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. 2004 Fall;13(4):36–42. doi: 10.1624/105812404X6216

Adolescents' Perception of Support During Labor

Donna J Sauls 1
PMCID: PMC1595221  PMID: 17273410

Abstract

Childbirth is a pivotal event in a woman's life. Labor support plays an important role in this experience because it influences the woman's classification of the birth experience as positive or negative. Studies of adult women have identified the type of labor support that enhances the childbirth experience. Few studies, however, have identified the type of labor support that adolescents perceive as being helpful. The purpose of this study was to identify the nursing behaviors that adolescents perceive as being helpful during labor. A descriptive study was conducted with a convenience sample of 16 adolescents. Findings indicated that adolescents' needs focus on pain relief, nonjudgmental nursing care, and emotional support.

Keywords: labor support, adolescents, childbirth

Introduction

Every year, approximately 500,000 adolescents in the United States experience childbirth (Martin, Hamilton, Ventura, Menacker, & Park, 2002). The childbirth experience is consistently described as a pivotal event of powerful psychological importance in a woman's life (Nichols, 1996). How the woman responds psychologically to this event is, to some extent, dependent on the type of support she receives. The quality of support provided influences the woman's satisfaction with the birth process. A satisfying or positive experience with childbirth increases when the woman's expectations are met (Tumblin & Simkin, 2001). In order to understand adolescents' expectations during labor, the current study explored the helpfulness of supportive behaviors by the labor and delivery nurses.

Literature Review

A large body of knowledge exists on the impact of supportive care during labor. Research has demonstrated that a positive childbirth experience helps the woman develop a positive attitude toward motherhood, which helps facilitate the transition into the maternal role (Mercer, Hackley, & Bostrom, 1983; Scott, Klaus, P., & Klaus, M., 1999; Watkins, 1998). The positive experience can also establish rich and successful family relationships (Hofmeyr, Nikodem, Wolman, Chalmers, & Kramer, 1991); ensure positive self-esteem (Manning-Orenstein, 1998; Watkins, 1998); improve self-confidence (Watkins, 1998); and ensure positive development as a woman (Gordon et al., 1999; Wolman, Chalmers, Hofmeyr, & Nikodem, 1993).

A positive childbirth experience can also impact the hypothesized sensitive period for parent-infant contact (Hofmeyr et al., 1991). The sensitive period occurs within the first days of birth and is a time in which interactions between the mother and child may significantly alter the mother's future behavior with her infant (Klaus & Kennell, 1982). Hofmeyr and colleagues (1991) commented that “to explain the pronounced and persistent effects on feelings, perceptions and behaviors of a relatively short-lived intervention [labor support], we need to accept the premise that labor time is a time of unique sensitivity to environmental factors, and that events and interactions during labor may have far-reaching and powerful psychological consequences” (p. 762). Therefore, for the benefit of both the parturient woman and her child, a positive childbirth experience is highly desirable.

In order to understand what type of support parturient women need, descriptive studies of their perceptions and expectations of supportive care in childbirth have been conducted since 1956. These studies have examined the nursing behaviors women considered important and supportive in helping them cope with and adapt to the process of birth in order to assure a positive experience. Several common themes of supportive behaviors, as described by adult women, are remarkably consistent throughout the studies: presence of the nurse, the nurse's acceptance of the laboring client as a unique individual with particular needs, respect for the client's birth plan, emotional support, and instructional information about labor (Bowers, 2002). Studies also affirmed that the intrapartum nurse will often be the deciding factor in whether the woman has a positive or negative experience during childbirth (Bryanton, Fraser-Davey, & Sullivan, 1994; Lavender, Walkinshaw, & Walton, 1999; Tarkka & Paunonen, 1996).

Several common themes of supportive behaviors, as described by adult women, are remarkably consistent throughout the studies: presence of the nurse, the nurse's acceptance of the laboring client as a unique individual with particular needs, respect for the client's birth plan, emotional support, and instructional information about labor.

Although evidence exists for the efficacy of support during labor and defines which supportive behaviors are most important to adult women (≥20 years old) in labor, little is known about the adolescent's perceptions of helpful labor support behaviors. Such studies need to be replicated with the adolescent mother in order to understand her needs during labor. The importance of identifying adolescents' perceived needs during labor is magnified since research has revealed that adolescents believe childbirth is a frightful experience (Mercer, 1986) and their focus is on surviving the experience (Nichols, 1996). When experienced by the adolescent, these feelings lead to a less positive perception of the childbirth experience (Nichols, 1996). A negative experience may interfere with the mother's psychological adaptation to the maternal role and her developing relationship with the infant. A relationship is necessary to ensure the positive development of mother-infant attachment (Bloom, 1995).

Little is known about the adolescent's perceptions of helpful labor support behaviors.

