieving their needs for intimacy could lead to a betterunderstanding of their risks for pregnancy.The young women's discussions in this study suggested thattheir cognitive thinking and decision-making progressed duringtheir pregnancies. Middle adolescents develop cognitively andCHAPTER FIVE208physically at different rates whether they are pregnant or not.Orr et al. (1988) suggested that assessing cognitive developmentwithin the context of physical maturation may be misleading, ascognitive and physical maturation occur at different rates.Further research is needed to identify how cognitive developmentinfluences decision-making for pregnancy resolution and howyoung women's cognitive development is influenced by their needto make decisions about pregnancy. Also, how cognitivedevelopment influences future decision-making re: sexual activity,contraception, and pregnancy resolution. How does cognitivedevelopment influence future decision-making? How does the needto make decisions about pregnancy influence cognitivedevelopment? Miller and Paikoff (1992) suggested that research isneeded to link adolescent social and cognitive growth toadolescents' social and sexual development. The young women inthis study indicated that their social environments influencedtheir development and their perceptions of their pregnancyexperiences. What is the relationship between pregnantadolescents' social environment and cognitive development?While the issue of child care and fathers applying forcustody was not explored in this study, it is an area that needsto be examined more closely. Is there a link between youngwomen not wanting to place their children in day-care facilitiesand fathers threatening to apply for custody? Because some ofCHAPTER FIVE209the fathers of their children were older than themselves, thepossibility of exploitation needs to be examined. What are theattitudes of young women toward day-care centers or other childcare facilities? There may be a link between their unwillingnessto place their children in day-care and fear that their partnerswill exploit or harm their children.While the findings from this study add to nursing'sunderstanding of adolescent pregnancy, they have also raised newquestions for research. The next section further expands on thefindings of this study, by presenting implications for publicpolicy.Public PolicyTopics in this section are included under the separateheading of public policy because they are political activities inwhich nurses must become involved in as the health care systemevolves in the 1990s. Anderson and McFarlane (1988) describedpublic policy as a planned course of action taken to addressissues that involves four stages: "the recognition and definition ofa problem, the development of programs and allocation ofresources to address the problem, implementation of the programs,and evaluation of the impact of the programs" (p. 102).Findings from this study indicated the young women viewedtheir pregnancies and the expected babies with hope and optimism.CHAPTER FIVE210It behooves nurses to educate other health care professionals toacknowledge young women's hope and optimism, and find ways toassist adolescents with their pregnancy experiences; after all, theconsequences for unmet needs are great for both the adolescentsand their infants.Many of the young women in this study had spent timeliving on the street. This has implications for where nurses offertheir services. Street front clinics or roving vans staffed withhealth professionals willing to understand the multiple problemsthese young women face in their lives must be funded. Suchclinics are accessible to youth and provide contact with familiarcaregivers, which is important for building trusting relationships.This approach would enable teenagers to access information onsexuality, contraception, and other health concerns in anonthreatening environment. It would also provide a place toaccess counseling and teaching during pregnancy, and possiblyencourage early prenatal care.Nurses need to advocate for programs that assistdisadvantaged adolescents who are pregnant and parenting. Inorder for young women to pursue their "new life course" theyneed support and services for themselves and their children,which promote normal growth and development, and encouragepositive parenting behaviors. Anderson and McFarlane (1988)defined advocacy as presenting the case of another, based onCHAPTER FIVE211awareness, knowledge, and sensitivity to the unique needs of theindividual or community. Several authors have acknowledged therole of nurses as an advocate for teens in their communities tolobby for programs (Mercer, 1991; Oz et al., 1992b; Rothenberg &Sedhom, 1991; Swenson, Oakley, Swanson, & Marcy, 1991)."Nursing intervention at the community level includes: workingwith community leaders as an advocate for youth to discuss theproblem [of adolescent pregnancy] . . . and lobbying politicalleaders