A qualitative analysis of adolescent motherhood within the broader family context in Peru

Abstract

Objective:

The purpose of this study was to characterize the impact of adolescent pregnancy on families and describe the needs of adolescent mothers and their infants in order to assess the need for intervention and identify potential intervention targets.

Background:

Adolescent mothers and their offspring face an increased risk of mental health problems. Adolescent mothers and their families also face significant resource constraints; 95% live in low- and middle-income countries (LMICs). Cost-effective interventions are needed to improve outcomes for this vulnerable group.

Method:

This qualitative study conducted in Lima, Peru, consisted of four clinician focus groups and 18 in-depth interviews with adolescent mothers and their family members. Data were coded thematically, and direct content analysis was employed.

Results:

The study identified the following issues facing adolescent parents: the transition to parenthood, the need for family support, difficulty accessing support, the difficulty for family members of providing support, and ideas about responsibility and adolescent autonomy.

Conclusion:

Overall, these findings demonstrate the need for interventions that engage families and address barriers to accessing support, including relationship conflict and differing beliefs about responsibility and autonomy.

Implications:

Interventions are needed for adolescent mothers in LMICs that mobilize family support. Clinicians who care for these patients need to be aware of the family context and the resources available where they practice.

INTRODUCTION

Global scope of adolescent pregnancy

Approximately 12 million girls ages 15–19 years gave birth in 2019 in low- and middle-income countries (LMICs; WHO, 2020a). LMICs account for 95% of adolescent births globally (WHO, 2011). The adolescent fertility rate in LMICs is 48 births per 1,000 girls ages 15–19 per year, more than triple the rate of 15 per 1,000 in high-income countries (HICs; World Bank, 2020). In Latin America and the Caribbean, the rate is 61 per 1,000.

Risk factors for and consequences of adolescent pregnancy

Lack of financial resources, limited educational opportunities, lack of family support, and history of abuse are all risk factors for adolescent pregnancy (Cherry & Dillon, 2014; Chung et al., 2018; Garwood et al., 2015; Mmari & Blum, 2009; Pradhan et al., 2015). Socioeconomic adversity worsens once these adolescents become mothers. Adolescent mothers experience lower educational attainment, higher poverty rates, greater trauma exposure, and worse health outcomes than their nulliparous counterparts throughout the world (Bearak et al., 2020; Raj & Boehmer, 2013). Compared with pregnant adult women, adolescents have higher rates of pregnancy-related complications, including eclampsia, puerperal endometritis, and life-threatening infections (WHO, 2020b). Infants born to adolescent mothers are also more likely to be born preterm, low birth weight, and small for gestational age, and experience severe neonatal health problems (Dallas, 2004; Finlay et al., 2011; Jacques et al., 2019; Pinzon et al., 2012). The offspring of adolescents also experience greater adversity, which has been linked to worse health outcomes across the life course (Pinzon et al., 2012).

Adolescent mothers face elevated risk for mental health problems. Adolescent girls have a higher risk of experiencing mood and anxiety disorders compared to boys (Kessler et al., 2005); among adolescent mothers, the risk is even higher than among nulliparous adolescent girls (Kleiber & Dimidjian, 2014). Adolescent mothers also experience higher rates of postpartum depression than adult mothers (Sangsawang et al., 2019) and have lower caregiving sensitivity (Crugnola et al., 2014; A. M. Culp et al., 1996; R. E. Culp et al., 1991). Sensitive caregiving is a protective factor that promotes resilience and mental health (Levey et al., 2016; Masten, 2007; Southwick et al., 2011).

Adolescent development and adolescent pregnancy from a cultural perspective

Adolescence is a period of intense physical and psychological change that can be emotionally destabilizing. Adolescent development involves self-exploration and a desire for autonomy (Silverberg & Gondoli, 1996; Soenens et al., 2017); problems in the parent–child relationship during adolescence can interfere with the development of autonomy (Allen et al., 1994; Garber & Little, 2001; Steinberg, 1990).

Culturally informed beliefs and practices related to adolescent sexuality and family relationships influence the social meaning of adolescent pregnancy and motherhood, which impacts the treatment adolescent mothers receive in their families and communities. In Latin American cultural groups, adherence to familismo, the value of family connection and sense of obligation, has been associated with less parent–adolescent conflict (Coohey, 2001; Kuhlberg et al., 2010; Smokowski et al., 2008). A comparative study of adolescents in the United States, Chile, and the Philippines suggests a more complicated picture. Adolescents in the United States reported that their parents set fewer rules but they felt greater obligation to follow the rules that were set (Darling et al., 2005). Conflict occurred when adolescents felt obligated to follow rules that they did not feel their parents had legitimate authority to set. In all three countries, adolescents expected and parents granted greater autonomy from early to late adolescence. Autonomy is also treated differently based on gender; Latina adolescents are granted less autonomy than their male counterparts (McKee & Karasz, 2006). This relates to marianismo, the value that girls and women should be pure and self-sacrificing.

The manner in which these values manifest varies by country, community, family, and individual, and they also interact with economic and other contextual factors. A group of Peruvian adolescents who were asked to give life story narratives consistently reported being impacted by such factors as family discord, poverty, racism, and migration (Bayer, Cabrera, et al., 2010; Bayer, Gilman, et al., 2010). Household poverty is among the leading factors associated with early sexual initiation, lack of condom use, and nonconsensual sex among adolescents in Latin America (Cunningham & Bagby, 2010; Cunningham et al., 2008).

