Family stress, perception of pregnancy, and age of menarche among pregnant adolescents.

Ravert, April A. ; Martin, Jennifer

INTRODUCTION

The number of adolescents who become pregnant in the United States each year has generated widespread public concern and has positioned adolescent pregnancy as a major social problem. Empirical data suggest that family stress, strain, and conflict may be predictors of high risk for early pregnancy (Hanson, Myers, & Ginsburg, 1987; Knowles & Tripple, 1986; Robbins, Kaplan, & Martin, 1985). The breakdown of the family system may encourage adolescents to seek other "love objects" in order to compensate for their lack of attention and nurturance (Fox, 1980). This love object may be the conceived child or the sexual partner, both of whom may provide a sense of security that is absent in maladapted families (Landy et al., 1983). Adolescents from families that lack resources and the ability to effectively manage these resources may face greater risk for early pregnancy (Fox, 1980). Family-related transitions and stressors may also contribute to exposure to negative consequences for the adolescents' mental health and development (Blom, Cheney, & Snoddy, 1986; Humphrey, 1988). Consequently, numerous adverse effects have been related to adolescent pregnancy and parenthood, including excessive stress, inadequate social support networks, interrupted education, welfare dependency, and repeat pregnancies (Elster, McAnarney, & Lamb, 1983; Furstenberg, Brooks-Gunn, & Chase-Lansdale, 1989; Mosher & Horn, 1988).

More specifically, the role of family stress has been linked with pubertal timing and early female maturation (Belsky, Steinberg, & Draper, 1991; Wierson, Long, & Forehand, 1993). Pregnant adolescents are faced with dual developmental crises - the situational crisis of pregnancy and parenthood superimposed on the maturational crisis of adolescence (Elster et al., 1983). Adolescence is a time when lifelong competencies and coping strategies develop. Thus, adolescence is a peak point for experiencing rapid changes and disorienting events. As a consequence, adolescents may be particularly vulnerable to stressful events (Newcomb, Huba, & Bentler, 1986).

Purpose

Because an empirical relationship between family stress and risky sexual activity among teens has been demonstrated (Chilman, 1985; Fox, 1980), these variables merit further exploration. When assessing the needs of adolescents at risk for early pregnancy and those already pregnant, a missing link is apparent. Although much is known about the consequences of pregnancy for adolescents, little is known about the experience of pregnancy from the adolescent's perspective (Stenberg & Blinn, 1993). The purpose of this study was to investigate whether there is a relationship between the pregnant adolescent's family stress level and the perception of her pregnancy as a life event. Also examined was age of first menarche among pregnant adolescents and its relation to family stress levels.

Background

While research concerning the relationship between family stress and adolescent pregnancy is limited, studies on family stress (Barnett, Papini, & Gbur, 1991; Belsky et al., 1991) and the individual's perception or appraisal of stressful events in life (Lazarus & Folkman, 1984) have been conducted. According to Newcomb et al. (1986), the subjective awareness that disruptive events occur, even without directly experiencing the change, can influence how individuals structure their lives and organize their internal coping strategies and defenses. Thus, the perception of potential life changes is seen as important for adolescents to consider when evaluating their own vulnerabilities and creating a self-perception, or self-identity, that will guide the remainder of their lives (Newcomb et al., 1986). Phenomenological theory suggests that persons will assign significance to an event based on their experience and mastery of the environment. Therefore, if a person appraises an event as important, the event would be expected to be more distressing than if the event were appraised as unimportant (Lazarus & Folkman, 1984).

Robbins (1981) conducted a study to determine if there is a relationship between "high life event scores" and adolescent pregnancy. Findings indicated that pregnant adolescents had higher life change event scores with a greater number of life change events than did their non-pregnant peers. Records (1993), in ascertaining adolescents' perception of life events, conducted a study to investigate the life events of pregnant and nonpregnant teens. Although findings revealed no significant differences between the groups in terms of total number of life events experienced, or in the perception of life events as good or bad, the nonpregnant group reported both fewer good and fewer bad events. It appears that some adolescents may view their pregnancy as an expected life event based on their family and extended family environments (Field, Widmayer, Stringer, & Ignatoff, 1980). Therefore, while educators view adolescent pregnancy as a pressing social problem, the adolescent may present an attitude of indifference or even contentment with her pregnancy. If the pregnancy is perceived as an expected life event, it may not generate feelings of surprise in the pregnant adolescent.

