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Family risk factors associated with adolescent pregnancy: study of a group of adolescent girls and their families in Ecuador
JOURNAL OF ADOLESCENT HEALTH 1999;25:166–172
INTERNATIONAL ARTICLE
Family Risk Factors Associated With Adolescent Pregnancy: Study of a Group of Adolescent Girls and Their Families in Ecuador ´ SUSANA GUIJARRO, M.D., JORGE NARANJO, M.D., MONICA PADILLA, M.D., ´ RICHARDO GUTIEREZ, M.D., CRISTINA LAMMERS, M.D., AND ROBERT W. BLUM, M.D., Ph.D.
Purpose: To identify characteristics within the family that were associated with adolescent pregnancy in a group of adolescent girls in Quito, Ecuador. Methods: Of 135 female adolescents (12–19 years of age), 47 were pregnant and seen at the adolescent prenatal care clinic at an inner city hospital in Quito, and 88 were students from schools located within the same geographic area. Family variables were compared for pregnant and nonpregnant adolescents using chi-square, Student’s t-test, and analysis of variance. Results: More nonpregnant adolescents lived with their biological parents when compared with their pregnant peers (p < .002). Pregnant adolescents reported lower mother– daughter and father– daughter communication (p < .02), lesser life satisfaction and happiness in general, and more school and economic difficulties (p < .001). They were less likely to find support for their problems in or outside the family (p < .0001) and showed higher levels of depression and sexual abuse than their nonpregnant peers (68.8% vs. 34.5%, and 14.9% vs. 4.5%, respectively). Nonpregnant adolescents showed higher school performance and expectations regarding school achievement and future perspectives (p < .001). Values From the Fundacion Internacional para in Adolescencia, Quito, Ecuador (S.G., J.N.); Fundacion Internacional para in Adolescencia, Quito, Ecuador (M.P.); UNFPA en Adolescencia, Fundacion Internacional para in Adolescencia, Quito, Ecuador (R.G.); University of Minnesota, Adolescent Health Program, Minneapolis, Minnesota (C.L.); University of Montevideo, Montevideo, Uruguay (C.L.); and Department of Pediatrics, Division of General Pediatrics and Adolescent Health, University of Minnesota, Minneapolis, Minnesota (R.W.B.). Address reprint requests to: Robert W. Blum, M.D., Ph.D., University of Minnesota, Box 721, 420 Delaware Street SE, Minneapolis, MN 55455. Manuscript accepted December 5, 1998. 1054-139X/99/$–see front matter PII S1054-139X(99)00020-8
such as respect for others and religiosity were higher among nonpregnant adolescents (p < .0001). Parental education was lower in the families of pregnant adolescents (p < .05). Among nonpregnant adolescents, both parents worked outside the home (p < .006), whereas mothers of pregnant adolescents usually stayed at home. Conclusion: The current study showed that parental separation or divorce, and poor parent– daughter communication were associated with adolescent pregnancy. Families of nonpregnant adolescents had a higher educational level, and both parents worked to provide financial support to the family in an environment where family authority is shared by both parents. There were also better problem-solving strategies and parent– daughter communication, higher levels of cohesion, connectedness, and life satisfaction in general, and higher future expectations. © Society for Adolescent Medicine, 1999 KEY WORDS: Family Adolescent pregnancy Ecuador
A close relationship exists between family dysfunction and early pregnancy. From a primary prevention perspective, if we could identify the different aspects of family dysfunction, we might be able to identify adolescents at risk of unwanted pregnancy and focus on their families to enhance the protective and diminish the risk factors. In the current study, it was hypothesized that
© Society for Adolescent Medicine, 1999 Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010
August 1999
FAMILY RISK FACTORS
Table 1. Age Distribution of Sample Age (yr) 12 13 14 15 16 17 18 19
167
Study Design and Instrument
% Pregnant (n ⫽ 47)
% Not Pregnant (n ⫽ 88)
4.3 12.8 34.0 34.0 10.6 4.2
9.1 15.9 18.2 17.0 12.5 15.9 10.2 1.1
specific family functioning patterns might be different when families of pregnant adolescents’ were compared with those of nonpregnant peers. The purpose of the current study was to identify the characteristics of the families of two groups of adolescents (pregnant adolescents vs. nonpregnant) using the Pan American Health Organization (PAHO)/ Kellogg survey. This instrument was developed in 1993–1996 by a group of professionals of North, Central, and South America, representing a comprehensive multidisciplinary effort to gather information about family functioning in general and family and adolescent risk and protective factors. The instrument seeks to obtain information about the different levels of family functioning, identify family factors associated with adolescent risk behaviors, and provide valid information to develop appropriate interventions and services and foster further research. Furthermore, the study aimed to determine whether the instrument is valid for use in adolescent health care services and schools throughout Ecuador. If it were, health providers would be able to assess the characteristics of adolescents and their families, and how they function together. Subsequently, this knowledge might allow more specific interventions or prevention programs that better serve families and adolescents.