to make necessary policies and appropriations of funds"(Mercer, 1991, p. 272). Swenson et al. (1991) noted that communityhealth nurses as primary care providers of reproductive healthservices for adolescents, are in key positions to act as advocatesfor services for pregnant and parenting adolescents.Nurses need to be aware of these young women's increasedneeds for food, shelter, emotional support, and sometimes legal aid.Poverty must be reduced if programs are to ameliorate thenegative consequences of adolescent pregnancy. Nurses can workwith community leaders to plan for and obtain funding to meet theinitial needs of adolescent mothers.Nurses need to advocate for programs that improve thechild-rearing skills and confidence of adolescents during theirpregnancies and the years following. Fleming et al. (1993) foundthat nurses were more effective in promoting parental and childCHAPTER FIVE212development when they praised positive parenting behaviors, thusenabling the adolescents to feel a sense of accomplishment.Nurses also need to advocate for programs that supportyoung women living in disadvantaged situations in their roles asmothers, by allowing them to finish their schooling. Being unableto complete their schooling, is linked to living in poverty and aneed for social assistance by the young women and their children.During the interviews the young women talked about anegative perception of being on social assistance. This perceptionhas implications for how adolescents access services, and needs tobe recognized when health care professionals develop and offerprograms and services to adolescents and their families. Programsand services that offer support and allow for gradualindependence could make social assistance more acceptable forboth pregnant adolescents and policy makers.Nurses also need to advocate to increase the public'sawareness of the incidence of abuse in this population. Supportgroups and counseling services for young women who have beenphysically or sexually abused must be made accessible. Raines(1991) also acknowledged that nurses need to advocate to increasethe public's awareness of the need for services for adolescentswho are victims of abuse.There is a great need to develop programs in the communitythat offer support to families that have problems within theirCHAPTER FIVE213family unit. Although some of these young women had run awayfrom home, they also went back to their families when theyexperienced a crisis. Nurses, who have knowledge of growth anddevelopment, family, and maternal-child health, need to advocatefor services that support these families in their coping on aday-to-day basis.In addition, nurses need to collect evaluation data onprograms and services that are effective in helping adolescents tomeet their needs during their pregnancy and parentingexperiences. This information would enable the health care systemto more effectively meet the needs of pregnant and parentingadolescents. Without data indicating effectiveness there will be nofunding for these programs. As well this information could assistcommunities to help adolescents channel their energy, hope, andoptimism into becoming knowledgeable capable parents.In conclusion, this study described the female adolescent'sexperience of pregnancy, which involved experiencingsimultaneously the developmental tasks of adolescence andpregnancy. Ambivalence was a dominant theme which occurredthroughout the pregnancy experience. Pregnancy was seen as alife changing event that occurred in five distinct phases:(a) suspecting the pregnancy, (b) confirming the pregnancy,(c) making decisions about the pregnancy, (d) living the reality ofpregnancy, and (e) experiencing a changed life. The descriptionCHAPTER FIVE214validated previous research, which acknowledged that growth anddevelopment are factors in adolescent's decision-making regardingsexual activity and resolution of pregnancy. Adolescents'pregnancy experiences were influenced by personal, social, andenvironmental factors. Pregnancy and the expected child providedthese disadvantaged adolescents with hope and optimism, whichcreated a sense of achievement and increased their self-esteem.Findings from this study add to the profession's knowledge aboutfemale adolescents from unstable family situations who becomepregnant. This study has provided direction for nursing practice,education, research, and public policy.REFERENCESAdams, B. N. (1983). 