1
Obst et ric Nursing, Specialist in Laborat ory, Universit y of São Paulo at Ribeirão Pret o, College of Nursing, WHO Collaborat ing Cent er for Nursing Research Developm ent , Brazil, e- m ail: acynt ia@eerp.usp.br; 2 Obst et ric Nursing at t he Am paro Mat ernal, SP, Brazil, e- m ail: zairadaud@yahoo.com .br; 3 PhD Professor, Universit y of São Paulo at Ribeirão Pret o, College of Nursing, WHO Collaborat ing Cent er for Nursing Research Developm ent , Brazil, e- m ail: am alm eid@eerp.usp.br, flagom es@eerp.usp.br, nakano@eerp.usp.br
Disponible en castellano/ Disponível em língua portuguesa SciELO Brasil w w w .scielo.br/ rlae
ADOLESCENT PREGNANCY: A COMPARATI VE STUDY BETW EEN MOTHERS W HO USE
PUBLI C AND PRI VATE HEALTH SYSTEMS
Ana Cy nt ia Paulin Bar aldi1 Zair a Pr ado Daud2 Ana Mar ia de Alm eida3 Flav ia Azev edo Gom es3 Ana Már cia Spanó Nak ano3
Bar ald i ACP, Dau d Z P, Alm eid a AM, Gom es FA, Nak an o AMS. Ad olescen t p r eg n an cy : a com p ar at iv e st u d y bet w een m ot h er s w h o u se pu blic an d pr iv at e h ealt h sy st em s. Rev Lat in am En f er m agem 2 0 0 7 set em br o-ou t u br o; 1 5 ( n ú m er o especial) : 7 9 9 - 8 0 5 .
This is a com parat ive and descript ive st udy of adolescent m ot hers who were at t ended in t hree m at ernit ies of t he public healt h syst em and t hree privat e m at ernit ies in a cit y in São Paulo, Brazil, bet ween 2000 and 2002. This st udy aim ed t o com par e t he pr ofile of m ot her s at t ended in bot h syst em s. The dat abase of Ribeir ão Pr et o w as u sed an d 5 , 2 8 6 adolescen t m ot h er s bet w een 1 0 an d 1 9 y ear s old w er e select ed accor din g t o t y pe of delivery, level of inst ruct ion, num ber of prenat al consult at ions and parit y. We found t hat t he users of t he public healt h sy st em had less pr enat al consult at ions, low er lev el of educat ion, higher par it y and t he v aginal deliv er y w as m ost fr equent . The user s of t he pr ivat e healt h syst em , on t he cont r ar y, had m or e pr enat al consult at ions, higher lev el of inst r uct ion, and pr im ipar it y and cesar ean sect ions w er e m or e fr equent .
DESCRI PTORS: obst et r ic nur sing; pr egnancy in adolescence; healt h sy st em s; pov er t y ; hum an dev elopm ent
EMBARAZO EN LA ADOLESCENCI A: ESTUDI O COMPARATI VO DE LAS USUARI AS DE
MATERNI DADES PÚBLI CAS Y PRI VADAS
Se trata de un estudio descriptivo y com parativo entre m adres adolescentes de nacidos vivos atendidas en tres m aternidades del sistem a público y tres del privado de una ciudad del estado de São Paulo, Brasil, entre 2000 y 2002. Su objetivo fue identificar y com parar el perfil de las m adres adolescentes atendidas en los dos sistem as de salud. Para la recolecta de datos, se utilizó el banco de datos del gobierno m unicipal de Ribeirão Preto, de donde fueran seleccionadas 5.286 adolescentes entre 10 y 19 años según el tipo de parto, grado de instrucción, núm ero de consultas de prenatal y núm ero de partos anteriores. Se descubrió que las usuarias del sistem a público hicieron m enor núm ero de consultas de prenatal, poseían escolaridad m ás baja, tenían m ayor paridad, y que el parto norm al fue m ás frecuente. En el privado, fue m ayor el núm ero de postventa de prenatal, la escolaridad, la prim iparidad y el parto cesárea.
DESCRI PTORES: enferm ería obst ét rica; em barazo en adolescencia; sist em as de salud; pobreza; desarrollo hum ano
GRAVI DEZ NA ADOLESCÊNCI A: ESTUDO COMPARATI VO DAS USUÁRI AS DAS
MATERNI DADES PÚBLI CAS E PRI VADAS
Trat a- se de est udo descrit ivo e com parat ivo ent re m ães adolescent es de nascidos vivos, at endidas em três m aternidades do sistem a público e três do privado de um m unicípio do Estado de São Paulo, Brasil. Teve com o obj et ivo ident ificar e com parar o perfil das m ães adolescent es at endidas nesses sist em as de saúde. Para a colet a de dados, utilizou- se o banco de dados da prefeitura de Ribeirão Preto, SP, de onde que foram selecionadas 5.286 adolescent es de 10 a 19 anos, segundo t ipo de par t o, gr au de inst r ução, núm er o de consult as de pr é- nat al e núm ero de partos anteriores. Encontrou- se que as usuárias do sistem a público fizeram m enor núm ero de consultas de pré- nat al, possuíam m enor escolaridade, t inham m aior paridade, o part o norm al foi m ais freqüent e, enquant o no privado foi m aior o núm ero de at endim ent o de pré- nat al, a escolaridade, a prim iparidade e o part o cesariano.
