Introduction

In Mexico, more than 2.2 million births were registered in 2017, 17.5 % of which occurred in adolescents ¹; by 2018 between 20 and 25 % of pregnancies within this population were subsequent ². It is worth mentioning that, by 2022, an increase in the Adolescent Specific Fertility Rate (TEFA by its acronym in Spanish) of 66.9 births per thousand adolescents was expected, coupled with the fact that the unmet need for contraceptive methods increased by 20 % as a side effect of the COVID-19 pandemic ³, which exposed young women to a second unplanned pregnancy, especially those who already had risk factors for repeating this phenomenon, such as, low education ⁴, those who were ambivalent and living as a couple ⁵, highlighting that eight out of ten adolescents who were married had a pregnancy ⁶. It is worth mentioning that, by 2022, an increase in the Adolescent Specific Fertility Rate of 66.9 births per thousand adolescents was expected, coupled with the fact that the unmet need for contraceptive methods increased by 20% as a side effect of the pandemic COVID-19 ³, which exposed young women to a second unplanned pregnancy, especially those who already had risk factors for repeating this phenomenon, such as, low education ⁴, those who were ambivalent and living as a couple ⁵, highlighting that eight out of ten adolescents who were married had a pregnancy ⁶.

The significance of the increase in TEFA attributed to Subsequent Pregnancy (SE by its acronym in Spanish) implies poor health, social and economic outcomes for all members of the young family ⁷ at risk of experiencing conditions inadequate for human development ⁸. Due to the consequences described, Prenatal Contraceptive Counseling (CAP by its acronym in Spanish) must be framed in the knowledge and skills of health providers (PS by its acronym in Spanish) to change people's lives ⁹ and in this way positively influence the ambivalence towards an ES, since it has been shown that this condition occurs more frequently in young women and has a significant association with non-use of contraceptives ⁵. For this reason, it is important to deepen into this communication dynamic since, as far as is known, there is little information on this topic in adolescents in the prenatal stage ⁸, It is also known that they take opinions and erroneous concepts as a reference to decide the use of contraceptives ¹⁰ so it is likely that the supply of health services is not covering the needs for their next pregnancy ⁸.

It is known that clinical contexts promote family planning in an authoritarian manner, citing the so-called best interest of the woman and even hiding information or deceiving women into giving their consent to contraception ¹¹. Therefore, contraception is imposed and driven by the reproductive risks that women present. In this regard, the physical space where pregnant adolescents (AG by its acronym in Spanish) receive counseling is called the clinical environment, as well as the interactions they carry out with other PS (social work, laboratory technicians, radiology technicians, etc.).

In this context, mexican adolescents who experienced CAP during the obstetric event mentioned that they felt coerced to use contraceptives, which is why they were not convinced and satisfied with the method used, which may represent a premature abandonment of contraception. In addition to the above, the position of the PS that reproves or demands an explanation about the reasons for her pregnancy, a situation that breaks communication between the professional and the patient ¹².

This study is considered innovative because it addresses the CAP of a vulnerable group that to this day is provided with counseling in the same way as adult women, with a certain detachment from their reproductive rights and continues to trend towards an increase in TEFA, therefore, its approach turns out to be a priority. Furthermore, this study with a social approach allows us to identify relevant aspects of the interaction of PS-pregnant adolescents and context that could generate foundations for the development of concepts to be included in instruments or theories of specific situation aimed at reproductive health in adolescents. In the understanding that these are developed from an integrative approach between research and practice where one of its premises is that the development of theory is a dynamic, clinical and changing process over time in various contexts ¹³.

Social representation (SR by its acronym in Spanish) emerges in moments of crisis or conflict ¹⁴ allowing us to know the system of values and practices that have their own logic and language with the double function of establishing order, providing individuals with the possibility of getting on the right track, dominating its material and social environment, as well as ensuring group communication from the various aspects of the world in a unique form. Based on the above, collective perspectives or knowledge are developed allowing them to understand the daily functioning of the social group ¹⁵. Therefore, the objective was established to explore the SR of the CAP based on the experiences and expectations of the pregnant adolescents and PS in a second-level hospital.

Methodology

Qualitative study, based on Serge Moscovici's Social Representations Theory (1979). Ten primiparous pregnant adolescents under 19 years of age, who attended prenatal consultation and seven PS directly or indirectly involved in the CAP participated. The sampling was non-probabilistic with the objective of obtaining information on the different positions of the PS from which they provided the CAP, who participated in the management of reproductive health and managers of a second level public hospital in the state of Guanajuato, México.