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I am a graduate student in theMaster of Science in Nursing program at the University of BritishColumbia School of Nursing. I would like your cooperation inidentifying potential subjects, for a study I am conductingentitled, The Adolescent Female's Experience of Pregnancy, as apartial requirement of my graduate education.The purpose of this study is to examine the experience ofadolescent females who are pregnant. This study is not concernedwith evaluating care, but with determining the client's perceptionsof their pregnancy experience.Understanding how the adolescent female describes herpregnancy can be beneficial for the following reasons: (a) providecurrent information regarding the pregnancy experience for agroup of adolescents in Vancouver in 1991, (b) increaseunderstanding of why adolescents do or do not access services,and (c) provide information from which prenatal programs can bedesigned to address the identified concerns of the pregnantadolescent.In order to determine the female adolescent's perception ofthe pregnancy experience, information will be obtained throughinterviews. Eight to twelve adolescents will be selected forinterviewing based on the following criteria: (a) in their thirdtrimester (i. e., 33 to 40 weeks gestation), (b) able to speak andread English, (c) 13 to 16 years of age, (d) unmarried, and(e) currently planning to keep the baby.The researcher will use an interview format designed todiscover the adolescent's perceptions of her pregnancy experience.Each participant will be interviewed two to three times. Theinterview will last approximately 45 minutes, and will be taperecorded. The participants will be informed that theirparticipation is voluntary, refusal to participate or a decision towithdraw from the study, or refusing to answer any question willnot jeopardize their care. The true identity of the participantswill be coded, so that their true identity will be known only bythe researcher.228Appendix A229If you have any questions regarding the study, pleasecontact me, or my faculty supervisor, Anna Marie Hughes.Thank-you for your cooperation.Yours sincerely,Kathryn Banks RN BN Telephone 222 - 8194Anna Marie Hughes RN Ed.D. Telephone 822 - 7437Assistant ProfessorUBC School of NursingAppendix BLetter to Attending PhysicianDear Dr. ^My name is Kathryn Banks. I am a graduate student in theMaster of Science in Nursing program at the University of BritishColumbia School of Nursing. I am conducting a study of thefemale adolescent's experience of pregnancy as a partialrequirement of my graduate education.^, a patient under your care has agreed toparticipate in a nursing research project, The Adolescent Female'sExperience of Pregnancy.The purpose of this study is to examine the experience ofadolescent females who are pregnant. This study is not concernedwith evaluating care, but with determining the client's perceptionsof their pregnancy experience.Understanding how the adolescent female describes herpregnancy can be beneficial for the following reasons: (a) providecurrent information regarding the pregnancy experience for agroup of adolescents in Vancouver in 1991, (b) increaseunderstanding of why adolescents do or do not access services,and (c) provide information from which prenatal programs can bedesigned to address the identified concerns of the pregnantadolescent.In order to determine the female adolescent's perception ofthe pregnancy experience, information will be obtained throughinterviews. Eight to twelve adolescents will be selected forinterviewing based on the following criteria: (a) in their thirdtrimester (i. e., 33 to 40 weeks gestation), (b) able to speak andread English, (c) 13 to 16 years of age, (d) unmarried, and(e) currently planning to keep the baby.The researcher will use an interview format designed todiscover the adolescent's perceptions of her pregnancy experience.Each participant will be interviewed two to three times. Theinterview will last approximately 45 minutes, and will be taperecorded. The participants will be informed that theirparticipation is voluntary, refusal to participate or a decision towithdraw from the study, or refusing to answer any question willnot jeopardize their care. The true identity of the participantswill be coded, so that their true identity will be known only bythe researcher.230If you have any questions regarding the study, pleasecontact me, or my faculty supervisor, Dr. Anna Marie Hughes.Yours sincerely,Kathryn Banks RN BN^Telephone 222 - 8194Anna Marie Hughes RN Ed.D.^Telephone 822 - 7437Assistant ProfessorUBC School of NursingAppendix B231APPENDIX CLetter to ParticipantDearMy name is Kathryn Banks. I am a graduate student in theMaster of Science in Nursing program at the University of BritishColumbia School of Nursing. I would like your help in a studyentitled, The Adolescent Female's Experience of Pregnancy.I want to know about the concerns of adolescent femaleswho are pregnant. I am not intending to evaluate the care youreceive, but I want to know how you view your experience ofbeing pregnant.Understanding how you view your pregnancy will bebeneficial to health professionals for the following reasons:(a) developing an idea of how adolescents who are pregnant feel,(b) assisting in identification of the reasons young women do ordo not access services, and (c) influencing prenatal programs thatare