I NTRODUCTI ON
T
h e n eed t o h av e social r igh t s gu ar an t eed b y t h e St at e af t er t h e Con st it u t ion of 1 9 8 8 led t oprofound changes in t he organizat ion of public policies
in Br azil. I n t er m s of h ealt h r ig h t s, t h ese ch an g es
aim ed t o universalize t he populat ion’s access t o healt h
services, in an at t em pt t o dim inish social inequalit ies
an d , con seq u en t ly, p ov er t y an d u n d er d ev elop m en t
in several r egions of t he count r y.
T h e h e a l t h s y s t e m s h a v e u n d e r g o n e
t r ansfor m at ions ov er t im e t ow ar ds t he fulfillm ent of
t h e i r u se r s’ n e e d s, a s w e l l a s o f e a ch co u n t r y ’ s
polit ical, social and econom ic int er est s. I n dev eloping
c o u n t r i e s , e s p e c i a l l y i n B r a z i l , a n e v i d e n t
d em og r ap h ic t r an sit ion h as occu r r ed , w h ich led t o
t h e r e o r g a n i za t i o n o f t h e h e a l t h sy st e m , w h o se
indicat or s( 1) ar e: r educed r at es of infant and per inat al
m o r t al i t y, d ecr eased f ecu n d i t y i n w o m en o v er 2 0
y ea r s o l d a n d i n cr ea sed l i f e ex p ect a n cy a t b i r t h .
How ever, t h e fecu n dit y rat e am on g adolescen t s h as
incr eased in t he per iod. I n 1999( 2- 3), 23% of m ot her s
w er e u n der 2 0 y ear s old.
Th e f ecu n dit y r at e is in v er sely pr opor t ion al
t o t hese adolescent s’ incom e and educat ion. I n 1996(
4-5 )
, t h e p r o p o r t i o n o f 1 5 y ear - o l d w o m en w h o h ad
init iat ed t heir r epr oduct iv e life r eached 5 5 % am ong
t hose who had no educat ion; 19% am ong t hose who
h ad f iv e t o eig h t y ear s of sch oolin g an d less t h an
1 0 % am on g t h ose w it h 9 t o 1 1 y ear s of sch oolin g.
Ther e ar e also ot her fact or s( 5) t hat cont r ibut e t o t he
increased num ber of pregnant adolescent s: precocious
m en ar ch e an d sex u al lif e an d p r ecar iou s access t o
healt h services, w hich offer deficient fam ily planning,
sin ce t h ese ar e con sid er ed t h e f ou r t h p lace w h er e
adolescent s find r eliable infor m at ion on sex ualit y( 6).
Desp it e t h e st r on g b iop sy ch osocial im p act
e x e r t e d b y a d o l e sce n t p r e g n a n cy, t h e b i o l o g i ca l
aspect is less affect ed, at least fr om t he age of 1 6
on w ar d s, b ecau se it s ef f ect s( 7 ) on t h e ad olescen t ’s
organism and obst et rical result are equivalent t o t hose
on adult w om en. The psy chological aspect is one of
t h e m o s t c o m p l e x , d u e t o t h e p e c u l i a r i t i e s o f
dev elopm en t in t h is st age of life. Th e social aspect
im plies sch ool ev asion an d con sequ en t pr of ession al
l i m i t at i on , w h i ch can com p r om i se t h ei r f u t u r e l i f e
ex p ect at ion s.
Po v er t y an d so ci al ex cl u si o n can b e seen
bot h as a cause and consequence of ear ly pr egnancy.
Th er e w as a decr ease in t h e pr opor t ion of liv ebor n
i n f a n t s f r o m t h e l e ss t o t h e m o r e e co n o m i ca l l y
fav or ed ar eas; t he highest r at es of specific fecundit y
w er e obser v ed in ar eas w it h t he w or st socioeconom ic
c o n d i t i o n s( 8 ), a c c o r d i n g t o a s t u d y o n t h e
i n t e r m u n i c i p a l r e l a t i o n b e t w e e n p o v e r t y a n d
adolescent pr egnancy in a cit y of São Paulo. Nat urally,
a cou n t r y ’s cap acit y of g en er at in g w ealt h d ep en d s
o n t h e p r o f e ssi o n a l f o r m a t i o n o f i t s m e m b e r s( 9 ).