Parent–child conflict during adolescence and intergenerational dependence around the birth of a child are each normative developmental shifts (Branje, 2018; Copeland, 2017; Lewin et al., 2011); for adolescent parents they occur simultaneously. The dual transition to adulthood and parenthood presents a unique challenge for adolescent mothers. Two studies of Latina adolescent mothers in the United States found that normative increases in autonomy were associated with better mental health outcomes (Nadeem & Romo, 2008; Umaña-Taylor et al., 2015).

Social support in the perinatal period

Studies have found that stable social support can mitigate the risk of depression, housing instability, isolation, and decreased educational and employment opportunities among adolescent mothers (Anchía, 2012; Campos et al., 2008; Copeland, 2017; Dallas, 2004; Finlay et al., 2011; Gavin et al., 2011; Hymas & Girard, 2019; Kalil et al., 1998; Kleiber & Dimidjian, 2014; Pinzon et al., 2012). As with other cultural groups, research conducted in Mexico and Costa Rica has indicated that Latina adolescent mothers fare better with family support (Albuja et al., 2017; Copeland, 2017). The impact of Latin American cultural constructs on access to social support among adolescent mothers is ambiguous. On one hand, these values indicate the centrality of family and the importance of supporting family members. On the other hand, adolescent mothers may be seen to be in violation of these cultural norms and therefore receive less support.

Despite the importance of social support, which adolescent parents typically receive from their parents, grandparents, and other extended family, family-based perinatal interventions have not been well studied. A recent systematic review and meta-analysis of family-based perinatal interventions found improvements in family functioning and maternal depression in the intervention group. This review identified just seven studies, all of which were conducted in the United States (Cluxton-Keller & Bruce, 2018).

Study objectives

In our previous studies of pregnant Peruvian women residing in Lima, 69% reported experiencing abuse in childhood, and the lifetime prevalence of intimate partner violence was 39% (Barrios et al., 2015). These estimates have been corroborated by a number of other studies (Bardales & Huallpa, 2015; Guerrero & Rojas, 2016). These experiences of violence further augment the risk adolescent mothers already face of poor maternal and child health outcomes (Boyer & Fine, 1992; Dube et al., 2001; Pinzon et al., 2012; Stier et al., 1993).

In low-resource settings, where many problems stem from poverty, it is critical to optimize available resources. For adolescent parents, families are a key resource. However, most perinatal interventions for vulnerable families focus on mothers and babies and do not endeavor to engage other family members. The purpose of this qualitative study is to characterize the impact of family support during the perinatal period on adolescent mothers and their infants and identify barriers to receiving adequate support. This will inform the development of a family-based intervention aimed at improving caregiving quality by supporting the relationships between the adolescent mother and other family members.

METHODS

Participants

This qualitative study consisted of four clinician focus groups (N = 25), 10 in-depth interviews with adolescent mothers (N = 10), and eight in-depth interviews with other caregivers (N = 8). Participants in the clinician focus groups were recruited through the heads of the clinical services. All clinicians who cared for adolescents during the perinatal period were eligible to participate. They were informed about this opportunity by the study coordinator, and all who were available on the appointed day elected to participate. Participants received lunch at the end of the focus group. No additional compensation was provided.

Three of the focus groups were composed of clinicians from the Instituto Nacional Materno Perinatal (INMP), and the fourth focus group was conducted with clinicians from Taller de Niños (TANI). At INMP, the first focus group consisted of psychologists and midwives, the second consisted of physicians, and the third consisted of nurses and social workers. The focus group at TANI was composed of nurses, psychologists, social workers, and community health workers. Each group was made up of five to eight participants who knew each other and worked together and were not in hierarchical relationships. This group size and composition was strategically chosen to maximize comfort and candor among participants (Hennink et al., 2010).

The INMP is the primary reference establishment for maternal and perinatal care operated by the Ministry of Health of the Peruvian Government. It serves low-income women who are publicly insured. Nearly 20% of pregnant patients seen at INMP are adolescents. INMP has a dedicated prenatal class and labor and delivery service specifically for adolescents. The classes are taught by midwives and psychologists. Social workers routinely visit adolescent mothers on the postpartum ward. The clinicians who work on these dedicated services were invited to participate in this research. All who were available on the day of each focus group participated.

TANI is a nongovernmental organization (NGO) that has been operating in Peru for over 40 years providing medical care and other services to infants and their families residing in San Juan de Lurigancho, Lima’s most populous district. Many of its residents have recently migrated from rural province areas and face significant resource constraints. The clinicians at TANI are typically younger, gaining the experience they will need to later secure a sought-after position at a government hospital. TANI also has a program dedicated to adolescent mothers, which is staffed by a multidisciplinary team. All members of the team who were available elected to participate in the focus group.

Participant demographics for the qualitative data are summarized in Tables 1 through 3. Twenty-five clinicians participated in the focus groups. They were between the ages of 24 and 66, with an average age of 47.7 years (SD = 14.5). Eighty-four percent were female. Clinical disciplines represented were physicians, nurses, psychologists, midwives, social workers, and community health workers. The duration of their clinical experience ranged from less than a year to 43 years, with an average of 16.6 years (SD = 13.2; see Table 1).

TABLE 1.

