Dominique P. Béhague 1,2 Helen D. Gonçalves 2

1. Teen pregnancy and mental morbidity: class struggles and social stigma amongst young women in a 1982 birth cohort in Pelotas, Brazil Dominique P. Béhague1,2 Helen D. Gonçalves2 1 – London School of Hygiene and Tropical Medicine, UK 2 – Federal University of Pelotas, RS, Brazil Acknowledgements: WHO, The Wellcome Trust, Cesar Victora, Fernando Barros

2. Teen pregnancy and mental morbidity in early adulthood • Several studies demontrate a statistical link between teen pregnancy and subsequent mental morbidity • Possible explanations • Unwanted pregnancy • Single motherhood • Lack of social support • Economic and educational set-back • Psychological predisposition/co-morbidity  Some of this literature premised on view that teen sexual behaviours are “irrational”

3. 1982 Pelotas birth cohort methodology: Linked epidemiological and ethnographic studies • Epidemiological: Population-based cohort of 5,914 live births with several follow-ups: • 2001 survey -- visits to all households in a systematic sample of 27% of the city's census tracts, 65% found (N=1,031) • 2004-5 survey – whole cohort, 77% found (N=4,297) • Applied questionnaire with young person & guardian + confidential questionnaire • Ethnographic: Randomly selected subsample of 96 youth from 2001 survey • Several years’ follow-up (more than 15 visits per participant from 2001-2007) • In-depth interviews, participant observation, interviews with family members

4. Sample and variables • Restrict analysis to women only • 602 (29%) teen pregnancies (11- 19 years) • Early teen pregnancy = 11-16 years of age (N=212) • Ethnographic study revealed experience of getting pregnancy at ages 17-19 is qualitatively different, and largely more socially acceptable (sometimes expected) • Preliminary data analysis from Pelotas shows that teen pregnancy is rising in the younger age groups (Victora: pers. comm) • SRQ-20 (2004-5 variable) cut-off score > 7 for women, validated for Brazilian setting, indicating common mental disorder (Mari and Williams: 1986)

5. **all associations with p-value < 0.0001

6. Logistic regression analysis for the effect of early teen pregnancy (11-16 yrs) on mental morbidity at 23 years of age ** adjusted for young person’s skin colour, family income (2004-5), educational levels (2004-5)

7. Possible explanations I: Undesired and unexpected pregnancy? • 2001 survey (N=184) • 48 % married or cohabitating at the time of interview • If not, 69% regularly see father of child • 92 % came to enjoy (“curtir”) the pregnancy • Of these, 28% enjoyed pregnancy from beginning • 89 % received help from family or father of child’s family • 94 % of children living currently with mother (or mother and partner) • Situation with contraceptive at the time you think you got pregnant (2001) • 24 % Were not using any contraceptive because actively trying to become pregnant • 34 % Generally using contraceptive but it failed • 35 % Forgot to use/wasn’t generally using • 7 % Don’t know how to use contraceptive • 1 % No money to buy/parents banned use  24 % Stated their pregnancy was planned in 2004-5 survey

8. [And your daughter, did you plan that pregnancy?] No, no, it wasn’t planned. [And what was it like when you found out you were pregnant?] It was, I was, I wasn’t nervous, or anything, I liked the idea, it was just that I was still a bit too young, I think I should have taken advantage of life a bit more before getting pregnant. [So you weren’t frightened.. What went through your head?] No, I wasn’t frightened, I didn’t feel desperate, I liked it. [And for your boyfriend? How did he recieve the news?] He was also happy with the news [And your family?] My mother, of course, she didn’t want this to have happened, she wasn’t happy, but once it happened, it happened. Typical “unplanned” pregnancy amongst families of lower incomes

9. Possible explanations I: Undesired and unexpected pregnancy? • No association between contextual variables relating to the pregnancy and SRQ score: • Except receiving help from family • Active planning of pregnancy = “not using contraceptive because wanted pregnancy” (2001) • No association between actively planning pregnancy and lower SRQ score