Ad o l escen t a r e i n t h e m i d d l e o f t h i s ca p a ci t a t i o n
pr ocess and it is desir able t hat t hey com plet e t heir
educat ional and pr ofessional for m at ion, ent er t he j ob
m ar k et an d t h en co l l ab o r at e i n t h e g en er at i o n o f
of f spr in g w h o w ill gu ar an t ee t h e con t in u it y of t h eir
so ci a l g r o u p . Be ca u se o f t h e p r e v a l e n ce o f l o w
-i n c o m e a d o l e s c e n t m o t h e r s w -i t h p r o f e s s -i o n a l
lim it at ions, t he dem and for healt h ser v ices t o childr en
w i t h d e v e l o p m e n t a n d n u t r i t i o n a l d e f i c i t s a n d
a f f e c t i v e a n d p s y c h o l o g i c a l p r o b l e m s h a s a l s o
i n cr e a se d . Co n se q u e n t l y, t h e so ci a l a n d f i n a n ci a l
cost s h av e also gr ow n , m ak in g t h e dev elopm en t of
t h ir d w or ld cou n t r ies’( 5 ) societ y an d econ om y ev en
m or e dif f icu lt .
Br azil liv es a dichot om y r egar ding it s healt h
se r v i ce s: o n t h e o n e si d e , t h e r e a r e t h e h e a l t h
i n su r a n ce p l a n s, u su a l l y a cce ssi b l e t o t h e m o r e
fav or ed classes and, on t he ot her, t he Single Healt h
Syst em - SUS - offered t o all cit izens, but in pract ice
u sed p r ed o m i n an t l y b y t h o se o f l o w er acq u i si t i v e
p ow er. Th e p u b lic an d p r iv at e h ealt h ser v ices ar e
i n f l u e n ce d b y t h e l i f e st y l e o f t h e i r u se r s, w h i ch
det erm ines t he care m odel t hat is im plem ent ed. Thus,
differ ent pr ofiles of user s at t ended in t he t w o healt h
s y s t e m s a r e i d e n t i f i e d , a s w e l l a s s i g n i f i c a n t
dif f er en ces in t h e r esu lt s of t h ese t w o su bsy st em s’
car e d eliv er y.
This st udy aim ed t o ident ify and com pare t he
p r o f i l e o f ad o l escen t m o t h er s u ser s o f p u b l i c an d
pr ivat e healt h syst em s of a cit y in São Paulo, Br azil,
t hr ough index es of m or t alit y and bir t h, or ganized by
t h e st at ist ical ser v ice of t h e Mu n icipal Secr et ar y of
Healt h - MSH, av ailab le in t h e cit y ’s ad m in ist r at ion
sit e( 10). I t is believ ed t hat , in defining t he pr ofile of
a d o l e sce n t m o t h e r s, f o r t h i s g r o u p o f u se r s, a n
an al y t i cal v i ew can b e co m p o sed o f t h e p o t en t i al
d i f f e r e n t i a l i m p l i ca t i o n s i n t h e f o r m o f ca r e t h a t
op er at e in ou r local h ealt h sy st em . I n t u r n , it can
provide support for t he planning of act ions, adequat e
st ruct ure and organizat ion of services and com posit ion
of t he support net work, t owards t he so desired equit y
MATERI AL AND METHODS
This descr ipt iv e st udy uses infor m at ion fr om
t h e d ecl ar at i o n o f l i v eb o r n i n f an t s o f ad o l escen t s
at t ended at t hr ee hospit als accr edit ed by t he public
healt h syst em and t hr ee pr ivat e inst it ut ions in a cit y
in t he St at e of São Paulo, in 2000- 2002.
Th e n u m b er o f d el i v er i es o ccu r r ed i n t h e
p er iod w as t ak en in t o accou n t f or t h e select ion of
hospit als and t hose wit h t he highest num ber of birt hs
w er e ch osen .
The bir t h indicat or s fr om t he MSH dat abase,
available in t he cit y adm inist rat ion sit e( 10), were used
for dat a collect ion. A t ot al of 5,286 liveborn infant s of
a d o l e s c e n t s m o t h e r s w a s c o m p u t e d , w h o w e r e
bet ween 10 and 19 years old, as est ablished by WHO.
The dat abase m ent ioned abov e is fed by t he healt h
s t a t i s t i c s s e c t o r o f t h e MS H , w h o s e s o u r c e o f
in f or m at ion is t h e Declar at ion of Liv ebor n I n f an t s
-DLI . Th e -DLI is f illed ou t in each h ospit al an d on e
copy is forward t o t he MSH, where t he inform at ion is
analyzed and classified by t he healt h st at ist ics sect or.
For t his st udy, t he follow ing var iables w er e select ed:
m o t h er ’s a g e, t y p e o f d el i v er y, m o t h er ’s l ev el o f
e d u ca t i o n , n u m b e r o f p r e n a t a l co n su l t a t i o n s a n d
n u m ber s of pr ev iou s deliv er ies.
Beca u se t h ese a r e seco n d a r y d a t a i n t h e
p u b lic d om ain , m ad e av ailab le w it h ou t cost b y t h e
inform at ics depart m ent of t he Single Healt h Syst em
-SUS, t h is p r oj ect d id n ot n eed t o b e su b m it t ed t o
appr eciat ion of t he Resear ch Et hics Com m it t ee.
RESULTS
Based on t he dat a obt ained, t he adolescent
m ot her s’ pr ofile for t he st udy v ar iables is pr esent ed.