Demographic characteristics of focus group participants (N = 25)

Characteristic	M (SD) or N (%)
Age	47.7 (14.5)
Female	21 (84%)
Male	4 (16%)
Physicians	5 (20%)
Nurses	5 (20%)
Psychologists	5 (20%)
Midwives	4 (16%)
Social workers	4 (16%)
Community health workers	2 (8%)
Years of clinical experience	16.6 (13.2)

TABLE 3.

Relationship of other caregivers to infants (N = 8)

Relationship category	N	Living together N (%)
Father	3	2 (67)
Maternal grandmother	2	2 (100)
Paternal grandmother	1	1 (100)
Maternal great grandmother	1	1 (100)
Maternal great grandfather	1	1 (100)

Adolescent mothers were recruited from birth records at INMP. Anyone who had given birth between May 1, 2018, and May 1, 2019, and was between the ages 14 and 19 at the time she gave birth was eligible. Potential participants were excluded if their infant had died, if they were not living in the Lima area, or if they did not speak Spanish. The research team attempted to contact 65 adolescent mothers to invite them to be interviewed; 47 were unreachable. Eight were unable to participate due to other responsibilities; the remaining 10 were interviewed. Adolescent mothers received a small baby gift valued at $10 USD.

In-depth interviews were conducted with 10 adolescent mothers and eight other caregivers. Adolescent mothers ranged in age from 14–19 years, with an average age of 16.6 years (SD = 1.6); the fathers of their infants ranged from 16–30 years of age, with an average age of 21.2 years (SD = 3.9). The infants ranged in age from 2 to 14 months, with an average age of 6.8 months (SD = 4.2; see Table 2).

TABLE 2.

Demographic characteristics of adolescent mothers (N = 10)

Characteristic	M (SD) or N (%)
Average age of mothers	16.6 (1.6)
Average age of fathers	21.2 (3.9)
Average age of infants (months)	6.8 (4.2)
Living with family	6 (60%)
Living with partner	4 (40%)
Graduated high school	3 (30%)
Enrolled in high school	3 (30%)
Not enrolled in school	4 (40%)

Participants were asked whether there was anyone helping them care for their infants who was available to be interviewed. In this way, eight other caregivers were identified. In some cases, the adolescent mother and the other caregiver were interviewed sequentially during a single visit; in other cases, a separate interview was scheduled. We were interested in learning about the variety of supports available to adolescent mothers, and for this reason, we did not restrict the type of relationship between the other caregiver and the mother. We included the infants’ fathers as well as other family members who were providing support. Of the eight other caregivers interviewed, three were the babies’ fathers, two were maternal grandmothers (mothers of the adolescents), one was a paternal grandmother, one was a maternal great grandmother, and one was a maternal great grandfather (see Table 3).

All participants provided written informed consent prior to the focus group discussion or interview. The institutional review boards of the INMP, Lima, Peru, and the Harvard T. H. Chan School of Public Health, Office of Human Research Administration, Boston, Massachusetts, approved all procedures used in this study.

Procedures

Focus group discussions (FGDs) were conducted first in order to identify major themes that could be explored in individual interviews. The FGDs and interviews were cofacilitated by two Spanish-speaking members of the research team. All FGDs and interviews were audio recorded. One member of the research team asked questions while the other took notes. After each FGD and interview, a member of the research team listened to the recording to review what had been discussed and consider how to explore topics of interest in greater depth until theoretical saturation was reached (Hennink et al., 2010). The interviews were transcribed verbatim and then translated into English by a bilingual member of the research team.

The FGDs were conducted from July 1–5, 2019. Each FGD was conducted in a private room at the clinical site and lasted for 90–120 minutes. Interviews began on July 8, 2019, and were completed on February 22, 2020. Each individual interview was conducted in a private space in the participant’s home. The interviewer spent a total of 4 hours in each home. The interview lasted about 1.5 hours, and the rest of the time was spent conducting a more informal ethnographic observation of the living situation of the mother and infant.

Measures

Focus groups

The FGD facilitator and cofacilitator introduced themselves to the group and explained the purpose of the FGD. Each participant then introduced themself, giving their training background, current position, and years of experience. The facilitator then began to pose questions about the clinicians’ perceptions of the teen mothers’ experiences, family involvement, and the role of the health system. Examples of questions posed include the following: What are pregnant teens concerned about? What are their concerns as mothers? Are you aware of any programs that offer assistance to your patients? How well do they achieve their goals? What are their strengths? What barriers do you perceive to the use of such programs by your patients?

Adolescent mothers

When the interviewer arrived that the home of the adolescent mother, she greeted her and explained the purpose of the interview. The interview guide covered the following themes: motherhood, support, education, childhood experiences, and future hopes. Examples of questions posed include the following: How is being a mother for you? What are your favorite parts? What are the challenges? What is your biggest worry about the future?

Other caregivers

The interview guide for the other caregivers was structured similarly to the interview guide for adolescent mothers. Themes covered included their experiences as caregivers, their relationship with the infant, their relationship with the adolescent mother, and their responsibilities as caregivers. Sample questions included the following: How does it affect you to care for the baby? Is it difficult to do while managing other responsibilities? How is your relationship with the mother? Do you have different ideas about how to care for the baby? In what ways do you differ?

