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Association between perceived social support and anxiety in pregnant adolescents

Abstract

Objective:

To evaluate the association between perceived social support and anxiety disorders in pregnant adolescents.

Methods:

We conducted a cross-sectional study with a sample of 871 pregnant women aged 10 to 19 years who received prenatal care in the national public health care system in the urban area of Pelotas, state of Rio Grande do Sul, southern Brazil. We assessed perceived social support and anxiety disorders using the Medical Outcomes Study Social Support Survey and the Mini International Neuropsychiatric Interview. A self-report questionnaire was used to obtain sociodemographic information.

Results:

The prevalence of any anxiety disorder was 13.6%. Pregnant adolescents with an anxiety disorder reported less perceived social support in all domains (affectionate, emotional, tangible, informational, and positive social interaction). Older teenagers reported lower perceived support in the emotional, informational, and positive social interaction domains, whereas those with low socioeconomic status reported lower perceived social support in the material domain. Women who did not live with a partner had less perceived social support in the affectionate and positive social interaction domains.

Conclusion:

Perceived social support seems to be a protective factor against anxiety disorders in pregnant adolescents, with a positive effect on mental health.

Pregnancy; adolescents; social support; anxiety disorder


Introduction

Pregnancy is associated with a variety of changes, ranging from biological alterations to changes in physical appearance and psychological disturbances. Such changes may have a special impact on teenagers, affecting behavior, attitudes, and decision-making; teenagers are usually not prepared to undertake the psychological, social, and economic responsibilities that come with motherhood. In addition, the instability of conjugal relationships might contribute to the onset of emotional and affective disorders, often exacerbated by the family’s reaction to the pregnancy.11. Sabroza AR, Leal Mdo C, Souza PR Jr, Gama SG. [Some emotional repercussions of adolescent pregnancy in Rio de Janeiro, Brazil (1999-2001)]. Cad Saude Publica. 2004;20:S130-7.

Teenage pregnancy is considered a social problem involving both the teenager and the family. Very often, the pregnant teenager is judged by the family; also, the pregnancy may be initially denied, increasing some pregnancy risks.22. Reis ABF, Silva JLL, Andrade M. Assistência das adolescentes gestantes na estratégia saúde da família. Promocao Saude. 2009;5:23-5. The lack of family support contributes to the risk of psychiatric disorders during pregnancy, especially anxiety disorders, the most common psychiatric disturbance in females of reproductive age.33. Kessler RC, Petukhova M, Sampson NA, Zaslavsky AM, Wittchen H-U. Twelve-month and life time prevalence and life time morbid risk of anxiety and mood disorders in the United States. Int J Methods Psychiatr Res. 2012;21:169-84.

4. Wittchen HU, Jacobi F, Rehm J, Gustavsson A, Svensson M, Jönsson B, et al. The size and burden of mental disorders and other disorders of the brain in Europe 2010. Eur Neuropsychopharmacol. 2011;21:655-79.
-55. Reyes A, Nunes A, Quevedo L, Ribeiro R, Castelli R, Oses JP, et al. Ansiedade em gestantes adolescentes. In: 18° Congresso de Iniciação Científica da UCPel. Pelotas: Universidade Católica de Pelotas; 2009.

Social support, especially from the family, is very important for the maintenance of mental health, increasing an individual’s capacity of coping with stressful situations. In the case of mothers, social support facilitates an adequate behavior towards the child.66. Dessen MA, Braz MP. Rede social de apoio durante transições familiares decorrentes do nascimento de filhos. Psic Teor Pesq. 2000;16:221-31. Some authors refer that emotional or practical support from the family and/or friends in the form of affection, companionship, assistance, and information, makes individuals feel loved, valued, and secure. However, it is important to distinguish between perceived and received social support: the first refers to what the individual perceives as available when needed, and the second refers to what is actually given and received at any given time.77. Cramer D, Henderson S, Scott R. Mental health and desired social support: a four-wave panel study. J Soc Pers Relat. 1997;14:761-75. Studies have found that perceived social support, rather than received support, is what influences individual attitudes, decreasing dysfunctional behaviors.77. Cramer D, Henderson S, Scott R. Mental health and desired social support: a four-wave panel study. J Soc Pers Relat. 1997;14:761-75.