Tab le 1 sh ow s t h e d ist r ib u t ion of liv eb or n
i n f a n t s o f a d o l escen t m o t h er s i n b o t h p u b l i c a n d
pr iv at e sy st em s, accor ding t o t he m ot her s’ age and
healt h est ablishm ent in w hich t hey w er e at t ended.
A t ot al of 5,286 liveborn infant s of adolescent
m ot h er s w as com pu t ed. Fr om t h is t ot al, 6 1 8 bir t h s
( 1 1 . 7 % ) o ccu r r e d i n p r i v a t e h o sp i t a l s a n d 4 , 6 6 8
( 88. 3% ) in public hospit als. The occur r ence of eight
liv ebor n in fan t s ( 1 . 3 % ) w as obser v ed am on g 1 0 t o
14 year- old m ot hers in privat e hospit als, against 188
( 4.03% ) in t he public syst em . I n t he 14 t o 19 year
-old r ange, 4, 480 ( 95. 97% ) bir t hs occur r ed in public
hospit als and 610 ( 98.7% ) in pr iv at e hospit als. I t is
im port ant t o appoint t hat t he percent age of birt hs, in
t h e 1 0 t o 1 4 y ear - old r an ge, is t h r ee t im es h igh er
bet w een SUS user s.
Table 1 - Dist ribut ion of liveborn infant s of adolescent
m ot h er s in t h e p u b lic an d p r iv at e h ealt h sy st em s
according t o t he m ot hers’ age and est ablishm ent t hey
were at t ended in, in a cit y in São Paulo St at e, bet ween
2000 and 2002
t n e m h s il b a t s
E Age(years) Total FreqRueelanitcvye(%) 4
1 -0 1 . q e r
F Freq15-19 e
t a v i r
P 8 610 618 11.7
c il b u
P 188 4480 4668 88.3
l a t o
T 196 5090 5286 100
Source: ht t p: / / w w w.ribeiraopret o.sp.gov.br
Tab le 2 sh ow s t h e d ist r ib u t ion of liv eb or n
i n f a n t s o f a d o l e sce n t m o t h e r s i n t h e p u b l i c a n d
p r i v at e h eal t h sy st em s acco r d i n g t o t h e m o t h er s’
ag e an d lev el of ed u cat ion . I t w as f ou n d t h at t h e
m a j o r i t y o f t h e p r i v a t e h e a l t h s e r v i c e s u s e r s ,
b et w een 1 5 an d 1 9 y ear s ol d , h ad ei g h t or m or e
y ear s of st u d y, t h at is, t h e ex p ect ed sch oolin g f or
t h is age r an ge w as m et in 7 0 . 3 3 % of t h e cases ( 4 2 9
m o t h er s) , w h i l e o n l y 2 4 . 2 6 % ( 1 4 8 m o t h er s) h a d
four t o sev en y ear s of schooling. Am ong t he m ot her s
of liv eb or n in f an t s, u ser s of SUS in t h e sam e ag e
r an ge, 4 9 . 5 3 % ( 2 , 2 1 9 m ot h er s) h ad f ou r t o sev en
y ear s of st u d y, t h at is, t h e ex p ect ed sch oolin g d id
not follow t he age r an ge; 4 4 . 5 5 % h ad eigh t or m or e
y ear s of sch oolin g . Am on g t h e ad olescen t m ot h er s
o f l i v eb o r n i n f a n t s, SUS u ser s b et w een 1 5 t o 1 9
y ear s old , 1 9 4 ( 4 . 3 3 % ) h ad on e t o t h r ee y ear s of
sch oolin g , ag ain st n in e m ot h er s ( 1 . 4 7 % ) w it h t h e
sam e lev el of sch oolin g in t h e pr iv at e ser v ice, t h at
is, a num ber alm ost t hr ee t im es higher of schooling
delay t han t hose or iginat ed fr om t he public sy st em .
Th er e w er e 4 5 SUS u ser s w it h n o sch oolin g, w h ich
did n ot occu r in t h e pr iv at e sy st em .