Analysis

The FGDs and interviews were transcribed verbatim by a Peruvian member of the research team and were then translated into English by a bilingual team member. Coders worked in three teams of two, with one team coding FGDs, another team coding mother interviews, and a third team coding caregiver interviews. There were a total of five coders, as one coder coded both mother interviews and caregiver interviews. First, coders read each transcript in the group they were coding and developed the initial codebook over a series of meetings. Once coding began, each team met after coding each transcript to discuss their findings and revise the codebooks. Any disagreements between coders were discussed with both coders and the principal investigator until a consensus was reached. All transcripts were then recoded once each codebook was finalized. The three coding teams met all together at the beginning and several more times throughout the coding process in order to share key findings and compare the themes that were emerging from each set of data. All transcripts were translated into English by a bilingual member of the research team and then back-translated into Spanish by another bilingual team member. After coding was complete, the codebook was translated into English in order to disseminate findings in English as well as Spanish.

NVivo was used for data management (QSR International, 2015). Intercoder reliability was found to be substantial (κ > .6; Cohen, 1960; McHugh, 2012). For FGDs, κ = .70; for the adolescent mother interviews, κ = .67; for the other caregiver interviews, κ = .79.

A directed content analysis was used based on the goals of informing the adaptation of an intervention (Hsieh & Shannon, 2005). The content analysis was carried out by the principal investigator, an American psychiatrist, and the team of five coders, which included another American psychiatrist, a Peruvian psychologist, a bicultural psychologist, a bicultural public health researcher, and a bicultural bioethicist. This diverse team met regularly to discuss their findings in order to arrive at a more nuanced understanding. Both inductive and deductive approaches were used to analyze the data (Hennink et al., 2010). First, manifest content was grouped thematically. Thematic groupings were then labeled, and these group labels were used to generate broad themes. These broad, overarching themes were divided into subthemes. Within each theme and subtheme, the researchers drew comparisons, looking for overlap and differences, as well as newly emerging topics and patterns.

RESULTS

Thematic overview

In alignment with the objectives of this study to inform a future intervention, we identified four themes and describe them below alongside illustrative excerpts from the interviews. In order to demonstrate the need for an intervention with these aims, we will describe the following issues that we observed in the families of adolescent parents: First, adolescent parents struggled with the transition to their new role. Many did not know how to take care of their infants, and some were very anxious and preoccupied about their well-being. Second, adolescent parents were better able to take care of their infants and themselves when they had the support of their families. Third, many adolescent parents struggled to access the support they needed. Fourth, family members (fathers and extended family) had difficulty providing needed support to the mother and infant while managing their other responsibilities. Table 4 illustrates the distribution of themes and subthemes across the categories of participants. The numbers indicate the number of FGDs or interviews in which each topic was mentioned.

TABLE 4.

Frequency of themes and subthemes

Themes and subthemes	Clinician FGDs (4)	Adolescent mothers (N = 10)	Adolescent fathers (N = 3)	Other caregivers (N = 5)
Transition to parenthood	4	10	3	2
Learning about infant care	4	10	3	2
Transition for adolescent fathers	0	1	3	1
Adolescent fathers lacked confidence	0	0	3	0
Adolescent fathers expressed a desire to parent	0	0	3	1
Change in relationship with partner	4	6	3	1
Managing emotional responses	3	10	3	2
Anxiety	2	4	3	2
Frustration	1	4	1	1
Loss	1	4	1	0
Need for support	4	10	3	4
Informational	3	8	3	1
Financial	3	8	3	2
Practical	4	9	2	2
Emotional	3	9	2	2
Barriers to accessing support	4	8	3	4
Initial support declines	2	4	0	0
Lack of access to family	1	3	2	0
Longstanding conflict	4	7	3	2
Conflict related to childcare	1	6	3	2
Challenges faced by other caregivers	0	6	3	4
Overburdened		4	3	4
Financial obligations		3	3	4
Poor health		1	0	1
Difficulty communicating with adolescent mother		2	1	3
Adolescent mother disengaged		0	0	1
Conflict with mother		2	1	3
Responsibility and autonomy	1	7	2	2
Beliefs about responsibility	1	2	0	2
Adolescent desire for autonomy	1	6	2	1

Note. FGDs = focus group discussions.

We conducted four FGDs with different groups of clinicians. In their comments, FGD participants took on the perspective of the adolescent mothers and commented about the challenges they face and not those faced by other caregivers. Psychologists and social workers spoke about family dynamics, whereas physicians and nurses commented primarily about the adolescent mothers themselves. We enrolled a total of eight other caregivers, including three adolescent fathers and five others. Although we did not recruit adolescent fathers separately, we found that the concerns they reported during the interviews differed from those reported by the other group of caregivers. For this reason, we have separated their responses in the data table.

Transition to parenthood

Learning about infant care

Adolescent mothers and their partners struggled with the transition to parenthood. All clinician focus groups and all adolescent parents reported this: “Because they are so young and new mothers, it is difficult for them to know the necessary things to do to care for the baby, and they stress out quite a bit.”

Although some had previously cared for young children, all of the adolescent parents interviewed struggled with some aspect of newborn care, including how to feed the infant, bathe the infant, or when to change the diaper. They were also anxious about the responsibility of caring for an infant and the infant’s apparent fragility. As one mother explained,

I wasn’t used to changing diapers. I would put it more there than here, and everything was a mess. Sometimes when I changed her clothes, I was a bit rough because I didn’t know.[…] I was afraid she would break.

Most adolescent parents did not have experience caring for an infant, and they lacked confidence.