The influence of familial stress and conflict on puberty timing has been explored extensively (Surbey, 1990; Belsky et al., 1991; Steinberg, 1988). Steinberg (1988) reported that pubertal changes were associated with changes in family relationships. In particular, a reciprocal relationship was found between earlier pubertal development and escalation in family conflict (Steinberg, 1988). Belsky et al. (1991) proposed that pubertal timing should be viewed and treated by psychologists as the dependent variable rather than the independent variable.

METHOD

Subjects

Participants were recruited from six community prenatal clinics. The sample was comprised of 97 adolescents who were experiencing a pregnancy at the time of the study. The ages ranged from 13 to 18 years with a mean age of 16 years, 7 months. Three ethnic groups were represented: (1) 48 African Americans, (2) Caucasians, and (3) 36 Latinas. All subjects were receiving public assistance at the time of data collection. Participation in the study was voluntary, and was incorporated into the last twenty minutes of a scheduled prenatal education class.

Measures

Family stress level. The Adolescent-Family Inventory of Life Events and Changes (A-FILE) developed by McCubbin & Thompson (1987) was used to measure the level of family stress experienced by each subject. The A-FILE is a 50-item self-report instrument designed to measure normative and nonnormative life events and changes an adolescent perceives his or her family has experienced during the past 12 months. The A-FILE also records certain life events (27 items which are a subset of the total 50) a family experienced prior to the past year. Those events which frequently take longer to adapt to or, by their nature, have chronic effects generating a prolonged residue of strain and possible distress upon the adolescents, are considered in the A-FILE. The instrument was designed for completion by adolescents of junior and senior high school age, 12 to 18 years (McCubbin & Patterson, 1982). For reliability purposes, the authors of the A-FILE utilized the Chronbach's alpha and obtained an overall internal reliability of .69 based on a sample of 500 junior and senior high school students. Test-retest reliabilities were then conducted two weeks later based on a sample of 74 junior and senior high school students for all categories of the A-FILE, resulting in an internal reliability score of .82.

Perception of pregnancy rating. The researcher developed a brief instrument for additional data collection. Based on a Likert-type design, this instrument contained one question designed to measure the impact of pregnancy as a life event. Each subject selected the amount of impact of her pregnancy by circling numbers 0 through 3. Answers to this question ranged from 0 "it has not changed my life at all," to 3 "it has been the biggest change ever in my life." A second question asked the subject's age at first menarche. The remaining questions requested: (a) number of family members or relatives who became pregnant within the last 2 years, (b) number of friends who became pregnant within the last 2 years, (c) age of subject's mother when her first child was born, (d) age of subject's grandmother, and (e) how pregnancy has changed the subject's life. The instrument was subjected to a pilot test in which clarity and readability were assessed; no adjustments or changes were required.

Procedure

The researcher, who is also a prenatal educator, conducted class prior to data collection. During the last 20 minutes of class, subjects who did not wish to participate in the study were free to leave the classroom before data collection began. Each subject who agreed to participate in the study was given a packet containing the data collection materials and consent forms. Each packet also contained a description sheet for the study, two copies of the informed consent form, the A-FILE instrument, the perception of pregnancy rating sheet, and a card requesting results. After an initial oral description of the study, subjects were informed that their identities would be kept completely confidential and that they would be allowed to discontinue participation at any time once the study had begun. After completing each instrument within the packet, subjects were given an opportunity to ask the researcher questions. Subjects who did not have questions were free to leave the classroom. Upon leaving the classroom, each subject received a prenatal gift packet from the researcher in appreciation for participation.

FINDINGS

The Biomedical Data Processing (BMDP) statistical package was used to analyze data. The level of significance was set at p [less than or equal to] .01 for all data tested. The mean family stress score for the subjects in the study was 16.84, with a median score of 16, and range of scores from 0 to 39 points out of a possible 50. This group of subjects reported higher than average stress means when compared with the mean score of 7.53 found in the A-FILE instrument norms.

The mean score for the perception of pregnancy ratings by the subjects was 1.86 on a scale of 0 to 3 with a median rating of 2. Five subjects rated their pregnancy as "0 - having no change on my life"; 30 subjects rated their pregnancy as "1 - having a little change on my life"; 36 subjects rated their pregnancy as "2 - having a lot of change on my life"; and 26 subjects rated their pregnancy as "3 - having the biggest change ever on my life." Because the mean of 1.86 rating fell between the "a little" and "a lot" categories, it was termed moderately influential for the purposes of this study. A point biserial correlation was used to test significance of the relationship between the level of family stress scores and perception of pregnancy ratings (rpb = .13, p = .22). Results indicated no significant relationship at the p [less than or equal to] .01 level.