The adolescents and their families were interviewed separately after obtaining active consent from parents and assent from adolescents, as well as permission from the principal at the school. The adolescent participants completed the survey as a group at school. An interviewer explained each question to the group and remained in the room to help. It took the girls 2 h to complete the survey. The families were interviewed by the same interviewers. Selfadministration was not possible owing to the reading skills of the study sample. The instrument consisted of two questionnaires: one answered by the adolescent, and one answered by the adolescent’s family. The two components of the instrument were developed by a multidisciplinary group of professionals from different countries in the Americas: the United States, Colombia, Chile, Brazil, Argentina, and Costa Rica, sponsored by PAHO/Kellogg in 1993–1996. The instrument was intended to serve as an assessment of the family and the adolescent characteristics, and how they function and interact. The ultimate objective was to identify risk and protective factors that were present within the family that could influence adolescent’s behaviors. In the present study, differences between the families of pregnant and nonpregnant adolescents were the primary focus. The covariates studied included type of family, relationships between the adolescent and her family, problem-solving strategies and authority identified within the family, families’ and adolescents’ resources to solve conflicts, values and beliefs, level of family stresses, connectedness and cohesion, and family transitions. These variables have been defined and scaled in the Family and Adolescent Health Indica-
Methods Study Population The study was composed of a convenience sample of 135 girls living in the city of Quito. Forty-seven were pregnant (ages 14 –19 years) and attending a prenatal care clinic for adolescents, and 88 were nonpregnant students (ages 12–19 years) and enrolled in school (6th to 12th graders) (Table 1). Both groups of girls lived in the same area as the hospital and had a similar socioeconomic background.
Figure 1. Types of Family.
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nonpregnant teens lived with stepfathers at the time of the survey. The average number of family members in the family was 5.6 and 5.1 for pregnant and nonpregnant adolescents, respectively. The average number of siblings among pregnant adolescents was higher than in the families of nonpregnant adolescents. The percentage of middle sisters was significantly higher among pregnant adolescents (p ⬍ .03) (Figure 2). Analysis of the socioeconomic background of the family and educational level of parents showed that 52% of pregnant adolescents had only one family income; this compares with 42% of nonpregnant adolescents from single-income families. The majority of parents of nonpregnant adolescents had a permanent job (p ⬍ .006). On the other hand, fathers of pregnant adolescents worked independently while the mothers stayed at home (Table 2). In general, the educational level of the parents who completed the survey was low; however, it was significantly lower in the group of pregnant adolescents (p ⬍ .05) (Table 3). Both pregnant and nonpregnant adolescents were asked who had authority in the family. There were significant differences, such that nonpregnant teens were more likely to indicate authority as shared between parents, while pregnant teens were much more likely to report either father or mother (usually father) as the central authority (p ⬍ .001) (Figure 3). Family cohesion, connectedness, and working together to solve problems were higher among the nonpregnant adolescent group (p ⬍ .02) (Table 4). Conversely, family problem-solving strategies were lower among the families of pregnant adolescents (p ⬍ .002) (Table 5). While communication between parents was poor in both groups of families (Figure 5), both mother– daughter and father– daughter communication were lower among pregnant adolescents when compared with nonpregnant adolescents (p ⬍
Figure 2. Position of the Adolescent Among Siblings.
tors—Instructions for Use of the Instruments Handbook (1). Statistical Analysis Data were analyzed by a team from the International Adolescent Foundation (FIPA), using Epi Info 6.0. Comparisons were performed between the characteristics of the families of nonpregnant and pregnant adolescents using chi-square, Student t test, and analysis of variance (␣ ⫽ .05) analyses.