Transition for adolescent fathers

Fathers found it particularly difficult to learn how to care for their infants, both practically and emotionally. This was ascribed to a combination of biological, cultural, and situational factors. As one father explained, “The woman is natural with the baby. The man is unnatural; he doesn’t know anything.” The word “natural” suggests that women have an innate, biologically based ability to care for a child. The man not knowing anything could refer to a knowledge that is biologically based, embedded in the body, but it also suggests the possibility of learning cognitively what is not known biologically.

Fathers also described how culture contributes to an expectation among fathers that caring for a child is a woman’s responsibility: “Peruvians are very sexist. [They will say], ‘That woman takes advantage of you, she takes your money’ [referring to child support].” While he felt pressure from his family and others around him to assert himself in his relationship with his child’s mother, this father wanted to be open to a different kind of relationship with her and with his son:

I am not good at understanding feelings, or putting myself in other people’s shoes.[…] It’s a bit difficult for me. Until now I did not do it so often, people have told me, and for me with my son it is a practice every day.

For adolescent fathers, culturally informed expectations de-emphasized understanding and expressing emotion. Their experience as fathers made them want to develop this capacity. This was both because their partners now had greater emotional demands of them and because they witnessed the gratification the mothers experienced through their emotional connection with the infants.

Assuming the role of a parent was challenging for young mothers and fathers. They had never had so much responsibility before, and most felt anxious about it. They had to acquire practical knowledge and develop the emotional capacity to bear this new responsibility in order to manage the transition successfully.

Change in relationship with partner

Both mothers and fathers reported a change in the relationship with their partner. Fathers reported that the mother was less available to them after the baby arrived:

When she was pregnant, you still share moments with your partner. When the baby is born, the woman does not see the father like a man. We were very affectionate [before the baby was born], and to be honest, I saw a difference.

Fathers also reported a significant change in the relationship with their partner and a loss of intimacy: “Between us, since the baby was born, it’s something like a separation. We have to focus on the child.”

Mothers expressed frustration that fathers seemed jealous of the baby:

He was jealous of [the baby]. He would say, “Ah, you give the baby everything, I am nothing to you now, you only care about him.” So then I told him, “You know what? You need to leave.” He doesn’t love his baby. What was I supposed to do? So I made the decision for good, because I don’t want a machista man like that as an example for my child. I think about him, and I don’t want [my son] to grow up and treat his wife like that.

This mother interpreted the father’s desire for connection with her as an indication of his lack of love for the baby.

In some cases, romantic relationships broke up following news of the pregnancy or the birth of the baby. One adolescent mother had moved with her partner to a neighboring country. At first it was exciting, but she began to feel the burden of the impending birth. She doubted whether her partner could provide the support she would need and decided to return home: “We were going to be three, we were no longer going to be just two of us. Things seemed to change. I think it was me, I changed more, I don’t know, I didn’t feel confidence with him anymore.”

Managing emotional responses

Becoming a parent activates powerful emotions. Adolescent parents described experiences of anxiety, frustration, and loss. Initially, their anxiety stemmed from their lack of experience caring for infants and their fear that they might unintentionally harm or damage their babies. As a midwife explained,

When adolescents have just given birth, they feel a lot of fear about whether they can fulfill the demands of the newborn. One also observes them in anguish when the baby is put in contact with their breast and cannot latch. It begins to cry. They ask for help, or they cry. They are in bad shape.

Once they began to learn how to care for their infants, some adolescent mothers worried that no one else would be able to care for the infant and felt anxious about separations. One mother began leaving her child for a few hours each day when he was 6 months old, in order to return to school. When we spoke with her, he was 11 months old, and she had become more comfortable being away from him, but it was difficult for her initially:

Since the first day that I had to go to school, I left and cried in the car because I had never had to be separated from him. I was filled with a lot of angst; I would wonder who could take care of him the way I would want my son to be cared for. I mean, as a mom you recognize some of the things that your child wants, no? I would wonder, “Will my mom be able to understand what he needs?” That was one of my worries. “What if he doesn’t want something? What if he cries the whole time? What if she doesn’t understand him? What if he gets burned? Or what if he gets hurt?” I was worried about a lot of things.

This can be heard as both anxiety about the well-being of her child and a sense of loss of the early state of total dependence on the mother and the beginning of the separation process of growing up. Indeed, adolescent parents had to bear a variety of losses, including the loss of their growing child, the loss of their own childhood, and the changes in their relationships with their partner, family, and friends.

Adolescent parents also had to manage anger and frustration when their infants did not do what they wanted. Introducing solid food was a challenge for many of them. Three mothers outsourced this task to older female relatives. One explained that her grandmother could manage feeding by being playful with him, but the adolescent mother found the experience frustrating: “I kind of don’t have much patience, and when he throws the food, I don’t have patience.”

Need for support

To manage the transition to parenthood, adolescents needed informational, financial, practical, and emotional support from their families. Families taught adolescents how to take care of their infants, they provided financial support, they helped with childcare so the adolescent could study, and they were also an important source of emotional support. Clinicians explained that there was a consistent relationship between family support and outcome for the adolescent mother: “When we find an ally and there is the family member that supports the adolescent, they are successful. They succeed because they have the support, they have a person who can give them a hand.”

Informational

In the immediate postpartum period, adolescent mothers relied on family members to teach them how to take care of their children. One adolescent mother learned “how to carry him, how to breastfeed him” from her own mother. Another adolescent mother described feeling “scared to burp him [the infant]” and was relieved when “my grandmother came and explained to me that I needed to put his head up higher on my shoulder.”