All m ot her s of liv ebor n infant s in t he 1 0 t o
1 4 y ear - o l d ag e r an g e i n t h e p r i v at e sy st em h ad
schooling com pat ible w it h t heir age, t hat is, four t o
s e v e n y e a r s o f s t u d y. Al t h o u g h t h e m a j o r i t y o f
m ot her s w ho w er e SUS user s in t he sam e age r ange
p o s s e s s s c h o o l i n g c o m p a t i b l e w i t h t h e i r a g e
( 9 6 . 8 % ) , t h er e w er e t h r ee m ot h er s w h o had on e t o
t h r ee y ear s of st u d y an d t w o w it h n o sch oolin g at
Ta b l e 2 - D i s t r i b u t i o n o f l i v e b o r n i n f a n t s o f
adolescent m ot her s in t he public and pr iv at e healt h
sy st em s accor ding t o t he m ot her s’ age and lev el of
ed u ca t i o n , i n a ci t y i n Sã o Pa u l o St a t e, b et w een
2 0 0 0 an d 2 0 0 2
Tab le 4 sh ow s t h e d ist r ib u t ion of liv eb or n
infant s of adolescent m ot hers according t o t he m ot hers’
age and num ber of prenat al consult at ions at t ended, in
t he sam e cit y and period considered. The m aj orit y of
adolescent m ot hers of liveborn infant s at t ended seven or m ore prenat al consult at ions in bot h healt h syst em s,
t hough t he percent age of m ot hers in t he public syst em
wit h t his num ber of consult at ions is lower t han in t he
privat e syst em ( 54.46% against 89.34% respect ively,
if we consider t he age range from 14 t o 19 years old
and 48.93% against 87.5% am ong adolescent s 10 t o 14 years old) . None of t he m ot hers bet ween 10 and 14
years old who were users of t he privat e healt h service
perform ed less t han six prenat al consult at ions, different
from what occurred in t he SUS: 31.38% ( 59 m ot hers)
at t ended four t o six consult at ions, 28 ( 14.9% ) at t ended
b et w een on e an d t h r ee con su lt at ion s, w h ile t h r ee
m ot hers did not at t end t o prenat al consult at ions. On ly on e adolescen t ( 0 . 1 6 % ) , in t h e r an ge
from 15 t o 19 years old from t he privat e syst em did
not per for m any pr enat al consult at ion. On t he ot her
hand, 1 1 3 ( 2 . 5 2 % ) adolescent s in t he public healt h
s y s t e m p r e s e n t e d s i m i l a r s i t u a t i o n s , t h a t i s , a
per cent age 15 t im es higher. I n t he sam e age range, am ong adolescent m ot hers who perform ed one t o t hree
pr enat al consult at ions, 433 ( 9.67% ) w er e SUS user s
and only five ( 0.82% ) used t he privat e healt h syst em .
Wh ile an ex pr essiv e n u m ber of m ot h er s per f or m ed
bet w een f ou r an d six pr en at al con su lt at ion s ( 1 , 3 6 3
adolescen t s - 3 0 . 4 3 % ) , in t h e pr iv at e sy st em , t h is
num ber decreases t o 46 adolescent m ot hers ( 7.54% ) .
Table 4 - Dist ribut ion of liveborn infant s of adolescent
m ot h er s in t h e p u b lic an d p r iv at e h ealt h sy st em s
according t o t he m ot hers’ age and num ber of prenat al
consult at ions, in a cit y in São Paulo St at e, bet w een
2000 and 2002 e g A ) s r a e y ( g n il o o h c S ) s r a e y ( c il b u
P Private
y c n e u q e r
F FreqRueelancitvye(%)FrequencyFreqRueelancitvye(%)
4 1 o t 0
1 None 2 1.07 -
-3 o t
1 3 1.59 -
-7 o t
4 182 96.8 8 100
d e r o n g
I 1 0.54 -
-l a t o t b u
S 188 100 8 100
9 1 o t 5
1 None 45 1 -
-3 o t
1 194 4.33 9 1.47
7 o t
4 2219 49.53 148 24.26
e r o m r o
8 1996 44.55 429 70.33
d e m r o f n i t o
N 3 0.07 -
-d e r o n g
I 23 0.52 24 3.94
l a t o t b u
S 4480 100 610 100
l a t o
T 4668 100 618 100
Source: ht t p: / / w w w.ribeiaopret o.sp.gov.br
Tab le 3 sh ow s t h e d ist r ib u t ion of liv eb or n
infant s in public and privat e healt h services according
t o t he m ot hers’ age and t ype of delivery. There were
1 4 2 v ag in al d eliv er ies ( 7 5 . 5 3 % ) an d 4 6 c- sect ion s
( 24.47% ) am ong m ot her s bet w een 10 and 14 y ear s
old in t he public healt h syst em . I n t he privat e syst em ,
o n l y o n e ch i l d w as b o r n t h r o u g h v ag i n al d el i v er y
( 12.5% ) and seven t hrough c- sect ion ( 87.5% ) . Am ong
m ot hers from 15 t o 19 years old, t his proport ion was
kept , wit h 3,275 vaginal deliveries ( 74.10% ) and 1,204
c- sect ions ( 2 . 8 7 % ) in t he SUS, against 1 0 3 v aginal
deliv er ies ( 16. 68% ) and 507 c- sect ions ( 83. 12% ) in
t he pr iv at e healt h sy st em .