The interviews were carried out from January to February 2022, in private spaces of the hospital. The topic of information related to contraception was addressed in the semi-structured interviews, from which two thematic axes were built, a) experiences related to the delivery of contraceptive information, b) expectations regarding contraception of the participants. The interviews were recorded and transcribed, later through fluctuating reading by two members of the research team, they sought to contrast the discourse with the proposed thematic axes in search of relevant words and phrases to treat the text and transform it into codes in a systematic way: Decomposition, enumeration and classification. Relationships between them were then identified to generate categories and subcategories ^16,17, to subsequently analyze the internal organization of the operation of the SR ¹⁸.

Subject to duly signed informed consent and approval, the principle of freedom of participation and confidentiality of information was complied with. The identity of all participants was protected with pseudonyms. Due to the nature of the study, it was classified as minimal risk in accordance with the general health law on research ¹⁹. It is worth mentioning that this study was approved by the ethics and research committee of the host hospital with folio R-2020-1006-029.

Results

The pregnant adolescents had a mean age of 17.7 (SD=1.8) years, all lived in common-law marriage, the average gestation week was 29.9; 80 % did not use a contraceptive before the current pregnancy, 60 % agreed that the implant was the ideal contraceptive after childbirth. Regarding school level, 80 % had completed secondary school. The PS had a mean age of 45.3 (SD=10.5) years, 85 % were women, among them were medical, nursing, and social work personnel in direct care of pregnant adolescents and hospital managers. For the analysis of the SR in the CAP, the data were organized according to the understanding of its functioning, which implied a double identification: regarding the structure, it was represented with an approximation scheme of the SR, (Figure 1).

* Health providers (PS) and † Pregnant adolescents (AG)

Figure 1. Social representation of prenatal contraceptive counseling, 2022 (n=17). Source: own-development 

It consists of three SR dimensions ^13,14: a) Information, which refers to the organization or amount of knowledge that PS and pregnant adolescents have; b) Field of representation, which integrates a level of organization in relation to its immediate sources, in this respect the categories and subcategories related to the expectations of the CAP and the environment where it is carried out are shown; and c) Attitude, which can be a favorable orientation or unfavorable in relation to the object of the SR, in this respect the attitude of the pregnant adolescents was the acceptance of counseling and PS showed a paternalistic position.

Regarding its content, it deals with the generation of categories and subcategories which were organized to identify the intersection of the social aspect with the psychologists, (Table 1).

In category 1: Acceptance of contraceptive counseling, it was noted that in the reconstruction of the CAP, the GAs linked the positive effects of contraceptive use with motherhood, the information was accepted in the face of ignorance and first maternal experience, they expressed:

AG 1: They give me a lot of information about how to take care of myself, and all of that, and I say that it's okay, because there are things that as a new mother scare me and we don't know many things that could negatively affect me.

AG 4: They tell me that it is for my own good and to give things to my baby, one who is a first-timer...

AG 9: That having a child is not just anything, it is a great responsibility.

With respect to category 2: Need for interaction, the expectations that the pregnant adolescents had of the CAP, evoked the female figure subcategory, the pregnant adolescents unanimously agreed on the preference of receiving counseling from a woman, someone with a medical degree because they see who had more knowledge, stating:

AG7: I would like the doctor to be a woman, it's just that it's hard to talk to men doctors, or something like that, it's better if it's a woman, so I can trust her from the first time...

AG4: That she was a doctor and with experience, older doctors have more experience in that…

AG5: The female Doctor would know how to explain things to me better and they would have a better point of view.

AG7: More than anything that she -the doctor- was a woman. A female Doctor would tell me more about risks and complications.

AG9: I can trust better a female nurse, it's easier to speak out...

AG1: Well, I don't know, especially that one can trust her, that one doesn't feel embarrassed talking to her, that it's not correct to clarify doubts.

The second subcategory was human values and proximity, where it was emphasized how important it was for them that the PS approached them and provided counseling based on respect, kindness, trust and honesty.

AG6: That they were respectful and kind, well I don't really know, I would have more confidence asking them what I want to know.

AG10: Ask us if we have doubts and that they give us the confidence to respond.