Financial

One mother noted that she was able to be ambitious about the future and also felt less worried because she had financial support from her family:

My family never stopped telling me “here for this” or “here, for that” [offering money for expenses]. Even now they are crazy about the baby, and they never abandoned me, and my partner works. So not a lot [worries me]. I am sure that I will accomplish everything I set forth. I already have my goals on the way. I’m sure I will graduate, I am sure I will get a job, and achieve my career plans.

Family support was also essential to the mother’s ability to invest in her infant. Adolescents who had this support expressed gratitude. One adolescent, whose parents struggled to afford her school tuition, wanted to repay them by investing in her child: “I want to work, I want to study something else, but more I want to work. So that not only my parents are giving, giving, giving, because I also want to give something to my son.”

Practical

When they were ready to resume outside activity, mothers who received family support navigated the transition with greater confidence. The combination of financial and practical support from someone who was willing to care for their infant made it possible for mothers to return to school. With fewer worries in the present, they could set goals for the future. Leaving her child with her mother or grandmother, in most cases, made the adolescent feel that the infant was “in good hands.”

Emotional

Several mothers described the need for emotional support in the perinatal period. Psychology and social work clinicians described how adolescents feel overwhelmed by the emotional task of parenting and may cling to their mothers in response, regressing to a childlike state: “The demand of motherhood [leads them to feel], ‘I need my mother.’ It’s like they have changed into another girl who cannot take care of that baby, and they need their mother so she can help them contain the baby’s screaming.”

Adolescent mothers also described feeling overwhelmed and alone. They were afraid and needed someone to talk to. As one adolescent explained, “What we need most is a person, like a friend, who is there, who you can confide in to be able to share things, how you’re feeling, what you like.”

While seeking more emotional support, adolescent mothers found that their social worlds were changing. They could no longer engage in the social lives they had enjoyed previously. As a result, they relied on those closest to them, namely their parents and their partners. As one adolescent explained, “You notice that your friends that you used to go out with are gone now that you are pregnant, they were only really acquaintances, because only my family members are still here.” Some adolescent mothers also found support in their partners, who “helped [them] to face difficult things.”

Barriers to accessing support

Adolescent mothers often faced barriers to accessing support. Some did not have family around them who were able to support them. Others had conflicts with family members related to issues that predated the pregnancy, disagreements about childcare, and adolescent desire for independence.

Initial support declines

In half of the focus groups, participants described a situation in which mothers have support in the immediate postpartum period, but it quickly disappears. One clinician explained that this is a typical pattern:

At the first visit there is a friend or the family present […] But with time, the majority start changing. We see that it’s girls who end up practically taking care of their child by themselves, either because the family is working or can’t help or because they leave her to make her own life.

Four adolescent accounts also reflected this loss of support, usually after the first month. They reported matter-of-factly that others had to return to their own responsibilities. One adolescent was living with her partner, and her mother came to stay with her for 3 weeks after giving birth. This was a reasonable sacrifice to expect her family to make when she gave birth, but only for a limited time: “She had to go [home] to take care of my siblings.”

Lack of access to family

Whereas some adolescent mothers enjoyed a brief period of additional support after giving birth, three others did not have even that due to limited access to family. One was an immigrant from Venezuela who had traveled alone to Peru. One had been estranged from her father since he left the family when she was a child, and she had recently become estranged from her mother, who disapproved of the pregnancy. A third lived with her mother, but her mother worked and was not available to help: “My mom works. She leaves at the same time as her partner and doesn’t come back until nighttime. I am the one who stays here all day with my son.”

Longstanding conflict

In some cases, longstanding family conflict prevented adolescents from accessing support. One adolescent mother had been physically abused by her parents and had to separate from them in order to protect herself:

I was pretty afraid of my mother because when my mother hits you, she turns into another person, and the truth is that I don’t like it. And since I decided to leave it, I paid attention to her words and dedicated myself to studying, nothing more, and that’s it. I got away from them.

Conflict related to childcare

One adolescent mother was reluctant to ask her mother-in-law for help because she found her to be intrusive. In one instance, the mother-in-law instructed the adolescent to continue breast feeding exclusively, despite having been told by her pediatrician that she could introduce formula:

The pediatrician told me that the normal [time to wean] is a year. Then I can give him a formula to supplement. Suddenly, the last time I went she told me that I can give formula to supplement. But my mother-in-law says no, I still have to breastfeed. […] Some of her ideas are old-fashioned.

Challenges faced by other caregivers

Other caregivers faced challenges in supporting adolescent mothers. Some were overburdened and struggling to meet their other obligations. Some also found it difficult to connect with the adolescent or manage conflict. Like the adolescent mothers, their male partners were also experiencing a significant role transition.

Overburdened

One adolescent father described feeling overwhelmed by the sudden need to balance school, income generation, and childcare responsibilities. He was expected to do everything he had been doing previously and also help with the baby and contribute financially. He felt he could not complain because the mother had to leave school to take care of the baby:

I did not have an hour free for me, [there was] nothing. I studied, I worked, and it killed me, and I could never separate things. […] My son was going to be born, and they fired me the [month before]. And for me it was like that, bang, bang. And in that moment I was independent. I knew I had to face things.

Grandparents and great grandparents sometimes took up the burden of caring for multiple generations. One great grandfather wanted to provide for his children and grandchildren, but he was overwhelmed by numerous financial obligations.