8. Antunes C, Fontaine AM. Percepção de apoio social na adolescência: análise fatorial confirmatória da escala Social Support Appraisals. Paidéia (Ribeirão Preto). 2005;15:355-66.
-99. Wethingston E, Kessler RC. Perceived support, received support, and adjustment to stressfull life events. J Health Soc Behav. 1986;27:78-89.

Various concepts have been used to define social support. Some authors define social support as a set of factors encompassing counseling, positive interactions, guidance, confidence, sense of belonging, information, and assistance,1010. Nunes MJC. Qualidade de vida: influência das variáveis psicossociais [dissertação]. Coimbra: Instituto Superior de Altos Estudos Miguel Torga; 1999. while others define it as the support provided by trusted and reliable people.1111. Cruz EBL. Estudo da relação entre a qualidade de vida relacionada com saúde e o bem-estar psicológico: a satisfação com a vida e o apoio social [dissertação]. Coimbra: Instituto Superior Miguel Torga; 2001. In the present study, the evaluation of social support is based on five domains: tangible support – having access to practical resources and material help; affectionate support – interacting with people who physically demonstrate their love and affection; positive social interaction – interacting with people with whom you relax and have fun; emotional support – ability of social network to meet individual needs in relation to emotional problems; and informational support – interacting with people who advise, inform, and guide.1212. Griep RH, Chor D, Faerstein E, Werneck GL, Lopes CS. Validade de constructo de escala de apoio social do Medical Outcomes Study adaptada para o português no Estudo Pró-Saúde. Cad Saude Publica. 2005;21:703-14. Regardless of the differences, authors emphasize the importance of social support for the well-being of women during pregnancy, as it provides a sense of control over the situation and greater satisfaction with life, and also contributes to low levels of depression and anxiety.1313. Stevenson W, Maton KI, Teti DM. Social support, relationship quality, and well-being among pregnant adolescents. J Adolesc. 1999;22:109-21.,1414. Cobb S. Presidential Address-1976. Social support as a moderator of life stress. Psychosom Med. 1976;38:300-14.

A recent study has found that anxiety and depressive disorders prior to pregnancy, as well as low social support, were important predictors of post-partum anxiety.1515. Martini J, Petzoldt J, Einsle F, Beesdo-Baum K, Höfler M, Wittchen HU. Risk factors and course patterns of anxiety and depressive disorders during pregnancy and after delivery: a prospective-longitudinal study. J Affect Disord. 2015;175:385-95. However, studies linking the different types of social support with anxiety disorders in pregnant adolescents are scarce.

The present study aims to assess the association between perceived social support and anxiety disorders in a sample of pregnant adolescents in the city of Pelotas, state of Rio Grande do Sul, southern Brazil.

Methods

Study design and sample

A randomized clinical trial (RCT) was carried out with a sample of pregnant teenagers aged 10 to 19 years receiving prenatal care in the national public health system in the urban area of Pelotas. Pelotas is a medium-sized city with about 330,000 inhabitants. Between October 2009 and March 2011, participants were invited to participate in the study during visits to 47 primary health care units and three public obstetric clinics across the city. We excluded pregnant teenagers who showed an inability to answer and/or understand the instruments and did not live in the urban area. In the present nested cross-sectional study, information from all 871 pregnant individuals included in the original RCT was evaluated regarding the presence of anxiety disorders and perceived social support.

Measures and variables

To evaluate perceived social support, we used a validated Brazilian Portuguese version of the Medical Outcomes Study (MOS) Social Support Survey1212. Griep RH, Chor D, Faerstein E, Werneck GL, Lopes CS. Validade de constructo de escala de apoio social do Medical Outcomes Study adaptada para o português no Estudo Pró-Saúde. Cad Saude Publica. 2005;21:703-14. to obtain scores regarding five dimensions of social support: tangible support, affectionate support, emotional support, informational support, and positive social interaction. The survey contains 19 questions in which 0 means that social support is available none of the time and 4 indicates that social support is available always. A higher score indicates more social support.