The subjects in this study reported an average age at first menarche of 12.5 years. A Pearson product-moment correlation coefficient was used to analyze whether there was a significant relationship between the pregnant adolescent's age of menarche and level of family relationship between the pregnant adolescent's age of menarche and level of family stress score. The results of the analysis revealed no significant relationship (r = .03, p = .77). The subject's age of menarche was consistent with the nation's average of 12 to 13 years (Swenson & Havens, 1987).

DISCUSSION

No significant relationship was found between level of family stress and perception of pregnancy as a life event. Results, however, did indicate that this group of subjects reported higher than norm stress means. Phenomenological theory contends that a life event is more distressing if it is perceived or appraised as important (Lazarus & Folkman, 1984). These subjects found the pregnancy only moderately life-changing, perhaps less stressful than might be expected because of the large amounts of overall family stress present in their lives, to which more importance and attention was attributed. Moreover, researchers have found that some adolescents may view their pregnancy as an expected life event based on their family environments (Field et al., 1980). If teen pregnancy is indeed an expected life event, it is likely to be viewed as less life-changing than other unexpected stressful life events.

The finding of no significant relationship between family stress level and age of first menarche was not supported by the research literature. Previous research has implicated an inverse relationship between family stress and pubertal timing and menarche (Belsky et al., 1991; Wierson et al., 1993). According to Belsky et al. (1991), moderate and relatively high levels of stress tend to stimulate earlier maturation. Although these subjects had higher than normal family stress levels, they reported age of first menarche at 12 to 13 years, which is consistent with the nation's average age of 12.5 years found in prior studies (Swenson & Havens, 1987).

CONCLUSIONS

The mean family stress scores for the subjects in this study were substantially higher than the average norm previously established for the A-FILE instrument (Kelly Elver, personal communication, March 18, 1994). This finding suggests that, overall, the subjects in this study had experienced a high degree of stressful life events within the family. The mean rating given by the subjects for perception of pregnancy was 1.86 on a scale of 0 to 3, with 3 being "the biggest change ever." This finding implies that subjects in this study did not perceive pregnancy as a highly stressful event, but only moderately stressful. Prenatal educators or counselors should not assume that the pregnancy is perceived as a crisis event by teens but should assess it on an individual basis. Other stressors may be considered more life changing than teen pregnancy. It is important for the health educator to be aware of how the adolescent may view the idea of being or becoming pregnant. Often, the educator may have an opportunity to emphasize the importance of preventing unwanted pregnancies when the adolescent perceives having a baby as a positive life experience or a solution to unmet emotional needs from earlier childhood. Therefore, it is imperative that the health or prenatal educator design curricula and interventions around the true needs and concerns of the adolescent.

The finding of no significant relationship between family stress level and age of menarche is noteworthy. Although these subjects had higher than normal family stress levels, they reported age of first menarche within the nation's average of 12.5 years. Perhaps this group of subjects did not come from the maladapted family types portrayed in the literature as contributing to earlier menarche and pubertal timing.

The findings in this study could be useful for prenatal, parenting, and health educators. Moreover, knowledge of family stress and its association with teen pregnancy would be helpful when developing or conducting prevention programs. Most importantly, this information may provide the health care professional with a greater understanding of how adolescents perceive pregnancy when it may be an integral part of their familial and external environments.

The absence of a control group of nonpregnant peers in this study limited the ability to investigate whether nonpregnant adolescents experience comparable family stress levels and perceptions of what the experience of pregnancy would be like. Further research could address whether family and environmental factors influence the adolescent's view of pregnancy as a normative life event. Another question pertains to whether group homogeneity may have played a role in limiting generaliziblity. All subjects who participated in this study were from very similar socioeconomic environments. A similar study with the addition of a control group and incorporating a more socioeconomically diverse sample of subjects would determine if these findings hold true for the general population.

Although the A-FILE instrument appears to be the most appropriate for assessing the particular life events and changes occurring in the lives of adolescents, it was not specially designed for pregnant adolescents. The A-FILE was originally designed for comparing current family stress levels with outcome measures such as use of chemical substances and internal/external locus-of-control health-related behaviors. The norms and comparative data for reliability and validity checks were conducted with only Caucasian subjects residing in the midwestern region of the country. Presently, there does not appear to be an instrument which specifically measures the female or pregnant adolescent's perception of life events and changes. Such an instrument would be useful when researching this particular population.

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April A. Ravert, M.S., Project Coordinator of The Better Chance Program, The Johns Hopkins Hospital, Baltimore, Maryland.