Table 3 - Dist ribut ion of liveborn infant s of adolescent
m ot h er s in t h e p u b lic an d p r iv at e h ealt h sy st em s
according t o t he m ot hers’ age and t ype of delivery, in
a cit y in São Paulo bet ween 2000 and 2002
e g A ) s r a e y
( dTyepilveeoryf
c il b u
P Private
y c n e u q e r
F FreqRueelancitvye(%)FrequencyFreqRueelanitcvye(%)
4 1 o t 0
1 Vaginal 142 75.53 1 12.5
n o it c e s
-C 46 24.47 7 87.5
l a t o t b u
S 188 100 8 100
9 1 o t 5
1 Vaginal 3275 73.1 103 16.88
n o it c e s
-C 1204 26.87 507 83.12
d e r o n g
I 1 0.03 0 0
l a t o t b u
S 4480 100 610 100
l a t o
T 4668 100 618 100
Source: ht t p: / / w w w.ribeiraopret o.sp.gov.br
) s r a e y ( e g
A CoPnsreuntlaataitolns Pubilc Private y c n e u q e r
F FreRqueelancitvye(%)FrequencyFreqRueelanitcvye(%)
4 1 o t 0
1 None 3 1.6 0 0
3 o t
1 28 14.9 0 0
6 o t
4 59 31.38 0 0
e r o m r o
7 92 48.93 7 87.5
d e r o n g
I 6 3.19 1 12.5
l a t o t b u
S 188 100 8 100
9 1 o t 5
1 None 113 2.52 1 0.16
3 o t
1 433 9.67 5 0.82
6 o t
4 1363 30.43 46 7.54 e r o m r o
7 2440 54.46 545 89.34 d e m r o f n I t o
N 2 0.04 0 0
d e r o n g
I 129 2.88 13 2.14
l a t o t b u
S 4480 100 610 100
l a t o
T 4668 100 618 100
Tab le 5 sh ow s t h e d ist r ib u t ion of liv eb or n
i n f a n t s o f a d o l e s c e n t m o t h e r s a c c o r d i n g t o t h e m ot her s’ age and num ber of pr ev ious childr en. The
m aj or it y of adolescent m ot her s ( 97. 3% ) , SUS user s
f r o m 1 0 t o 1 4 y e a r s o l d , d i d n o t h a v e p r e v i o u s ch ild r en , w h ile f ou r of t h em h ad b et w een on e an d
t hree children. None of t he adolescent m ot hers in t he
sam e age range from t he privat e syst em had previous
childr en. Ther e w as a case in w hich t his infor m at ion w as not know n in each age range m ent ioned. I n t he
pr iv at e sy st em , 84.2% of t he adolescent m ot her s in
t he age range from 15 t o 19 years old had no previous ch ildr en an d 1 3 . 6 % of t h em h ad bet w een on e an d
t hr ee childr en. Am ong t he adolescent user s of SUS,
76% did not have previous children and 23.9% ( 1,071 m ot hers) had bet ween one and t hree children. I n t he
public healt h syst em , t hree adolescent s had from four
t o six ch ild r en , w h ich d id n ot occu r in t h e p r iv at e
syst em . There was one case in which t his inform at ion was given as “ ignored” in t he public syst em and 13 in
t he pr iv at e sy st em in t he age r ange consider ed.
Table 5 - Dist ribut ion of liveborn infant s of adolescent
m ot h er s in t h e p u b lic an d p r iv at e h ealt h sy st em s
according t o t he m ot hers’ age and num ber of previous liveborn children, in a cit y in São Paulo St at e, bet ween
2000 and 2002.
in t he sam e per iod, 17% of t he adolescent s had no
easy access or healt h services available t o specifically
m eet t he y oung and t he needs t y pical of t heir age,
w h i c h w a s a m a j o r o b s t a c l e i n t h e a c c e s s t o
i n f o r m a t i o n a n d a ct i o n s t o p r o t e ct t h e i r h e a l t h ,
hindering t heir free and responsible decision m aking( 6).
I t is k now n t hat fecundit y t ends t o dim inish
wit h t he increase in years of educat ion and educat ional
per for m ance( 4). Dat a fr om lit er at ur e show t hat ear ly
pregnancy can lead t o, besides low self- est eem , giving
u p sch o o l , w o r k an d ev en l ei su r e; am o n g f act o r s
det er m ining t he adolescent ’s abandonm ent of school
b e f o r e t h e ch i l d ’ s b i r t h a r e e m b a r r a ssm e n t a n d
pr essur e fr om dir ect or s, t eacher s, peer s and fr iends’
p ar en t s( 1 1 ). Tab le 2 sh ow s t h e d if f er en ces b et w een
sch oolin g of adolescen t m ot h er s of liv ebor n in f an t s
bet ween t he t wo syst em s st udied. Schooling followed
t h e age r an ge for t h e m aj or it y of m ot h er s u ser s of
privat e healt h services, while t he sam e is not t rue for
t h e SUS u se r s. Th e r e w e r e d i f f e r e n ce s b e t w e e n
schooling of m ot her s bet w een 10 and 14 y ear s old:
in t h is age r an ge, t h er e w er e n o m ot h er s w it h less
t h an t h r ee y ear s of sch oolin g in t h e pr iv at e h ealt h
syst em , while t here were five m ot hers in t his sit uat ion
in t he public syst em , t wo of whom had no educat ion
-t he ex pec-t ed lev el in -t his age r ange is fr om four -t o
five years of schooling. These dat a indicat e t he need
for public policies t hat st im ulat e t he insert ion of t hese
young in school life, value school as an inst rum ent of
int ellect ual and social ascension, and avoid t he evasion
o f t h o se w h o a r e a l r e a d y i n se r t e d i n t h e f o r m a l
e d u c a t i o n p r o c e s s . Th e Pa n A m e r i c a n H e a l t h
Or g a n i z a t i o n ( PA H O) a p p o i n t s t h a t a d o l e s c e n t
pr egnancy is an ent r ance door t o pov er t y because it
l e a d s t o a d e cr e a se d se t o f so ci a l a n d e co n o m i c
possibilit ies, including school access( 12). The dem ands
of t he m oder n, indust r ialized and infor m at ized w or ld
do not absorb t his disqualified and non- prepared labor,
w hich per pet uat es t he sit uat ion of pov er t y fr om t he
y oung t o t heir childr en.