AG4: That they be kind to understand better […] that the female doctor would treat us well, with responsibility and honesty.

AG6: To be kind… because we feel insecure, and all of that (laughs), the doctor won't see us.

AG5: Respect, dignity, responsibility; to be told if I'm doing well, if I'm missing something... and so on.

AG3: Female doctors must be respectful in giving patients advice and therapies.

AG9: It is a new topic, well not so new, but, maybe we feel embarrassed to talk about it and we need confidence; yes, that they give us the confidence to ask if we have doubts.

AG2: That the doctor approached the person, well, I would say, approach and start the conversation.

Regarding the value subcategory of the clinical context, the AGs did not view the environment as an element that could influence in the CAP or in the decision to use a contraceptive.

AG1: That I was well attended, because there are times when we don't know who to ask anymore, because everyone is very busy and we are afraid to interrupt.

AG3: It would be like normal, it's more important that they take good care of me, mm-hm ... I don't pay attention to that, as long as they take good care of me, that's fine.

AG4: I don't need to be seen a lot, for me it would be more important the trust, the way the doctor treats me and the way she expresses herself.

Category 3: Lack of knowledge about contraceptives allowed us to identify that the dialogue about CAP was transformed into the need for safe and reliable information, where it was shown that the AGs were interested in learning about contraception, which is closely related to the prevention of the second pregnancy. They were asked the following question: If you had the opportunity to give advice to female doctors about how to provide contraceptive counseling to young mothers like you, what would you tell them?

AG1: I would like to be informed about the advantages of one or the other and the risks they have.

AG2: That the doctor explains well what each of the methods is for, that is, the implant, what is it good for? Or, for example, can he explain to me if the patch is better? Have each method explained to me.

AG3: Let them tell us if they work 100% so that we don't get pregnant again so soon.

AG10: That they inform us well, above all, that they give us information so that we can make the right choice.

AG9: That they make recommendations depending on our body, because they are all different like those that are hormonal or those that are not, those that have reactions in the bodies and in what way.

AG7: I think the best thing to do would be to explain the most effective ones, until one is sure that the chosen method is the right one.

AG8: That if the method I choose is going to work for me [...] that it won't affect me to feed my baby.

In relation to category 4: Reproductive risk, it was shown that the assessment and counseling carried out by the PS visualized the complexity that AG care represents such as premature birth, hemorrhages, vaginal tears, and the risk of mortality for both the mother and of the newborn. From this, the paternalism subcategory emerged, where it seems that the PS choose from their perspective the appropriate method for the AG, the expressions shown were:

PS1… According to the risk, the planning method is offered…

PS4: When the patient arrives at the outpatient clinic referred to from the first level and is at the second level, knowing that it is an adolescent pregnancy, what happens next? …. They know that they have a high-risk pregnancy! So, counseling is given...

PS7: A pregnant or postpartum adolescent is a risk, doctors talk to her about the intergenesis period, the appropriate age of pregnancy… they are still in the growth stage and giving life to another little person, well that's where the risk began.

PS8: Young mothers do not realize the risk and then return pregnant again, it is important that they receive information so that they do not become pregnant again… it is easy for them to leave without a method.

In category 5: Recognition of reproductive rights, from this the need for privacy emerged as a subcategory, the PS recognized the need for privacy and dignified attention to AG, although they did not provide relevance to this topic, the CAP involves sensitive issues, therefore, an exclusive space could improve this interaction. In this regard, the following were obtained:

PS2: We would have to look for a medical office where there is the material we need, with a gynecological table to place an Intrauterine Device (IUD) [...] a space where the woman feels confident and secure...

PS4: A decent place is required, suitable for working on the processes [...] for more personalized counseling.

The subcategory focused counseling refers to an exclusive CAP for AG taking into account their experiences and contraceptive needs,

PS3: It is very important that the information provided to adolescents be different according to their maturity and experience so that it is digestible, that they understand such information at their young age.

PS2: … We could add that this care be more... mm-mh more in line with the needs of each patient […] we have to know how to reach them, know what is their interest for their future? And according to this, we can make offers.

PS4: … Seeing it as a public health problem for adolescents, it should be focused on the mission, particularizing this population group.