Results The average age of pregnant subjects was approximately 16.5 years, while the nonpregnant group was nearly 15 months younger. More nonpregnant adolescents lived with their biological parents at the time of the survey, compared with their pregnant peers (p ⬍ .02) (Figure 1). Seventeen percent of pregnant adolescents and 6.2% of nonpregnant teens lived with stepsiblings, and 8.5% of pregnant and 3.7% of Table 2. Parents’ Employment Status Mother
Father
Occupation of Parents
Pregnant
Not Pregnant
p Value
2
Pregnant
Not Pregnant
p Value
2
Not applicable QHD Regular employment Unstable employment Self-employed Student/disabled/other Retired Unemployed/student/other
4.3 41.3 13.0 6.5 30.4 2.2 2.2 0.0
1.2 16.7 34.5 10.7 32.1 3.6 1.2 0.0
.257 .002 .005 .442 .803 .667 .658 NA
1.29 9.67 7.83 0.59 0.06 0.19 0.20 NA
22.7 0.0 22.7 13.6 36.4 2.3 2.3 2.3
1.3 12.0 40.0 5.3 34.7 4.0 2.7 1.3
.001 .002 .048 .100 .879 .647 .937 .672
16.37 9.24 3.92 2.71 0.02 0.21 0.01 0.18
August 1999
FAMILY RISK FACTORS
169
Table 3. Parental Education Mother Highest Academic Level
Pregnant
Not Pregnant
Primary school Did not complete secondary school Completed secondary school Post– high school Completed post– high school Not sure what the other is
63.8 19.1 6.4 2.1 0.0 2.3
39.8 28.9 10.8 10.8 3.6 2.9
.02). In both groups, parents’ perception of the level of communication with their daughters was higher than reported by the daughters (Figure 4). Regarding seeking help or support outside the family, families of pregnant teens did not ask for help in the community or among relatives, and believed the family could solve the problem by themselves, while families of nonpregnant teens were much more likely to seek nonfamilial assistance (p ⬍ .05) (Figure 5). Pregnant adolescents reported they were less likely to find support or sources of help when they had concerns or problems than their nonpregnant peers (p ⬍ .0001). According to the survey, the primary source of support for both pregnant and nonpregnant adolescents was their parents (74.4% and 72.8%, respectively), followed by siblings (44% and 46%, respectively). Friends and other adults were less important supports for both groups. Nonpregnant adolescents showed higher school performance and higher personal expectations regarding school achievement and future perspectives than pregnant adolescents (p ⬍ .001).
Figure 3. Authority in the Family.
Father p Value
2
.010 .227 .541 .164 .551 1.000
6.69 1.46 0.59 3.54 2.61 0.00
Pregnant
Not Pregnant
p Value
2
67.5 15.0 5.0 5.0 0.0 2.6
38.2 32.9 13.2 11.8 3.9 3.1
.002 .040 .135 .325 .552 1.000
10.01 4.23 1.68 0.86 0.48 0.00
Values such as respect for others and religiosity were higher among nonpregnant adolescents (p ⬍ .0001). In general, pregnant adolescents felt they were less happy than their nonpregnant peers (26% vs. 12%). When comparing life satisfaction and happiness in general, pregnant adolescents and their families scored lower than then nonpregnant adolescents and their families. Deaths within the family, youth school problems, and economic issues were the most important stresses affecting families and teens in both groups. However, these stresses were more prevalent among pregnant teens and their families (p ⬍ .001) (Table 6). Pregnant adolescents showed a higher level of depression and sexual abuse than nonpregnant adolescents (68.8% vs. 34.5%, and 14.9% vs. 4.5%, respectively). Interestingly, none of the adolescents who reported these problems had received specific treatment.
Discussion The family is experiencing deep changes in Ecuador. There is an increasing rate of separation and divorce (2,3), leading to an increasing number of single parent families. Research has shown that early separation of parents and the fact that parents engage in new relationships with new partners are associated with early onset of sexual activity, unwanted pregnancy, and adoption of a more liberal sexual behavior in the adolescent. However, it is not the type of family per se that constitutes a risk factor; rather, it is fewer resources to raise children (2,3). Single-parent families, in general, are more vulnerable to emotional problems and present more difficulties in supervising, monitoring, and setting limits for the adolescents (4). While the dual-parent family predominates as the primary Ecuadorian family structure, this is slowly changing, leading to more egalitarian roles for the female and male partners in the family, but increasing stress on the family as well.
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Table 4. Family Functioning Pregnant
Not Pregnant
Family Functioning
High
Middle
Low
High
Middle
Low
p Value
2
Authority limits Family cohesion Participation in solving problems Family routines
95.7 55.3 36.9 23.4
4.3 31.9 54.3 74.4
0.0 12.8 8.6 2.1
89.8 68.2 56.8 28.4
8.0 29.5 39.8 71.6
2.2 2.3 3.4 0.0
.328 .011 .004 .619
1.62 6.50 8.31 0.25
Today, more women are participating in the workforce, especially in medium and medium/high social classes. This new role of the mother has two main consequences: It adds an additional burden to the working mother, since in Latin society working outside the home does not alter her domestic, caretaker role; and it makes it necessary to review the traditional criteria regarding the meaning and consequences of the presence of the mother at home. Although in general birth rates in Ecuador have diminished from 6.76 in 1964 to 3.61 in 1994, adolescent birth rates have increased or remained at the same level at the most (5–10). Likewise, the current study showed that family size is greater among families of pregnant adolescents. In most families of nonpregnant adolescents, both parents shared not only the responsibility of the financial support of the family, but also the decisionmaking authority as well. Within these families, we found more cohesion, solidarity, and cooperation; all members of the family worked together to solve problems or conflicts. On the other hand, families of pregnant adolescents tended to have only one source of income. The family depended totally on one of its member’s income, who was also the one who held the authority in the family. This tended to be the father. Among pregnant adolescents, the authority within the family is mainly paternal; there is no democratic or balanced authority compared with families of nonpregnant adolescents. Likewise, family cohesion scores were low among pregnant adolescents’ families; thus, if authority is rigid and associated with physical or psychological abuse, a dysfunctional family environment is created (10).
