Teen pregnancy and mental morbidity:
class struggles and social stigma amongst
young women in a 1982 birth cohort in
Pelotas, Brazil
Dominique P. Béhague1,2
Helen D. Gonçalves2
1 – London School of Hygiene and Tropical Medicine, UK
2 – Federal University of Pelotas, RS, Brazil
Acknowledgements: WHO, The Wellcome Trust,
Cesar Victora, Fernando Barros
Teen pregnancy and mental morbidity in
early adulthood

Several studies demontrate a statistical link between
teen pregnancy and subsequent mental morbidity

Possible explanations





Unwanted pregnancy
Single motherhood
Lack of social support
Economic and educational set-back
Psychological predisposition/co-morbidity
 Some of this literature premised on view that teen sexual behaviours are “irrational”
1982 Pelotas birth cohort methodology: Linked
epidemiological and ethnographic studies

Epidemiological: Population-based cohort of 5,914 live births with several
follow-ups:




2001 survey -- visits to all households in a systematic sample of 27% of
the city's census tracts, 65% found (N=1,031)
2004-5 survey – whole cohort, 77% found (N=4,297)
Applied questionnaire with young person & guardian + confidential
questionnaire
Ethnographic: Randomly selected subsample of 96 youth from 2001 survey


Several years’ follow-up (more than 15 visits per participant from 20012007)
In-depth interviews, participant observation, interviews with family
members
Sample and variables

Restrict analysis to women only


Early teen pregnancy = 11-16 years of age (N=212)



602 (29%) teen pregnancies (11- 19 years)
Ethnographic study revealed experience of getting
pregnancy at ages 17-19 is qualitatively different, and
largely more socially acceptable (sometimes expected)
Preliminary data analysis from Pelotas shows that teen
pregnancy is rising in the younger age groups (Victora:
pers. comm)
SRQ-20 (2004-5 variable) cut-off score > 7 for
women, validated for Brazilian setting, indicating
common mental disorder (Mari and Williams: 1986)
Variable
Number of youth
Youth with an SRQ score > 7 in
2004-5, %
No
1867
31
Yes
212
47
< = 1 minimum salary/month (@£70)
142
47
1.1 – 3.0 minimum salary
703
39
3.1 – 6.0 minimum salary
688
30
6.1 – 10.0 minimum salary
286
28
> = 10 minimum salary
258
23
0-4 years
136
57
5-8 yrs
490
42
9-11 yrs
1060
29
12+ yrs
393
23
White
1578
30
Mulatto/black
435
41
Other
66
46
Early teen-age pregnancy (11-16 yrs)
Family income (2004-5)
Young person’s schooling (2004-5)
Young person’s skin colour
**all associations with p-value < 0.0001
Logistic regression analysis for the effect of early teen
pregnancy (11-16 yrs) on mental morbidity at 23 years
of age
Odds ratios (95% confidence intervals) for SRQ score > 7
Crude
Early teen pregnancy
p-value
Adjusted for
confounders**
< 0.0001
p-value
< 0.0001
No
1.0
1.0
Yes
2.0 (1.5 – 2.6)
1.4 (1.0 – 1.9)
** adjusted for young person’s skin colour, family income (2004-5), educational levels (2004-5)
Possible explanations I: Undesired and
unexpected pregnancy?

2001 survey (N=184)
 48 % married or cohabitating at the time of interview
 If not, 69% regularly see father of child
 92 % came to enjoy (“curtir”) the pregnancy
 Of these, 28% enjoyed pregnancy from beginning
 89 % received help from family or father of child’s family
 94 % of children living currently with mother (or mother and partner)
 Situation with contraceptive at the time you think you got pregnant
(2001)
 24 %
Were not using any contraceptive because actively trying
to become pregnant
 34 %
Generally using contraceptive but it failed
 35 %
Forgot to use/wasn’t generally using
 7 %
Don’t know how to use contraceptive
 1 %
No money to buy/parents banned use
 24 % Stated their pregnancy was planned in 2004-5 survey
Typical “unplanned” pregnancy amongst
families of lower incomes
[And your daughter, did you plan that pregnancy?] No, no, it
wasn’t planned. [And what was it like when you found out you
were pregnant?] It was, I was, I wasn’t nervous, or anything, I
liked the idea, it was just that I was still a bit too young, I think I
should have taken advantage of life a bit more before getting
pregnant. [So you weren’t frightened.. What went through your
head?] No, I wasn’t frightened, I didn’t feel desperate, I liked it.
[And for your boyfriend? How did he recieve the news?] He was
also happy with the news [And your family?] My mother, of
course, she didn’t want this to have happened, she wasn’t happy,
but once it happened, it happened.
Possible explanations I: Undesired and
unexpected pregnancy?