PS3: … It is very important that adolescent girls learn in their own way and needs, that they leave convinced that they must plan…

PS5: … Talk to them, at their level…

The timing for offering contraception has an ideal moment according to the speeches of the PS who agreed that the prenatal stage is appropriate to provide CAP:

PS4: … They come to us directly to the tocosurgery emergency care, practically at the end of the pregnancy referred from their unit [...] one focuses a little more on what the outcome of the pregnancy will be like and certainly sometimes there is not much space, without it being justifiable that they are not directly guided about family planning...

PS3: …It is difficult in labor, adolescents no longer pay attention to one thing or another […] being talked to from pregnancy is good, but generally they do not have an informed consent.

PS2: …Because it is a more vulnerable population… well, it would be important to give them counseling from the prenatal consultation, because they must have their ten, eleven prenatal consultations and from there it is explained to them…

In category 6, barriers of the clinical environment, the PS expressed greater relevance to the contextual aspects that made it difficult to provide a CAP according to the needs of the AG and to openly discuss to give way to their particular decisions. In the subcategory, influence of family members, they said:

PS1: … It is difficult for them to accept because perhaps they love their mother and they always give their opinion, it is not easy for the girl to speak or decide so easily, the mothers do not let them!

PS2: … Sometimes the husband does not agree, because what the partner says or what the mother-in-law or mother says has a lot of influence...

PS3: … The mothers get upset because the staff is insistent, they feel harassed, it is necessary to inform them and convince them...

En la segunda subcategoría: opciones limitadas, se apreció una lucha de valores, dónde a pesar de que los PS reconocieron los derechos reproductivos de las AG y contaban con conocimientos para brindar consejería de acuerdo con las demandas de información de las AG, su consejería se limitó a debido a las recursos disponibles y políticas institucionales. In the second subcategory: limited options, a struggle of values was seen, where even though the PS recognized the reproductive rights of the AG and had the knowledge to provide counseling in accordance with the information demands of the AG, their counseling was limited due to available resources and institutional policies.

PS4: … At the second level of care, the methods that are suggested as contraceptive methodology after an obstetric event are the IUD or the definitive method, they are the ones that qualify at a given time by program...

PS5: … What methods does each institution have? Ours has very few, it has the basics, the family medicine units have others and here we counterpoint each other...

As a second subcategory in the barriers of the clinical environment, compliance with the indicator emerged where directive communication could be seen:

PS2: We assure that new mothers leave with some contraceptive method…

PS1: …From level one, […] they begin to be told about the methods... not this method!, and that is where our success rate drops and they come with the mentality that the female doctor already told them that was going to give them the implant or that this other one and they divert a lot of information from us, but in any case they leave protected.

PS3: …Actually very few leave without a method, the work that the specialist female nurses and the head of the program do is good.

PS5: …No se va sin método, la que se va sin método de las adolescentes es porque tuvo alguna complicación, alguna hemorragia, alguna preeclampsia… Patient don't leave without a contraceptive method, the adolescent who knows she went out without a method is because she had some complication, hemorrhage, preeclampsia, etc.

Discussion

Based on the objective of exploring the social representations of the CAP based on the experiences and expectations of AG and PS, it can be stated that SR comprise modes of practical thinking aimed at communication, understanding and mastery of the social environment. The social characterization of the contents must refer to the conditions and contexts in which they arise ²⁰. In the clinical context where CAP is provided, antagonistic and concordant behaviors of the participants permeate. Among the first, the AG expressed the need for interaction and proximity, requiring safe and reliable information, recognizing and trusting the figure of the PS, a position shared by adolescents in a similar study ²¹.

In contrast, the PS visualized the AG as having little knowledge of contraception, a situation that could sustain a paternalistic attitude with the authority to decide the most convenient contraceptive for the reproductive risk that the AG represented and, at the same time, convince them to recognize their risk, by admitting an error, which can be repaired by using a contraceptive, emphasizing directive counseling based on the fear of getting sick or dying, leaving aside the right to choose in a free and informed manner about one's reproductive life ²², a situation that matches with the discourse from other AG, where they mentioned that the postponement of a subsequent pregnancy is more like a medical prescription than an informed decision that is their responsibility to apply ¹².

In this sense, it is necessary to mention that it is in the clinical context where most of the therapeutic relationships between SPs and users converge. However, a loss of humanized communication has been observed, impacting the detriment of the user's health, especially in those who could feel vulnerable towards the hegemony of the PS, as in the case of the AG since there is still a tendency to pathologize natural reproductive processes in the context of pregnancy, childbirth and postpartum care, losing the ability to freely decide about their body and sexuality ²³.