The current pregnancy was not identified as causing family crisis. Rather, dysfunctional communication patterns appear to have predated the pregnancy. Thus, the adolescent might search for connectedness outside the family in an attempt to fulfill her needs. Family communication implies not only transmitting information, but also establishing an environment of negotiation. It is essential to communicate family values, expectations, and role models, and parent– child communication is of utmost importance to facilitate and promote family members’ development. The present study found important differences in family communication between families of pregnant and nonpregnant adolescents. In both groups, communication was better with the mother than father; however, among pregnant girls, communication was even worse with the father. Other studies (9 –11) have suggested that high rates of physical abuse and fear limit father– daughter relationships. As was true for mothers, fathers reported better communication with their daughters than their daughters did with them. The lack of openness of families of pregnant teens to outside assistance may be explained in a number of ways: (a) There are not sufficient community services in place to provide counseling or support to families and/or adolescents. (b) Family counseling and support agencies are not considered useful or important. (c) Pregnant teens still rely on family to assist with problems. (d) Families tend to hide their problems. Not only are there significant differences in families, values and beliefs were found to be different between nonpregnant and pregnant adolescents.
Table 5. Types of Problem-Solving Strategies Pregnant
Not Pregnant
Strategies
High
Low
Total
High
Low
Total
p Value
2
Social support Religious support Professional support Confidence in problem resolution
12.8 12.8 4.2 70.2
87.2 87.2 95.8 8.5
100% 100% 100% 100%
14.8 8.8 6.0 52.7
85.2 91.2 94.0 10.8
100% 100% 100% 100%
.745 .512 1.000 .053
0.11 0.43 0.00 3.74
August 1999
FAMILY RISK FACTORS
Figure 4. Communication.
171
Figure 5. Support Sources for the Adolescent.
Nonpregnant adolescents valued academic achievement more and had higher expectations regarding going to college and finding good jobs. This is consistent with findings in North America and elsewhere (14). Also consistent with findings from other studies was the greater family connectedness reported among nonpregnant teens. Influencing their attitude toward school is the reality that the majority of pregnant adolescents are not enrolled, most likely owing to both school policies and their prepregnancy school performance. In addition, academic achievement of parents was higher in the nonpregnant group of teens.
Limitations of the Study A few factors limit the generalizability of the study. First, the sample was relatively small, with only 47 adolescent females in the pregnant group. This group does not necessarily represent all pregnant young people in Quito, let alone internationally. Second, the comparison group of adolescents were younger, and age alone may affect family dynamics. In addition, some of these young women may themselves become pregnant when they reach the age of
the study group. Finally, given that this is a crosssectional study, directionality and causality cannot be determined. Specifically, we cannot say that certain family dynamics increased the risk of pregnancy. Observed associations may be the result of the influence adolescent pregnancy has on family dynamics.
Conclusions Doubtless, the family is the structural unit of our society, and its appropriate functioning promotes the well-being and development of all its members, including the adolescent. By looking at how the family functions, and ensuring that families, especially the ones most disadvantaged, have resources and supports available, we will be moving toward primary prevention of adverse outcomes among teenagers. The authors acknowledge the assistance of Marjorie Ireland, Ph.D., University of Minnesota, with certain statistical calculations; and Linda Boche and Linda Pratt with manuscript preparation.
Table 6. Adolescent Satisfaction Pregnant
Not Pregnant
Satisfaction
High
Low
Total
High
Low
Total
Life satisfaction Feeling of happiness Satisfaction with work and parent’s employment
44.4 52.2 12.8
8.9 47.8 87.2
100% 100% 100%
44.0 54.0 87.5
0.0 46.0 12.5
100% 100% 100%
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References 1. Pan American Health Organization. Family and adolescent health indicators—instructions for use of the instruments handbook. Washington, DC: Authors 1997. 2. Sarquis C, Zegers B. Familia y Adolescencia: Una nueva dimensio´n en Salud Mental. En: La salud del adolescente en Chile. Chile: Corporacio´n de promocio´n universitaria, 1988. 3. Florenzano R. Risk factors and youth: The role of family and community. J Adolesc Health 1993;14:619 –25. 4. Molina V. Familia. En: Psiquiatrı´a de Toro R, Ye´pez L, eds. Corporacio´n para la investigacio´n en biologı´a. Medellı´n Colombia. 1985:139 –146. 5. Guijarro S, Barreto D, Hidalgo G, et al. Investigacio´n sobre situacio´n socioecono´mica y expectativas generacionales de los adolescentes y jo´venes ecuatorianos: Una visio´n panora´mica. Editorial. A&H. Quito-Ecuador, 1996. 6. International Programs and Population Reference Bureau (PRB). La actividad sexual y la maternidad entre las adolescents en Ame´rica Latina y el Caribe: Riesgos y consecuencias. Virginia Lithograph 1992;4.