No association between contextual variables
relating to the pregnancy and SRQ score:


Except receiving help from family
Active planning of pregnancy = “not using
contraceptive because wanted pregnancy” (2001)

No association between actively planning pregnancy
and lower SRQ score
Possible explanation II: Stigma and class
struggles

Although teen pregnancy is more expected amongst lower
classes, psychological effects are more pronounced
amongst the poor, because young women:





feel socially and institutionally alienated, but concerned about their
lack of education and opportunity for upward mobility
demonstrate sensitivity to social stigma relating to teen pregnancy
amongst the poor
have strong impetus to reject the values and prescriptions of
“normative” society and the upper class in various arenas of life
want to engage with local community so as to change social
injustices, but not do so in a way that “buys into” upper class values
Young girls who actively sought to create a new family
demonstrated highly politicised attitudes (and practices)
regarding the upper class and inequities as a whole
10 teen pregnancies, 5 who wanted to become pregnant, remaining 81 informants + parents, key informants
We decided to marry... yes, I think I really resolved many of my
problems, everything is so much nicer now, I have more freedom.
I'm not working, but I still help my mother, I help her clean up her
house, I wash the dishes, I clean the floors... basically, now I stay at
home. But I will not say that I am happy, no, because I'm not, the
work is hard… I am doing everything possible to try to get paid work,
but it's really hard... you know, its the rich people that make us
people poor, no really, I mean it. {why do you think that?} Because if
we work for a rich person, you earn a tiny amount, a miserable
amount, ok, so it's a minimum salary and a half, but you work like
crazy, you do everything... then they tell you to do just one more little
thing and then before you know it they are exploiting you... don't you
go denying it! They want us poor people to be fucked, they are not
interested in us. I think this way, because it is the truth. For now, it's
ok because I am not hungry, thank God, but it's awful. There are
people here (in neighborhood) that are always asking, begging, and
they are right, because they don't have food, they are right to ask.
Lilian: I only want to have children if I can give them everything, I mean
everything, so that they don't have to feel any wants. Lilian's friend: Oh, not
me, I want to give everything to my child, but only what is necessary. If not
they turn into these very spoiled children, No you have to tell them to get
their own things. I can't stand children like that. Lilian: Oh yes, the children
who are poorly educated, who get into fights all the time, who use bad
language, I don't like that. Lilian's friend: It doesn't matter how much money I
will end up having, at least from the first to the sixth grade, I am going to put
my child in a state school, if you put them straight into the private system
from the beginning, they are raised extremely “metida.” I want to give my
children a future, but only starting in high school. [But why, what is it about
private schools?] Lilian: Only the little “filinhos de papai” (sons of rich
fathers) go there…the children end up all the same, one like the other.
Lilian's friend: Yeah, a child that socializes with those types of people, they
become completely metida, they will not be raised normally. Imagine, what
happens then if you don't have any more money after having put a child
through private school, and they have to go back to a public state school?
They will have absolutely no friends, because of the way they will be so
“izibido” (showing off). [And who do you two know that goes to a private
school and that is metido?] Lilian: Oh, we just imagine them… but there are
tons of them, I tell you.
Effect modification of the association between early teen pregnancy (1116 years) and high mental morbidity in early adulthood (23 years)
Odds ratios (95% confidence intervals) for SRQ score > 7
according to young teen pregnancy (11-16 years)
Effect modifier
No teen pregnancy
p-value
Number of
youth
Teen pregnancy
Young person’s
educational level
.05*
0-4 years
1.0
3.0 (1.4 – 6.1)
< 0.001
141
5-8 years
1.0
1.1 ( .7 – 1.6)
.7
490
9 + years
1.0
1.3 (1.0 – 2.0)
.1
1453
Views on what is
important for the future
0.07*
Education
1.0
2.4 (1.7 – 3.5)
< 0.0001
1241
Family/personality/
money
1.0
1.4 ( .9 – 2.2)
.1
838
Political participation
< 0.01*
None
1.0
1.8 (1.3 – 2.4)
< 0.0001
1766
Some&
1.0
5.4 (1.0 – 14.0)
< 0.0001
316
* p-value for test of homogeneity
&
In one or more of following activities: Neighbourhood association, Protest or petition, Political campaign,
Political groups


For some lower class youth, the active
decision to find a partner and parent a child is
part and parcel of larger politicised attitudes
and class struggles
But these struggles have negative
psychological repercussions

stress, “nerves,” anxiety, depression, social
isolation

Active decision to become pregnant not
associated with lower SRQ, but given
ethnographic results…

Could the active decision to become pregnant be
a risk factor for higher SRQ amongst lower youth
who are sensitive to inequities and who are
politicised?
Effect modification of the association between desire to
become pregnant (11-19 years) and high mental
morbidity in early adulthood (23 years)
Effect modifier
Odds ratios (95% confidence intervals) for SRQ
score > 7 according to desire for pregnancy
amongst families with less than 6 minimum
salaries
Did not want
pregnancy
P-value
Number
of youth
Actively wanted
pregnancy
Political participation
0.03*
None
1.0
.8 ( .4 – 1.3)
.3
222
Some
1.0
2.1 (1.0 – 4.4)
.05
151
* p-value for test of homogeneity
Conclusions

Need to tackle assumptions in public health
campaigns and society more generally:




Is teen pregnancy due to emotional “irrationality”?
Social contexts push youth towards wanting
pregnancy for “rational” reasons
Class inequities and sense of prejudice linked to
the “rationality” of teen pregnancy
Possible weaknesses in quantitative study


Residual confounding
Reverse causality