10. Possible explanation II: Stigma and class struggles • Although teen pregnancy is more expected amongst lower classes, psychological effects are more pronounced amongst the poor, because young women: • feel socially and institutionally alienated, but concerned about their lack of education and opportunity for upward mobility • demonstrate sensitivity to social stigma relating to teen pregnancy amongst the poor • have strong impetus to reject the values and prescriptions of “normative” society and the upper class in various arenas of life • want to engage with local community so as to change social injustices, but not do so in a way that “buys into” upper class values • Young girls who actively sought to create a new family demonstrated highly politicised attitudes (and practices) regarding the upper class and inequities as a whole 10 teen pregnancies, 5 who wanted to become pregnant, remaining 81 informants + parents, key informants

11. We decided to marry... yes, I think I really resolved many of my problems, everything is so much nicer now, I have more freedom. I'm not working, but I still help my mother, I help her clean up her house, I wash the dishes, I clean the floors... basically, now I stay at home. But I will not say that I am happy, no, because I'm not, the work is hard… I am doing everything possible to try to get paid work, but it's really hard... you know, its the rich people that make us people poor, no really, I mean it. {why do you think that?} Because if we work for a rich person, you earn a tiny amount, a miserable amount, ok, so it's a minimum salary and a half, but you work like crazy, you do everything... then they tell you to do just one more little thing and then before you know it they are exploiting you... don't you go denying it! They want us poor people to be fucked, they are not interested in us. I think this way, because it is the truth. For now, it's ok because I am not hungry, thank God, but it's awful. There are people here (in neighborhood) that are always asking, begging, and they are right, because they don't have food, they are right to ask.

12. Lilian: I only want to have children if I can give them everything, I mean everything, so that they don't have to feel any wants. Lilian's friend: Oh, not me, I want to give everything to my child, but only what is necessary. If not they turn into these very spoiled children, No you have to tell them to get their own things. I can't stand children like that. Lilian: Oh yes, the children who are poorly educated, who get into fights all the time, who use bad language, I don't like that. Lilian's friend: It doesn't matter how much money I will end up having, at least from the first to the sixth grade, I am going to put my child in a state school, if you put them straight into the private system from the beginning, they are raised extremely “metida.” I want to give my children a future, but only starting in high school. [But why, what is it about private schools?] Lilian: Only the little “filinhos de papai” (sons of rich fathers) go there…the children end up all the same, one like the other. Lilian's friend: Yeah, a child that socializes with those types of people, they become completely metida, they will not be raised normally. Imagine, what happens then if you don't have any more money after having put a child through private school, and they have to go back to a public state school? They will have absolutely no friends, because of the way they will be so “izibido” (showing off). [And who do you two know that goes to a private school and that is metido?] Lilian: Oh, we just imagine them… but there are tons of them, I tell you.

13. Effect modification of the association between early teen pregnancy (11-16 years) and high mental morbidity in early adulthood (23 years) &In one or more of following activities: Neighbourhood association, Protest or petition, Political campaign, Political groups * p-value for test of homogeneity

14. For some lower class youth, the active decision to find a partner and parent a child is part and parcel of larger politicised attitudes and class struggles • But these struggles have negative psychological repercussions • stress, “nerves,” anxiety, depression, social isolation

15. Active decision to become pregnant not associated with lower SRQ, but given ethnographic results… • Could the active decision to become pregnant be a risk factor for higher SRQ amongst lower youth who are sensitive to inequities and who are politicised?

16. Effect modification of the association between desire to become pregnant (11-19 years) and high mental morbidity in early adulthood (23 years) * p-value for test of homogeneity

17. Conclusions • Need to tackle assumptions in public health campaigns and society more generally: • Is teen pregnancy due to emotional “irrationality”? • Social contexts push youth towards wanting pregnancy for “rational” reasons • Class inequities and sense of prejudice linked to the “rationality” of teen pregnancy • Possible weaknesses in quantitative study • Residual confounding • Reverse causality