Likewise, another opposite aspect will be observed in the representation of the CAP in this hospital with respect to the importance that the participants gave to the values of the clinical environment where the exchange of information occurs. The PS reported that privacy and adequate spaces were required to place the contraceptives, a situation that is consistent with the reproductive rights of adolescents with respect to privacy and to have information to achieve the highest level of sexual and reproductive health ²⁴. Furthermore, it has been shown that an exclusive space for counseling favors comprehensive, quality care and provides security to the person ²⁵.

In contrast, the AG did not give importance to the furniture or exclusive spaces; this value was given to the human values with which the PS provided the CAP, prevailing trust, respect, tolerance, kindness and honesty, given their first maternal experience and the fear of the unknown, such as the side effects of contraceptives on her body and shame of being judged for anticipating a stage of life ²¹, the need for value-based communication has been reported in other research ²⁶. Given that SR are situated at the intersection of the psychological and the social, in the first activity individuals establish their position in certain situations and in the social sphere the specific context participate, communication, codes, values and ideologies related to the situations, positions and belongings, in this way knowledge is socially produced and shared ¹⁹. Therefore, it would be important to evaluate the impact of these values on the CAP to understand how PS influence the result ^25,26 and in the future modify this knowledge and deliver it reorganized to future generations.

Given the AG need for safe and reliable information, it is complex for PS to provide CAP honestly because they are limited to offering information on contraceptives available in the hospital. Beyond the fact that the PS and the AG manage to overcome the communication aspects, it is necessary to increase contraceptive provision and, if appropriate, rethink the institutional provisions, policies and indicators that account for good practices in the CAP with emphasis on rights and needs of the AG, so that they are monitored in the same way as the quantitative aspect of provision.

In this regard, SR comprises the establishment of a relationship whose characteristics are to be able to exchange the sensitive, the idea, and the perception, thus, providing counseling in the prenatal stage could allow the exchange of perceptions and concepts during the dialogue; this opinion is shared in other studies where they mention that one should take advantage of the fact that one hundred percent of adolescents receive prenatal care in health institutions ²⁷ and that counseling during the clinical visit is low cost ² which is why it has been considered this period as the ideal to ensure receipt of a contraceptive ²⁸.

The strength of this work is to have presented the evocation of the experiences and perspectives of the main people involved in the CAP, which can be difficult to access due to the legal, social and health condition of the AG and generally the phenomenon is addressed separately and aimed at the adult population. This knowledge can be useful to generate or adapt reproductive health interventions in the understanding that to provide viability and acceptability to the interventions, it is necessary to analyze the context and needs of the participants ²⁹. From this knowledge it is possible to reconstruct this RS to improve the conduct of a therapeutic plan based on the other, who is for whom the attention is intended ³⁰ and initiate the change of the paradigm from a paternalistic counseling to one focused on the needs of AG, especially in countries with high rates of teenage pregnancy. Nevertheless, since this is a qualitative exploratory study, its results are not generalizable and should be taken with caution according to the context in which the phenomenon occurs.

Conclusions

In the social construction of the CAP, similar experiences and expectations of the participants emerged regarding the ideal time to receive counseling is during pregnancy. Within the antagonistic aspects, a difference in values was found with respect to the CAP experiences.

With the understanding that SR respects the laws of logic, giving rise to empirical research products through its three dimensions, information, field and attitude. In the first, the PS must take into account that the AG pursue a similar objective: to space out their pregnancies, in addition to considering that at this stage they are interested in receiving information. In the second, represented by the field where expectations differed with respect to the values with which the CAP is experienced, given that the PS focused their discourse on the importance of the material resource. Therefore, hospital administrators must be involved in solving this phenomenon since for there to be communication based on values and proximity as referred to by the AG, a change in the paradigm is required from the management, direction and control of human and material resources. Likewise, it is necessary to raise awareness in the PS about the needs of the AG, in addition to having proper spaces and sufficient material to meet the demands in contraception demands in order to fully comply with reproductive rights and gradually eradicate paternalism, since this attitude has not been successful in preventing adolescent pregnancy.

Conflict of interests

The authors stated there was no conflict of interest.

Financing

The authors stated there was no financing for this research.