Because adolescent s spend, on t he av er age,
fiv e hour s per day at school, it could be used as an
im port ant healt h prom ot ion agent , since t his populat ion
is a pr ior it y in t he public policies dir ect ed at sex ual
and r epr oduct iv e r ight s. Resear ch( 6,13) show s t hat , in
t he period bet ween 2001 and 2002, 94% of Brazilian
a d o l e sce n t s b e t w e e n 1 2 a n d 1 7 y e a r s o l d w e r e
r egist er ed in som e t each in g est ablish m en t , 5 4 % of
w h o m w e r e m a l e . Th e i n t e r v e n t i o n i n t h e s e
a d o l e sce n t s a t sch o o l h a s t h e a d v a n t a g e o f a l so
e g A
) s r a e y (
s u o i v e r P
n r o b e v i L
n e r d li h C
c il b u
P Private y
c n e u q e r
F FreqRueelancitvye(%)FrequencyFreqRueelanitcvye(%)
4 1 o t 0
1 None 183 97.3 7 87.5
3 o t
1 4 2.1 -
-d e r o n g
I 1 0.6 1 12.5
l a t o t b u
S 188 100 8 100
9 1 o t 5
1 None 3405 76 514 84.2
3 o t
1 1071 23.9 83 13.6
6 o t
4 3 0.07 -
-d e r o n g
I 1 0.03 13 2.2
l a t o t b u
S 4480 100 610 100
l a t o
T 4668 100 618 100
Source: ht t p: / / w w w.ribeiraopret o.sp.gov.br
DI SCUSSI ON
I n t he m unicipalit y and period under st udy, a
num ber of adolescent m ot hers eight t im es higher was
co m p u t ed i n t h e m a t er n i t i es o f t h e p u b l i c h ea l t h
sy st em . Th e UNI CEF r epor t sh ow s t h at 6 2 % of t h e
Br azilian ad olescen t s b elon g ed t o class C an d on ly
2.5% t o class A, bet ween 2001 and 2002( 6). This fact
leads t o a pot ent ial dispar it y regar ding t he access t o
h e a l t h se r v i ce s, d e t e r m i n i n g a h i g h e r n u m b e r o f
e d u c a t i n g b o y s o n c o n t r a c e p t i v e m e t h o d s a n d
r epr odu ct iv e r igh t s, sin ce h ealt h ser v ice act ion s for
b oy s in t h is ag e ar e p r act ically n on - ex ist en t . Th e
increase of educat ion in t he count ry, t he incent ive for
Br a zi l i a n s t o f o l l o w f o r m a l e d u ca t i o n b e y o n d t h e
p r im ar y lev el p r esen t som e im m ed iat e r ef lex es on
t he r epr oduct iv e healt h of t he w hole populat ion( 4).
Th e r e a r e d i f f e r e n c e s n o t o n l y i n t h e s e
m ot hers’ profiles, but also in t he professionals’ conduct
an d in t h e in st it u t ion s’ h ealt h policies. Th e t y pe of
birt h t o which t he adolescent s were subm it t ed clearly
show s t his dichot om y. St udies( 14- 15) show a high rat e
o f c- sect i o n s i n Br a zi l , m a i n l y d u e t o i n a d eq u a t e
m e d i c a l c a r e , p r e g n a n t w o m e n ’ s p r e c a r i o u s
educat ion, causes of econom ic nat ure, am ong ot hers.
Th is in cr ease is p r og r essiv e an d ex ag g er at ed , an d
occu r s especially am on g t h e socioecon om ic f av or ed
classes, who at t end privat e clinics and/ or have healt h
p l a n s, w h i l e t h e se i n d e x e s a r e l o w e r a m o n g t h e
econ om ically less f av or ed classes, w h ose deliv er ies
m a i n l y o c c u r i n p u b l i c h o s p i t a l s o r t e a c h i n g
hospit als( 14). Table 3 confir m s t his pr ofile: 73.10% of
t he bir t hs occur t hr ough v aginal deliv er y in m ot her s
bet w een 1 5 an d 1 9 y ear s old in pu blic m at er n it ies,
against 26.87% of c- sect ions. I n deliveries perform ed
in privat e m at ernit ies, t he relat ion is invert ed: 16.68%
of v aginal deliv er ies and 83. 12% of c- sect ions. This
proport ion was also found for t he deliveries of m ot hers
bet w een 10 and 14 years old.