JOURNAL OF ADOLESCENT HEALTH Vol. 25, No. 2
7. Breilh J, Granda E, Campan˜a, et al. Deterioro de la vida. Corporacio´n Editora Nacional. 1990;39. 8. CEPAR. Encuesta demogra´fica y de salud materna e infantil. Ecuador (EDEMAIN-94) Gra´ficas Avile´s 1994;45. 9. Monroy A, Morales M, Velasco L. OPS. Fecundidad en la adolescencia. Causas, riesgos y opciones. Cuaderno Te´cnico 1988;12:11. 10. Covarrubias P. En bu´squeda de la familia Chilena. Santiago de Chile: Ediciones Pontificia Universidad Cato´lica de Chile, 1986. 11. Watzlawick P, Helmick J, Jackson D. Teorı´a de la comunicacio´n humana. Barcelona: Editorial Herder; 1986. 12. Fromm E. El arte de amar: Una investigacio´n sobre la naturaleza del amor. Argentina: Paido´s Studio; 1992. 13. Davis S. Embarazo en adolescentes: Clı´nicas pedia´tricas de Norteame´rica. Ginecologı´a y obstetricia en adolescentes, Vol 3; 1989. 14. Resnick MD, Bearman PS, Blum RW, et al. Protecting adolescents from harm: Findings from the National Longitudinal Study on Adolescent Health. JAMA 1997;278:823–32.
INTERNATIONAL ARTICLE
Family Risk Factors Associated With Adolescent Pregnancy: Study of a Group of Adolescent Girls and Their Families in Ecuador ´ SUSANA GUIJARRO, M.D., JORGE NARANJO, M.D., MONICA PADILLA, M.D., ´ RICHARDO GUTIEREZ, M.D., CRISTINA LAMMERS, M.D., AND ROBERT W. BLUM, M.D., Ph.D.
Purpose: To identify characteristics within the family that were associated with adolescent pregnancy in a group of adolescent girls in Quito, Ecuador. Methods: Of 135 female adolescents (12–19 years of age), 47 were pregnant and seen at the adolescent prenatal care clinic at an inner city hospital in Quito, and 88 were students from schools located within the same geographic area. Family variables were compared for pregnant and nonpregnant adolescents using chi-square, Student’s t-test, and analysis of variance. Results: More nonpregnant adolescents lived with their biological parents when compared with their pregnant peers (p < .002). Pregnant adolescents reported lower mother– daughter and father– daughter communication (p < .02), lesser life satisfaction and happiness in general, and more school and economic difficulties (p < .001). They were less likely to find support for their problems in or outside the family (p < .0001) and showed higher levels of depression and sexual abuse than their nonpregnant peers (68.8% vs. 34.5%, and 14.9% vs. 4.5%, respectively). Nonpregnant adolescents showed higher school performance and expectations regarding school achievement and future perspectives (p < .001). Values From the Fundacion Internacional para in Adolescencia, Quito, Ecuador (S.G., J.N.); Fundacion Internacional para in Adolescencia, Quito, Ecuador (M.P.); UNFPA en Adolescencia, Fundacion Internacional para in Adolescencia, Quito, Ecuador (R.G.); University of Minnesota, Adolescent Health Program, Minneapolis, Minnesota (C.L.); University of Montevideo, Montevideo, Uruguay (C.L.); and Department of Pediatrics, Division of General Pediatrics and Adolescent Health, University of Minnesota, Minneapolis, Minnesota (R.W.B.). Address reprint requests to: Robert W. Blum, M.D., Ph.D., University of Minnesota, Box 721, 420 Delaware Street SE, Minneapolis, MN 55455. Manuscript accepted December 5, 1998. 1054-139X/99/$–see front matter PII S1054-139X(99)00020-8
such as respect for others and religiosity were higher among nonpregnant adolescents (p < .0001). Parental education was lower in the families of pregnant adolescents (p < .05). Among nonpregnant adolescents, both parents worked outside the home (p < .006), whereas mothers of pregnant adolescents usually stayed at home. Conclusion: The current study showed that parental separation or divorce, and poor parent– daughter communication were associated with adolescent pregnancy. Families of nonpregnant adolescents had a higher educational level, and both parents worked to provide financial support to the family in an environment where family authority is shared by both parents. There were also better problem-solving strategies and parent– daughter communication, higher levels of cohesion, connectedness, and life satisfaction in general, and higher future expectations. © Society for Adolescent Medicine, 1999 KEY WORDS: Family Adolescent pregnancy Ecuador
A close relationship exists between family dysfunction and early pregnancy. From a primary prevention perspective, if we could identify the different aspects of family dysfunction, we might be able to identify adolescents at risk of unwanted pregnancy and focus on their families to enhance the protective and diminish the risk factors. In the current study, it was hypothesized that
© Society for Adolescent Medicine, 1999 Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010
August 1999
FAMILY RISK FACTORS
Table 1. Age Distribution of Sample Age (yr) 12 13 14 15 16 17 18 19
167
Study Design and Instrument
% Pregnant (n ⫽ 47)
% Not Pregnant (n ⫽ 88)
4.3 12.8 34.0 34.0 10.6 4.2
9.1 15.9 18.2 17.0 12.5 15.9 10.2 1.1
specific family functioning patterns might be different when families of pregnant adolescents’ were compared with those of nonpregnant peers. The purpose of the current study was to identify the characteristics of the families of two groups of adolescents (pregnant adolescents vs. nonpregnant) using the Pan American Health Organization (PAHO)/ Kellogg survey. This instrument was developed in 1993–1996 by a group of professionals of North, Central, and South America, representing a comprehensive multidisciplinary effort to gather information about family functioning in general and family and adolescent risk and protective factors. The instrument seeks to obtain information about the different levels of family functioning, identify family factors associated with adolescent risk behaviors, and provide valid information to develop appropriate interventions and services and foster further research. Furthermore, the study aimed to determine whether the instrument is valid for use in adolescent health care services and schools throughout Ecuador. If it were, health providers would be able to assess the characteristics of adolescents and their families, and how they function together. Subsequently, this knowledge might allow more specific interventions or prevention programs that better serve families and adolescents.