The problem is that we have grandchildren, we have many things, and I have already had my children, and I do not want to abandon them. […] Her husband left my daughter, had a son, abandoned her, this man is in prison. That is why we have taken responsibility for her. […] I also have to pay electricity, water, that frankly does not concern me. I have all my children who work, and it is not possible that I am paying that either.

He also developed a progressive lung condition due to years of toxic exposure as a mine worker: “The company already knew that I had this disease, but the company never said, ‘Take him to a private doctor, you have to take him to such a place.’ Never, as you would expect.”

As he speaks about the history of abandonment in his family, he suggests that taking care of his children, grandchildren, and great grandchild is a way of righting past wrongs and setting an example as a strong caretaker. The counterexamples of taking responsibility appear in the forms of the son-in-law who abandoned his family and went to prison and the mining company who knew that the toxic exposures caused the lung disease but refused to accept responsibility. Others do not take responsibility, so all the burden falls on him.

Difficulty communicating

The demands of caring for the infant impacted the relationships among the mother, her partner, and their families, creating new conflicts and magnifying simmering tensions. In some cases, the relationships were pulled apart by this tension, and adolescent parents found themselves alienated from each other or their families.

Overt conflict within the family and efforts to avoid conflict presented challenges to family members in their attempts to communicate with each other and support the adolescent parents. Clinicians described tension between the mother’s family and the father’s family: “When we see them in the emergency room, we see the competition that there is between the mother and the partner, whether they live together or not.” Some fathers were actively excluded from the caregiving process by the family members of the mother. One clinician described a situation in which the maternal grandfather did not want the baby’s father, a substance user, to be involved with the baby at all. He threatened the father that, “Even when the baby is born, you will not see it.”

In order to avoid conflict, some families avoided difficult conversations altogether. One grandmother commented on the difficulty of talking to her daughter, particularly about topics related to sex and pregnancy. When she learned her daughter was pregnant, she did not know what to say to her: “She is so sensitive, and the little that I can tell her makes her feel bad.” This grandmother also described the challenges she faced in attempting to engage her daughter in caring for her infant:

I worry because I no longer know how to tell her where to start to solve this. […] I am waiting in this case for her to change a little, to have more interest in this, I keep waiting but nothing, I do not see an answer, neither good nor bad, when she wants to, she comes when she doesn’t want to, she doesn’t come, lives here, lives there.

Beliefs about responsibility and adolescent desire for autonomy

Parenthood created a greater need for dependence on their families at a time when adolescents otherwise wanted to be independent. The question of who should be responsible for the baby, as well as for the adolescent parents, was discussed. Issues raised included the role of the adolescents’ parents in providing support, the role of the adolescents in caring for the baby, how they could manage this in addition to their other responsibilities, and the function of becoming parents in their personal growth and psychological development.

Clinician perspective

Clinicians focused on the importance of support for the adolescents. Clinicians in the psychologist and midwife group briefly acknowledged that adolescent desire for independence could impact the situation, but this was seen as a problem and as unrealistic given the circumstances. Instead, they emphasized the importance of the grandparents taking responsibility for the baby and for their adolescent children. One clinician spoke as a parent, explaining, “Us parents are also responsible for what happens, and we need to see too, and invest in our children.”

Parent perspective

Parents of the adolescents had differing attitudes toward the idea of adolescent autonomy and responsibility. According to some adolescents, their parents declared that they were not responsible for their adolescent children because they had disobeyed them by becoming pregnant: “You think you’re ready to be an adult? Fine. Then leave my house, and you can take care of yourself.”

Some felt responsible for their adolescents because even though they were now parents, they were also still children. As one maternal grandmother explained, “Most importantly, we are her parents. Why would we not support her? We made the decision, with my husband, and I said, ‘She’s going to continue [with her education], let her continue.’” Having articulated her own responsibility toward her daughter, this maternal grandmother also articulated her daughter’s responsibilities, the implication being that it was the grandmother’s responsibility to help her daughter face her responsibilities:

As I say, “It is your responsibility as a mother. We are supporting you, we are holding your hand, but it is not for you to abuse,” so that she learns, because I don’t think everything is going to be served up on a platter, easily. She has to know her responsibilities. And she does, she does, thank God.

Still others recognized that the adolescent mothers needed support but worried about intruding. They felt they needed to step back and let the adolescents make their own mistakes. As one maternal grandmother explained to the paternal grandmother,

I am not going to interfere in their problem. It’s ok if I try and guide them or talk to them, but I am not going to force them to do things. […] I am not going to be nosey and eavesdrop and gossip behind their backs, they have to learn and if they make a mistake they will learn from it. That’s how it is, I can’t be trying to solve all their life problems, there are things that we are responsible for as parents, but we can’t stop them from making mistakes and they have to learn for themselves.

Adolescent perspective

Adolescent fathers also recognized the mothers’ desire for independence and their need to prove that they were capable and could function independently as mothers. Although they wanted support from their partners, they also wanted to show that they were competent mothers. The fathers were impressed with how well the mothers seemed to know how to care for the babies, but they also felt intimidated at times, worrying that they did not know enough to help or that their help would be rejected:

She knows the needs […] And for me that is the difference between her and me that has shocked us, because she has taken care of her little brothers and knows [the baby’s] needs. She knows if he is hungry at that moment, and she gives this or that to him.