If adequate and efficient support in labor by the intrapartum nurse can help the adult woman have a positive experience and positive psychological outcomes, effective labor support should also help the adolescent. By knowing what behavior adolescents find supportive, nurses may be able to improve the adolescent's childbirth experience. In order to promote a positive experience, nurses need to understand what the adolescent requires during childbirth. By understanding the adolescent's perceptions, researchers can discern if the current practice of labor support is relevant and provides positive health outcomes in the adolescent. If the current practice is not helpful, researchers must determine what changes need to be made. The focus of this study was to begin to identify supportive nursing behaviors that are perceived as most helpful during the labor process in the adolescent population.

Methods

Sample

Following university and hospital human subject approval, data for this study were collected over a three-month period at two hospitals in Texas. All adolescents (≤20 years old) on the postpartum units who had delivered within 48 hours were approached and invited to participate in the study. Once verbal consent was obtained, the researcher or postpartum nurse provided the adolescent mother with a research packet. Each research packet contained the following items: a cover letter; the Bryanton Adaptation of the Nursing Support in Labor Questionnaire—Adolescents (BANSILQ-A) (Bryanton et al., 1994); a demographic sheet; a self-addressed, stamped postcard for study results; and a manila envelope in which to place their completed surveys. The researcher then returned to the postpartum units and collected the sealed manila envelopes. Returning the completed questionnaire served as the participant's consent to participate in the study. Fifty-nine percent of the 27 adolescents (N = 16) who were approached completed the questionnaire.

Adolescents ranged in age from 16 to 19 years, with a mean age of 17 years (SD = 0.99 years). The last educational level completed by the adolescents ranged from eighth grade to the first year of college (M = 11th grade, SD = 1.62). Ethnicity of the sample was white (60%), Hispanic (6.7%), African American (26.7%), and other (6.7%). Identifying the adolescents' living arrangements revealed that 14.3% lived with their husbands, 21.4% lived with the babies' fathers, 50% lived with their parents, 7.1% lived alone, and 7.1% listed “other.” Eighty percent were primigravidas and 20% were multigravidas. Forty-seven percent attended childbirth classes. The “typical” adolescent in this study was a white primigravida who had attended childbirth classes and was living with her parents.

Instrument

The Bryanton Adaptation of the Nursing Support in Labor Questionnaire—Adolescents (BANSILQ-A) was used to measure the perceived helpfulness of supportive nursing behaviors for adolescents during childbirth. The BANSILQ-A is a modification of the BANSILQ (Bryanton et al., 1994). Prior to modification of the BANSILQ, the author was contacted in order to obtain permission to make the appropriate modifications for the adolescent.

The BANSILQ (Bryanton et al., 1994) is an existing tool designed to elicit the perceptions of adult postpartum mothers concerning how helpful certain supportive nursing behaviors were to them during their labor and delivery experience. It is a modification of the Nursing Support in Labor Questionnaire (NSILQ) developed by Kintz (1987). The BANSILQ is a 26-item, 5-point, Likert-type scale that describes various supportive nursing behaviors. These behaviors are categorized into three subscales: emotional support behaviors (attaching, reassuring, and giving the feeling that one is able to be relied upon or confided in); informational support behaviors (providing information or advice and giving feedback); and tangible support behavior (providing direct aid, such as taking care of someone, and physical care).

The questionnaire first asks women if they experienced the behaviors described above. If they answer yes, they then rate each behavior on a Likert-type scale, from 1 (not at all helpful) to 5 (very helpful). The last item addresses the overall perception of how supportive and helpful the nurses were during labor. Higher scores on the total scale and higher mean scores on the subscales indicate greater perception of the supportive nursing behavior that helped them during labor. In the adult population, reliability was estimated with a Cronbach's alpha of .99 (Bryanton et al., 1994).

Prior to data collection, the BANSILQ-A was mailed to a panel of four experts who work with and understand the female adolescent population. This panel of experts consisted of two pediatric nurse practitioners and two pediatric registered nurses. While reviewing the instrument for content validity, these experts were asked to evaluate the items for clarity and readability for the adolescent population. They were encouraged to reword, make additions, and/or delete items that were not appropriate or not syntactically appropriate to the adolescent population.

The expert review revealed that all items were judged relevant. However, the panel recommended rewording of all the items and instructions in order to simplify and clarify. In addition to the content review, three of the four experts reviewed the items with three adolescents, two of whom were aged 13 years and one aged 16 years. The two 13-year-olds needed much more clarification of terms than the 16-year-old. Furthermore, the researcher reviewed the items with two adolescents aged 15 and 17 years. They needed very little clarification of the items. Based on these findings, the clarifications that made the items understandable to the 13-year-olds were used in the final instrument. After item revision, readability level was established using the Microsoft Word computer program. The readability was estimated at a Flesch-Kincaid 6.8 grade level. Cronbach's alpha coefficient for the study was .94.