The adolescents and their families were interviewed separately after obtaining active consent from parents and assent from adolescents, as well as permission from the principal at the school. The adolescent participants completed the survey as a group at school. An interviewer explained each question to the group and remained in the room to help. It took the girls 2 h to complete the survey. The families were interviewed by the same interviewers. Selfadministration was not possible owing to the reading skills of the study sample. The instrument consisted of two questionnaires: one answered by the adolescent, and one answered by the adolescent’s family. The two components of the instrument were developed by a multidisciplinary group of professionals from different countries in the Americas: the United States, Colombia, Chile, Brazil, Argentina, and Costa Rica, sponsored by PAHO/Kellogg in 1993–1996. The instrument was intended to serve as an assessment of the family and the adolescent characteristics, and how they function and interact. The ultimate objective was to identify risk and protective factors that were present within the family that could influence adolescent’s behaviors. In the present study, differences between the families of pregnant and nonpregnant adolescents were the primary focus. The covariates studied included type of family, relationships between the adolescent and her family, problem-solving strategies and authority identified within the family, families’ and adolescents’ resources to solve conflicts, values and beliefs, level of family stresses, connectedness and cohesion, and family transitions. These variables have been defined and scaled in the Family and Adolescent Health Indica-
Methods Study Population The study was composed of a convenience sample of 135 girls living in the city of Quito. Forty-seven were pregnant (ages 14 –19 years) and attending a prenatal care clinic for adolescents, and 88 were nonpregnant students (ages 12–19 years) and enrolled in school (6th to 12th graders) (Table 1). Both groups of girls lived in the same area as the hospital and had a similar socioeconomic background.
Figure 1. Types of Family.
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nonpregnant teens lived with stepfathers at the time of the survey. The average number of family members in the family was 5.6 and 5.1 for pregnant and nonpregnant adolescents, respectively. The average number of siblings among pregnant adolescents was higher than in the families of nonpregnant adolescents. The percentage of middle sisters was significantly higher among pregnant adolescents (p ⬍ .03) (Figure 2). Analysis of the socioeconomic background of the family and educational level of parents showed that 52% of pregnant adolescents had only one family income; this compares with 42% of nonpregnant adolescents from single-income families. The majority of parents of nonpregnant adolescents had a permanent job (p ⬍ .006). On the other hand, fathers of pregnant adolescents worked independently while the mothers stayed at home (Table 2). In general, the educational level of the parents who completed the survey was low; however, it was significantly lower in the group of pregnant adolescents (p ⬍ .05) (Table 3). Both pregnant and nonpregnant adolescents were asked who had authority in the family. There were significant differences, such that nonpregnant teens were more likely to indicate authority as shared between parents, while pregnant teens were much more likely to report either father or mother (usually father) as the central authority (p ⬍ .001) (Figure 3). Family cohesion, connectedness, and working together to solve problems were higher among the nonpregnant adolescent group (p ⬍ .02) (Table 4). Conversely, family problem-solving strategies were lower among the families of pregnant adolescents (p ⬍ .002) (Table 5). While communication between parents was poor in both groups of families (Figure 5), both mother– daughter and father– daughter communication were lower among pregnant adolescents when compared with nonpregnant adolescents (p ⬍
Figure 2. Position of the Adolescent Among Siblings.
tors—Instructions for Use of the Instruments Handbook (1). Statistical Analysis Data were analyzed by a team from the International Adolescent Foundation (FIPA), using Epi Info 6.0. Comparisons were performed between the characteristics of the families of nonpregnant and pregnant adolescents using chi-square, Student t test, and analysis of variance (␣ ⫽ .05) analyses.