Most adolescent mothers believed that their autonomy was important for their development. Although they relied on their parents, and in some cases their partners, for support, some adolescents experienced this dependence as an impediment to becoming mothers in their own right. One adolescent discussed her fear that she would not be able to extract herself and her child from her mother’s influence in order to have a separate life:

My future scares me too much, it scares me too much that I live here with my mom all my life, and that [my son] becomes too fond of my mom that I can’t become independent. I am too scared of being of legal age and that my mother continues to take control of everything I do or all the decisions that I want to make with [him].

Another adolescent mother described her desire for an independent life with her partner where they could “learn to live together” away from their families of origin.

Independence meant different things to adolescent parents. In some cases it meant functioning independently as a mother. It could also mean having the support to continue to pursue an education that could lead to an independent life in the future.

DISCUSSION

This study explored the relationship between the need for support and the desire for autonomy among adolescent mothers. It underscored that adolescent mothers need family support in their transition to parenthood, particularly in resource-limited settings. Adolescent mothers need financial, practical, and emotional support. A number of barriers limited adolescent mothers from accessing support, including a decline from initial support, having no family available, and family conflict. When family members were available, they often faced challenges to providing support, which included financial constraints, their own personal obligations, conflict with the adolescent mother, and difficulty connecting with her. Another challenge for adolescent parents and families was navigating the tension between the adolescents’ need for support and their desire for autonomy.

Previous studies have indicated that adolescent parents benefit from family support (Copeland, 2017; Hymas & Girard, 2019) but have not addressed how this impacts adolescent autonomy. Overall, this study demonstrated that adolescent mothers thrived when their families respected their autonomy as mothers and offered support without undermining their role. In these instances, family members did not take control of the adolescent or the infant, dictating how she would parent; rather, they helped her with what she needed in order to live and parent the way she chose. This allowed the adolescent to feel supported and develop more confidence in herself as a mother.

Other studies have found that interpersonal conflict and lack of social support are both predictive of perinatal depression (Cluxton-Keller & Bruce, 2018; Leathers & Kelley, 2000; Morinaga & Yamauchi, 2003; Morse et al., 2000). Resource constraints, which are a common challenge for adolescent parents in LMICs, can exacerbate family conflict (Chung et al., 2018; Mmari & Blum, 2009; Pradhan et al., 2015). Indeed, we found that adolescent mothers needed financial support, and resource constraints made it difficult for families to provide needed support, leading to conflict about how limited family resources should be used.

Another source of tension was differing beliefs about who should be responsible for adolescent parents and their children. Clinicians emphasized the importance of the family taking responsibility. Grandparents and other family members believed adolescents needed to take responsibility. Adolescents felt they needed support but also valued their autonomy. Confronted with these conflicting needs, some adolescent mothers in our study chose to separate from their families and rely on their partners; others remained with their families but worried that they would not become separate people and have autonomy as mothers.

The cultural values of familismo and marianismo were also relevant to postpartum family functioning (Kuhlberg et al., 2010; McKee & Karasz, 2006). In some cases, the pregnancy catalyzed a shift in family dynamics, and adolescent mothers were recognized as becoming adults and having elevated status and greater power within their families. However, some families were angry that their daughters did not live up to the ideal of marianismo, which led to conflict. One mother of an adolescent tried to exert greater control over her daughter, in terms of her approach to caring for her infant and her educational and career pursuits, as if to prevent what had already happened.

There were also specific relationship challenges between adolescent mothers and fathers, who felt a sudden loss of the relationship they had prior to the birth of the child. Mothers were angry that fathers seemed jealous of the baby, and fathers felt ignored, as though they had no role. Overall, these relationship tensions, fueled by the stress of resource constraints, ideological differences, and major life changes, present a potential target for a family-based intervention.

There were a number of limitations to this study. First, participants were recruited from a single tertiary care women’s hospital in Lima, Peru. Adolescent mothers in other parts of Peru, or, for that matter, those receiving care at other clinical sites, were not included, and the data may not represent their experience. Second, although the sample size for both the FGDs and the interviews was small, data analysis indicated that theoretical saturation was reached. Third, there is the possibility of selection bias, as adolescents who chose to participate may be different from those who did not, although the demographic characteristics of the study participants are comparable to other adolescent mothers we have studied in Lima (Levey et al., 2021). Selection bias also occurred among other caregivers, who were only invited to participate if the adolescent mother gave permission and provided contact information. This naturally biased the sample of other caregivers toward those who were on favorable terms with the mothers. Nevertheless, relationship conflicts emerged. Finally, although these data highlight the importance of family support and the frequency of conflict or disconnection between adolescent parents and their families, indicating the need for intervention, further research is needed to identify the best approach. Support for adolescents and guidance for families in working through conflict is indicated, but it may not be adequate in some cases.

IMPLICATIONS

Despite the overwhelming evidence for the importance of social support for maternal and infant health outcomes, particularly for adolescent mothers, family intervention data is lacking. This is particularly concerning in LMICs, where most adolescent births occur and where extended family involvement is the norm. At the same time, financial stressors impose a particular burden on families during the perinatal period such that they may struggle to support the mother and infant. Additionally, differences in expectations and changes for the newly parenting couple interfere with communication in the family. Interventions for this population should focus on addressing family conflict and other barriers faced by other family members in providing support, including family conflict. Family members may need help understanding how to support the adolescent mother while promoting her autonomy.