Cronbach's alphas for the three subscales were .91 (emotional support), .81 (informational support), and .89 (tangible support).

Results

Sixteen adolescents completed the BANSILQ-A, rating the nursing support behaviors that they experienced according to their perceived helpfulness. The mean ratings for each supportive behavior on the questionnaire were ranked from most helpful to least helpful. The top three most helpful behaviors were “praised me” (M = 4.67, SD = 0.82), “gave me pain medication” (M = 4.64, SD = 0.50), and “accepted what I said and did so without judgment” (M = 4.53, SD = 0.83). The Table presents the top 10 supportive behaviors as perceived by the adolescents. Mean scores for all 25 supportive behaviors ranged from 4.67 to 2.11.

Table.

Top 10 Labor Support Behaviors That Are Most Helpful

Labor Support Behavior N = 16 M SD Support Category
The nurse…
 1. praised me. 4.67 0.82 I/E
 2. gave me pain medication. 4.64 0.50 T
 3. accepted what I said and did so without judgment. 4.53 0.83 E
 4. appeared calm and confident when giving care. 4.50 0.94 T/E
 5. made me feel cared about as an individual. 4.50 1.03 E
 6. treated me with respect. 4.50 1.03 E
 7. attempted to lessen demands on me. 4.38 1.19 T/E
 8. answered my questions truthfully. 4.37 1.02 E
 9. provided distractions by talking to me. 4.31 0.95 E
 10. assisted me in breathing/relaxing. 4.27 1.39 T
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E = Emotional Support

I = Informational Support

T = Tangible Support

Mean score based on 5 points.

Out of the 25 supportive behaviors, some were identified by the adolescents as behaviors they never experienced from the nurses. The four behaviors experienced the least were:

  1. “provided for my partner's physical needs” (n = 7);

  2. “gave me pain medication” (n = 5);

  3. “communicated my needs/wishes” (n = 3); and

  4. “familiarized me with my surroundings” (n = 3).

When asked overall how supportive and helpful the nurses were with their labors, the adolescents perceived that the nurses were supportive and helpful (M = 4.73, SD = 0.46).

Further analysis revealed that of the three supportive categories—emotional support, informational support, and tangible support—adolescents perceived emotional support behaviors as being most helpful (M = 4.04, SD = 0.91). Informational support, which includes such behaviors as “taught me how to breathe and relax during labor pains” and “explained hospital routines and procedures,” was second in importance (M = 3.87, SD = .95). Tangible support, such as “assisted me in breathing/relaxing” and “made me physically comfortable,” was least important (M = 3.80, SD = 1.16).

The data were also explored according to the psychosocial developmental stages of adolescents—middle adolescent (15–16 years old) and late adolescent (17 years old to adulthood) (Mercer, 1979)—to determine differences between the two stages. This analysis revealed that late adolescents' (n = 9) priorities were centered more on pain control and emotional support. The top three behaviors that were most helpful for them were “gave me pain medication” (M = 5.00, SD = 0.00), “made me feel cared about as an individual” (M = 4.65, SD = 0.37), and “answered my questions truthfully” (M = 4.86, SD = 0.37). In contrast, middle adolescents (n = 7) focused on approval, respect, and nurse competency, as evidenced in the three most helpful behaviors: “praised me” (M = 4.63, SD = 1.06), “treated me with respect” (M = 4.63, SD = 1.06), and “appeared calm and confident when giving care” (M = 4.67, SD = 0.82). When supportive categories were evaluated, both the late and middle adolescents found emotional support behaviors were most helpful (M = 4.31, SD = 0.42 and M = 4.03, SD = 1.02, respectively). No data analysis is available on the early adolescent (12–14 years old) because this age group was not represented in the sample.

Discussion

Adult women's perceptions concerning the childbirth experience have been studied for over 40 years. Knowledge of the adolescent's childbirth experience, however, is very limited. This study gives some preliminary insight into the adolescent's experience. Adolescents' needs appear to center around pain control, emotional support, and individualized care. When compared to adults' perceptions revealed in studies in which the BANSILQ was used (Bryanton et al., 1994; Corbett & Callister, 2000), five of the top 10 behaviors that adolescents perceived as helpful were consistent with adults' perceptions. Like adults, adolescents appear to desire individualized care. When support categories were compared, adolescents—again, like adults—seemed to perceive that emotional support (as opposed to informational and tangible support behaviors) was most helpful during childbirth.

Although perceptions appeared similar between adult and adolescent groups, an important difference emerged. The adolescents in this study identified their desire for the means to control their pain as a higher priority than adults did in previous studies. Adults ranked “gave me pain medication” 17th and 19th, respectively, out of 25 behaviors (Bryanton et al., 1994; Corbett & Callister, 2000), while adolescents ranked it second. This finding is also consistent with Nichols' (1992) study in which she found that epidural block was the common response of the control group (n = 10) when asked, “What was the most helpful to you during labor and delivery?” (p. 46).