Results The average age of pregnant subjects was approximately 16.5 years, while the nonpregnant group was nearly 15 months younger. More nonpregnant adolescents lived with their biological parents at the time of the survey, compared with their pregnant peers (p ⬍ .02) (Figure 1). Seventeen percent of pregnant adolescents and 6.2% of nonpregnant teens lived with stepsiblings, and 8.5% of pregnant and 3.7% of Table 2. Parents’ Employment Status Mother
Father
Occupation of Parents
Pregnant
Not Pregnant
p Value
2
Pregnant
Not Pregnant
p Value
2
Not applicable QHD Regular employment Unstable employment Self-employed Student/disabled/other Retired Unemployed/student/other
4.3 41.3 13.0 6.5 30.4 2.2 2.2 0.0
1.2 16.7 34.5 10.7 32.1 3.6 1.2 0.0
.257 .002 .005 .442 .803 .667 .658 NA
1.29 9.67 7.83 0.59 0.06 0.19 0.20 NA
22.7 0.0 22.7 13.6 36.4 2.3 2.3 2.3
1.3 12.0 40.0 5.3 34.7 4.0 2.7 1.3
.001 .002 .048 .100 .879 .647 .937 .672
16.37 9.24 3.92 2.71 0.02 0.21 0.01 0.18
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FAMILY RISK FACTORS
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Table 3. Parental Education Mother Highest Academic Level
Pregnant
Not Pregnant
Primary school Did not complete secondary school Completed secondary school Post– high school Completed post– high school Not sure what the other is
63.8 19.1 6.4 2.1 0.0 2.3
39.8 28.9 10.8 10.8 3.6 2.9
.02). In both groups, parents’ perception of the level of communication with their daughters was higher than reported by the daughters (Figure 4). Regarding seeking help or support outside the family, families of pregnant teens did not ask for help in the community or among relatives, and believed the family could solve the problem by themselves, while families of nonpregnant teens were much more likely to seek nonfamilial assistance (p ⬍ .05) (Figure 5). Pregnant adolescents reported they were less likely to find support or sources of help when they had concerns or problems than their nonpregnant peers (p ⬍ .0001). According to the survey, the primary source of support for both pregnant and nonpregnant adolescents was their parents (74.4% and 72.8%, respectively), followed by siblings (44% and 46%, respectively). Friends and other adults were less important supports for both groups. Nonpregnant adolescents showed higher school performance and higher personal expectations regarding school achievement and future perspectives than pregnant adolescents (p ⬍ .001).
Figure 3. Authority in the Family.
Father p Value
2
.010 .227 .541 .164 .551 1.000
6.69 1.46 0.59 3.54 2.61 0.00
Pregnant
Not Pregnant
p Value
2
67.5 15.0 5.0 5.0 0.0 2.6
38.2 32.9 13.2 11.8 3.9 3.1
.002 .040 .135 .325 .552 1.000
10.01 4.23 1.68 0.86 0.48 0.00
Values such as respect for others and religiosity were higher among nonpregnant adolescents (p ⬍ .0001). In general, pregnant adolescents felt they were less happy than their nonpregnant peers (26% vs. 12%). When comparing life satisfaction and happiness in general, pregnant adolescents and their families scored lower than then nonpregnant adolescents and their families. Deaths within the family, youth school problems, and economic issues were the most important stresses affecting families and teens in both groups. However, these stresses were more prevalent among pregnant teens and their families (p ⬍ .001) (Table 6). Pregnant adolescents showed a higher level of depression and sexual abuse than nonpregnant adolescents (68.8% vs. 34.5%, and 14.9% vs. 4.5%, respectively). Interestingly, none of the adolescents who reported these problems had received specific treatment.
Discussion The family is experiencing deep changes in Ecuador. There is an increasing rate of separation and divorce (2,3), leading to an increasing number of single parent families. Research has shown that early separation of parents and the fact that parents engage in new relationships with new partners are associated with early onset of sexual activity, unwanted pregnancy, and adoption of a more liberal sexual behavior in the adolescent. However, it is not the type of family per se that constitutes a risk factor; rather, it is fewer resources to raise children (2,3). Single-parent families, in general, are more vulnerable to emotional problems and present more difficulties in supervising, monitoring, and setting limits for the adolescents (4). While the dual-parent family predominates as the primary Ecuadorian family structure, this is slowly changing, leading to more egalitarian roles for the female and male partners in the family, but increasing stress on the family as well.