I t is im port ant t o appoint t hat t he index of
c-sections tolerated by the Ministry of Health is 15 to 20% ,
and t hat t he current high rat e of c- sect ions const it ut es
a public health problem , since it has led to higher rates
of m at ernal and perinat al m orbidit y and m ort alit y( 16).
The Minist r y of Healt h r ecom m ends as ideal
a m inim um of six prenat al consult at ions, and st resses
t h at t h e ad h er en ce o f w o m en t o p r en at al car e i s
r el a t ed w i t h t h e q u a l i t y o f ca r e d el i v er ed b y t h e
ser v ice and by t he healt h pr ofessionals, w hich ends
up being essent ial for t he r educt ion of t he elev at ed
rat es of m at ernal and perinat al m ort alit y in Brazil( 17).
We can not e in t able 4 t hat , alt hough a m aj or it y of
adolescent m ot her s at t ended seven or m or e pr enat al
consult at ions in bot h healt h sy st em s, t he per cent age
of m ot her s w it h a r educed num ber of consult at ion is
h igh er am on g SUS u ser s: t h er e w as n o adolescen t
wit h less t han six prenat al consult at ions in t he group
from 10 t o 14 years old in t he privat e syst em . I n t he
public syst em , 28 of t hem ( 14.9% ) at t ended bet ween
on e an d t h r ee con su lt at ion s, an d t h er e w er e t h r ee
m ot hers who did not at t end any prenat al consult at ion.
Am ong m ot hers from 15 t o 19 years old, a percent age
15 t im es higher did not at t end prenat al consult at ions
in t he public healt h sy st em ( 0.16% against 2.52% ) ;
9.67% of SUS users in t he sam e age range at t ended
bet w een one and t hr ee consult at ions, against 0.82%
in t he pr iv at e healt h sy st em .
Besides t he young age in t he first pregnancy,
w e can al so n o t e t h at so m e o f t h ese m o t h er s g o
t h r o u g h m o r e t h a n o n e p r e g n a n c y d u r i n g
a d o l e s c e n c e . I n b o t h s y s t e m s , t h e m a j o r i t y o f
adolescent s did not have pr evious childr en. How ever,
t h er e w as a h ig h er p er cen t ag e of ad olescen t s w h o
alr ead y h ad ch ild r en am on g p u b lic h ealt h ser v ice’
users. I t is rem arkable t hat four adolescent s bet ween
10 and 14 y ear s old in t he public ser v ice, had fr om
one t o t hree children and m ot hers from 15 t o 19 years
old had from four t o six previous children. These dat a
con f ir m issu es alr ead y d iscu ssed ear lier, r elat ed t o
t he dir ect pr opor t ional r elat ion bet w een pov er t y, low
schooling, low adher ence t o pr enat al car e and ear ly
pr egnancy, besides pr ecocious m enar che, v er y ear ly
sex u al in it iat ion , lack of r esou r ces an d in f or m at ion
r e g a r d i n g se x u a l l i f e , r e p r o d u ct i v e r i g h t s, f a m i l y
plan n in g an d u n pr epar ed pr ofession als an d ser v ices
t o deal w it h a different client ele.
CONCLUSI ON
I n bot h healt h syst em s, t he adolescent users
o f t h e p u b l i c s y s t e m a t t e n d t o l e s s p r e n a t a l
consult at ions, w it h less educat ion and higher par it y,
n or m al d eliv er ies ar e m or e f r eq u en t w h ile, in t h e
privat e syst em , t he num bers of prenat al consult at ions,
schooling, pr im ipar it y and c- sect ion ar e higher.
Such disparit ies dem onst rat e t he influence of
social inequalit ies in access t o healt h services, form al
ed u cat ion an d in t h e p er p et u at ion of t h e p ov er t y
-p r e c o c i o u s -p r e g n a n c y - -p o v e r t y c y c l e . I t i s
f u n d am en t al t o im p lem en t m u lt id im en sion al p u b lic
p olicies t h at m eet t h is clien t ele’s n eed s, f r om t h e
educat ional pr epar at ion of t hese y oung people aft er
b asic ed u cat ion t o ser v ice an d h ealt h p r of ession al
t raining, so t hat t hey can provide adequat e access t o
i n f o r m a t i o n , f a m i l y p l a n n i n g , se x u a l h e a l t h a n d
r epr oduct iv e r ight s, besides t eam s especially t r ained
f o r t h i s g r o u p ’s p ar t i cu l ar i t i es, t h u s g u ar an t eei n g
im m ediat e r eflect ion s on t h e r epr odu ct iv e h ealt h of
I n a d d i t i o n , t h e St a t e n e e d s t o e x e r t a
regulat ory role in privat e init iat ive, so as t o guarant ee
p r iv at e h ealt h sy st em u ser s ob st et r ical car e b ased
on t he principles of hum anizat ion and encouragem ent
of norm al delivery, in order t o im prov e m at ernal and
per inat al m or bidit y and m or t alit y index es.
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