When developmental stages of the adolescent were explored, middle adolescents wanted supportive care that focused on affirmation of themselves, while late adolescents wanted pain relief. The difference could be due to the fact that middle adolescents want to be treated like adults and that they tend to maintain a stoic front during stress (Mercer, 1979).

Middle adolescents wanted supportive care that focused on affirmation of themselves, while late adolescents wanted pain relief.

Finally, the most interesting finding in this study was that 27% of the adolescents stated they never experienced the nursing behavior “offered me pain medication.” This is a disturbing finding because adolescents' needs seem to focus on pain relief. In addition, 47% of the adolescents stated their partners' needs were not met. The reason for this occurrence is open to speculation. One could hope pain medication was not offered because intense physical support was being offered and a desire for pain medication was not evident. Another possibility is the adolescent appeared outwardly stoical while inwardly feeling unmet needs regarding pain. An even more disturbing possibility would be the nurse's discriminatory or judgmental behavior toward pregnant adolescents. The latter would fit with the apparent ignoring of the partner's needs; thus, this is an area for further research from both the adolescent and the nurse's perspective.

The findings in this study must be interpreted with caution as a result of limitations. A convenience sample of adolescents was used for the study and only 59% consented to participate. The sample possibly is not representative of the majority of pregnant teens. Therefore, the findings are not generalizable to all pregnant adolescents. Collecting data from a more representative sample of pregnant adolescents would be beneficial. No controls were included to assess the truthfulness of responses; thus, participants could have responded in a socially desirable manner. Due to practical considerations, the method of instrument administration was not consistent across both sites. Despite the fact that they were assured of anonymity and confidentiality, participants possibly responded differently based on the type of administration (e.g., a researcher distributing the instruments versus the postpartum nurse asking the adolescent to complete the questionnaire prior to discharge from the hospital). Additionally, the small sample size (N = 16) limited the generalizability of the findings and the reliability estimate of the BANSILQ-A.

Implications for Practice

The adolescent in labor appears to have different supportive care needs than the adult. Additionally, when adolescent developmental stages are considered, differences between middle and late adolescents are evident. Therefore, birth educators and labor and delivery practitioners need to be aware of adolescents' needs. The family's needs and how the adolescent fits into that family must also be considered when planning and providing care for the adolescent (Montgomery, 2003).

In this time of budget-conscious management that leads to limited staffing, birth educators also need to be aware that labor and delivery nurses often encounter barriers to providing supportive care (Davis & Hodnett, 2002; Sauls, 2000) and that, in many settings, nurses actually provide very little support. Studies reveal that nurses spend only 6–24% of their total time providing supportive care to laboring women (Gale, Fothergill-Bourbonnais, & Chamberlain, 2001; Hodnett, 1996). Educators should suggest that the adolescent childbearing family bring a supportive person (i.e., a doula, a family member, or a friend) in order to receive the positive care they expect in labor. Given that labor and delivery nurses experience barriers to providing adequate supportive care, they should educate themselves about the needs of all age groups and develop developmentally tailored supportive interventions for the adolescent. This strategy would allow them to provide the type of supportive care their clients need, within the time constraints of their work environment.

Conclusions

As prenatal educators and intrapartum nurses provide services to childbearing women of all ages, it is important for them to understand the support needs of all age groups, including adolescents. Adolescence is a time of transition between childhood and adulthood. It is a time when the adolescent struggles for independence, a sense of identity, and development as an adult (Erickson, 1986).

In addition to the normal physical and emotional demands of adolescents, the pregnant teenager struggles to cope with the physical and emotional demands of pregnancy, as well as the development of the relationship with the fetus and the assumption of the maternal role. These additional developmental tasks inherent in having a baby place the adolescent in a highly vulnerable position. Pregnancy has the potential to inhibit and interfere with the normal developmental processes of adolescence and cause psychological damage to the development of self and self-esteem (Bloom, 1995).

In order to assist the pregnant adolescent with her developmental process, Nichols (1992) suggested that a need exists for theoretical development on the adolescent childbirth experience. This can be accomplished by exploring the adolescent childbirth experience using the dimensions of values, psychological development, and cognitive development. By identifying helpful supportive behaviors for the adolescent during childbirth, this strategy would help fill in some of the gaps in that framework. Based on the findings of this study, adolescents' needs appear to focus on pain relief, nonjudgmental nursing care, and emotional support.

Adolescents' needs appear to focus on pain relief, nonjudgmental nursing care, and emotional support.

In conclusion, by understanding the needs of the adolescent during childbirth, more nurses may begin to theorize and develop the framework needed to identify and describe the adolescent's childbirth experience. Further research with a larger and more diverse adolescent sample is needed to substantiate the findings of this study.

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