being designed to address the identified concerns of youngwomen.To meet these aims I need to interview you. If you are:(a) in your third trimester (i. e., 33 to 40 weeks gestation),(b) able to speak and read English, (c) 13 to 16 years of age,(d) not married, and (e) currently planning to keep the baby, Iwould be very interested in hearing about your experience.Each interview will last approximately 45 minutes, will betape recorded, and you will be interviewed two to three times.Your participation is voluntary, you can refuse to participate, ordecide to withdraw from the study, or refuse to answer anyquestion without any risk to your care. Your true identity willbe protected by coding, so that your true identity will be knownonly by this investigator. A summary of the information will bereported in a thesis, and possibly published in professionaljournals.If you would like to talk to me about your pregnancy,please call me at the number below, or leave your name andnumber with the clinic nurse.Thank-you for your cooperation.Yours sincerely,Kathryn Banks RN BN Telephone 222 - 8194Anna Marie Hughes RN Ed.D. Telephone 822 - 7437Assistant Professor, Faculty AdvisorUBC School of Nursing232Appendix DClient Consent FormI understand that the purpose of the study, The AdolescentFemale's Experience of Pregnancy, is to identify my concerns, andhow I feel about being a teenager and pregnant.I understand that this study will involve the following:1. The researcher will interview me about my experience forapproximately 45 minutes, on two or three occasions.2. Our conversation will be tape recorded.I understand that my name and any identifying informationwill not be used in the study or revealed. Confidentiality will beensured by the researcher using a code to identify my name. Shewill be the only person who knows my true identity. If theinformation is published, my identity will not be revealed and allinformation will be reported as group, not individual information.I understand that my participation in this study isvoluntary. I may refuse to participate without risk to my care. Imay decide to withdraw from the study or refuse to answer anyquestion at any time without any effect on my future care.I understand that if I have further questions regarding thestudy, I can contact the researcher or her faculty advisor.I acknowledge that I received a copy of this consent form.Dates^Signature of Subject .^Kathryn Banks RN BN^Telephone 222 - 8194ResearcherAnna Marie Hughes RN Ed.D. Telephone 822 - 7437Faculty AdvisorAssistant Professor, UBC School of Nursing233Appendix EParental Consent FormI understand that the purpose of the study, The AdolescentFemale's Experience of Pregnancy, is to identify ^Isconcerns, and how she feels about being a teenager and pregnant.I understand that ^ will be asked to participatein the following ways:1. be interviewed about her experience for approximately 45minutes on two or three occasions.2. such interviews will be tape recorded.I understand that ^'s name and any identifyinginformation will not be used in the study or revealed.Confidentiality will be ensured by the researcher using a code toidentify ^'s name, and she will be the only person whoknows her true identity. If the information is published,^'s identity will not be revealed and all information willbe reported as group, not individual information.I understand that parents are not present during theinterview.I understand that ^'s participation in this studyis voluntary. She may refuse to participate without risk to hercare. She may decide to withdraw from the study or refuse toanswer any question at any time without any effect on futurecare.I understand that if we have further questions regardingthe study, we can contact the researcher or her faculty advisor.I consent / I do not consent to my teenager's participationin this study.I acknowledge that I received a copy of this consent form.Dates^Signature of Parent ^Kathryn Banks RN BN^Telephone 222 - 8194ResearcherAnna Marie Hughes RN Ed.D.^Telephone 822 - 7437Faculty Advisor,Assistant Professor, UBC School of Nursing234Appendix FDemographic Information235Participant's InitialsAgeEthnic GroupGestationLevel of EducationLiving at home?Parent's occupation?Appendix GTrigger Questions1. What is it like for you to be pregnant?2. What are your expectations about your pregnancy?3. How has being pregnant changed your life?4. About what aspects of your pregnancy do you feel happy?5. What are the major difficulties that being pregnant hascaused for you?6. Have you experienced any losses from your pregnancy?7. Have you experienced any gains from your pregnancy?8. What do you feel apprehensive about in regards to yourpregnancy?9. How has your pregnancy affected you physically?10. How has your pregnancy affected you mentally?11. How do you think this will affect your life in the future?236

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