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Table 4. Family Functioning Pregnant
Not Pregnant
Family Functioning
High
Middle
Low
High
Middle
Low
p Value
2
Authority limits Family cohesion Participation in solving problems Family routines
95.7 55.3 36.9 23.4
4.3 31.9 54.3 74.4
0.0 12.8 8.6 2.1
89.8 68.2 56.8 28.4
8.0 29.5 39.8 71.6
2.2 2.3 3.4 0.0
.328 .011 .004 .619
1.62 6.50 8.31 0.25
Today, more women are participating in the workforce, especially in medium and medium/high social classes. This new role of the mother has two main consequences: It adds an additional burden to the working mother, since in Latin society working outside the home does not alter her domestic, caretaker role; and it makes it necessary to review the traditional criteria regarding the meaning and consequences of the presence of the mother at home. Although in general birth rates in Ecuador have diminished from 6.76 in 1964 to 3.61 in 1994, adolescent birth rates have increased or remained at the same level at the most (5–10). Likewise, the current study showed that family size is greater among families of pregnant adolescents. In most families of nonpregnant adolescents, both parents shared not only the responsibility of the financial support of the family, but also the decisionmaking authority as well. Within these families, we found more cohesion, solidarity, and cooperation; all members of the family worked together to solve problems or conflicts. On the other hand, families of pregnant adolescents tended to have only one source of income. The family depended totally on one of its member’s income, who was also the one who held the authority in the family. This tended to be the father. Among pregnant adolescents, the authority within the family is mainly paternal; there is no democratic or balanced authority compared with families of nonpregnant adolescents. Likewise, family cohesion scores were low among pregnant adolescents’ families; thus, if authority is rigid and associated with physical or psychological abuse, a dysfunctional family environment is created (10).
The current pregnancy was not identified as causing family crisis. Rather, dysfunctional communication patterns appear to have predated the pregnancy. Thus, the adolescent might search for connectedness outside the family in an attempt to fulfill her needs. Family communication implies not only transmitting information, but also establishing an environment of negotiation. It is essential to communicate family values, expectations, and role models, and parent– child communication is of utmost importance to facilitate and promote family members’ development. The present study found important differences in family communication between families of pregnant and nonpregnant adolescents. In both groups, communication was better with the mother than father; however, among pregnant girls, communication was even worse with the father. Other studies (9 –11) have suggested that high rates of physical abuse and fear limit father– daughter relationships. As was true for mothers, fathers reported better communication with their daughters than their daughters did with them. The lack of openness of families of pregnant teens to outside assistance may be explained in a number of ways: (a) There are not sufficient community services in place to provide counseling or support to families and/or adolescents. (b) Family counseling and support agencies are not considered useful or important. (c) Pregnant teens still rely on family to assist with problems. (d) Families tend to hide their problems. Not only are there significant differences in families, values and beliefs were found to be different between nonpregnant and pregnant adolescents.
Table 5. Types of Problem-Solving Strategies Pregnant
Not Pregnant
Strategies
High
Low
Total
High
Low
Total
p Value
2
Social support Religious support Professional support Confidence in problem resolution
12.8 12.8 4.2 70.2
87.2 87.2 95.8 8.5
100% 100% 100% 100%
14.8 8.8 6.0 52.7
85.2 91.2 94.0 10.8
100% 100% 100% 100%
.745 .512 1.000 .053
0.11 0.43 0.00 3.74
August 1999
FAMILY RISK FACTORS
Figure 4. Communication.
171
Figure 5. Support Sources for the Adolescent.
Nonpregnant adolescents valued academic achievement more and had higher expectations regarding going to college and finding good jobs. This is consistent with findings in North America and elsewhere (14). Also consistent with findings from other studies was the greater family connectedness reported among nonpregnant teens. Influencing their attitude toward school is the reality that the majority of pregnant adolescents are not enrolled, most likely owing to both school policies and their prepregnancy school performance. In addition, academic achievement of parents was higher in the nonpregnant group of teens.
Limitations of the Study A few factors limit the generalizability of the study. First, the sample was relatively small, with only 47 adolescent females in the pregnant group. This group does not necessarily represent all pregnant young people in Quito, let alone internationally. Second, the comparison group of adolescents were younger, and age alone may affect family dynamics. In addition, some of these young women may themselves become pregnant when they reach the age of
the study group. Finally, given that this is a crosssectional study, directionality and causality cannot be determined. Specifically, we cannot say that certain family dynamics increased the risk of pregnancy. Observed associations may be the result of the influence adolescent pregnancy has on family dynamics.
Conclusions Doubtless, the family is the structural unit of our society, and its appropriate functioning promotes the well-being and development of all its members, including the adolescent. By looking at how the family functions, and ensuring that families, especially the ones most disadvantaged, have resources and supports available, we will be moving toward primary prevention of adverse outcomes among teenagers. The authors acknowledge the assistance of Marjorie Ireland, Ph.D., University of Minnesota, with certain statistical calculations; and Linda Boche and Linda Pratt with manuscript preparation.
Table 6. Adolescent Satisfaction Pregnant
Not Pregnant
Satisfaction
High
Low
Total
High
Low
Total
Life satisfaction Feeling of happiness Satisfaction with work and parent’s employment
44.4 52.2 12.8
8.9 47.8 87.2
100% 100% 100%
44.0 54.0 87.5
0.0 46.0 12.5
100% 100% 100%
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