We used a Brazilian Portuguese validated version of the Mini International Neuropsychiatric Interview, a short structured interview with adequate validity and reliability, to diagnose the following anxiety disorders: panic disorder, social phobia, post-traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), and generalized anxiety disorder (GAD).1616. Amorim P. Mini International Neuropsychiatric Interview (MINI): validação de entrevista breve para diagnóstico de transtornos mentais. Rev Bras Psiquiatr. 2000;22:106-15. We considered an individual as a positive case of anxiety if he or she had at least one of the evaluated anxiety disorders.

We used a self-report questionnaire to obtain sociodemographic data, including age, education, and socioeconomic and marital status. We assessed socioeconomic class using Brazilian Market Research Association (ABEP) criteria.1717. Associação Brasileira de Empresas em Pesquisas (ABEP). Critério de classificação econômica no Brasil [Internet]. [cited 2013 Oct]. http://www.abep.org/
http://www.abep.org/...
This classification is based on the accumulation of material wealth. Subjects are categorized into five classes, from A (highest socioeconomic status) to E. Information on parity, gestational risk and planned pregnancy, and tobacco use was also collected.

Analysis

The t test and analysis of variance (ANOVA) were used to compare the mean score obtained in each MOS Social Support Survey domain by different groups of exposure. Variables with p ≤ 0.20 were analyzed using multivariate linear regression. Data were analyzed with SPSS version 22.0. GPower 3.1 was used to calculate effect size.

Ethics

The present study was approved by the Ethics Committee at Universidade Católica de Pelotas (protocol 2007/95). Informed consent was obtained from all participants or their parents.

Results

The sample consisted of 871 pregnant women. The prevalence of any anxiety disorder was 13.6%. Mean age was 17.3 (standard deviation [SD] = 1.6) years; 61.5% were classified as socioeconomic class C, 42.9% had between 5 and 7 years of schooling, 62.8% lived with a partner, 78.7% were primiparous, 72.4% did not plan the pregnancy, 17.7% had at least one gestational risk factor, and 19.1% were smokers (Table 1).

Table 1
Demographic, socioeconomic, behavioral, and gestational characteristics of pregnant adolescents and perceived social support, Pelotas, state of Rio Grande do Sul, Brazil, 2009-2011

Bivariate analysis showed that pregnant adolescents with an anxiety disorder, those with pregnancy risks, and those who smoked had a lower mean perceived social support score in all domains. Similarly, those with fewer years of schooling presented a lower mean perceived social support score in all except the emotional domain. In addition, those in socioeconomic class D and E and who did not live with a partner had a lower mean perceived social support in the tangible and affectionate domains respectively. Pregnant women aged 18-19 years presented a lower mean perceived social support score in the emotional and informational domains. Non-primiparous women had a lower mean perceived social support score in the affectionate, emotional, and informational domains.

Table 2 describes the prevalence of each anxiety disorder and the mean perceived social support score obtained for each dimension in relation to anxiety disorders. The most prevalent anxiety disorder was GAD (8.7%), followed by social phobia (4.8%), OCD (3.7%), PTSD (2.4%) and panic disorder (2.1%). Women with social phobia, OCD, or GAD had a lower score in all social support domains. Those with PTSD or panic disorder had a lower score in the positive interaction domain only.

Table 2
Dimensions of social support associated with anxiety disorders in a sample of pregnant adolescents, Pelotas, state of Rio Grande do Sul, Brazil, 2009-2011

Table 3 shows that all variables associated with a lower social support score in bivariate analyses were still important predictors of perceived social support in adjusted models. Most importantly, having any anxiety disorder reduced the mean perceived social support score by 1.5 for tangible support, 1.1 for affectionate support, 2.4 for emotional support, 2.1 for informational support, and 2.4 for positive social interaction.

Table 3
Adjusted analysis of social support domains in pregnant adolescents, Pelotas, state of Rio Grande do Sul, Brazil, 2009-2011

Discussion

The aim of this study was to assess the association between anxiety disorders and perceived social support in a sample of pregnant adolescents. The results after adjusting for confounding variables demonstrated that pregnant teenagers with any anxiety disorder had a worse perception of social support in all the evaluated domains as compared to those without anxiety disorders. We found a moderate association between anxiety disorders and affectionate, emotional, tangible, and informational domains; and a strong association with the positive social interaction domain. Some authors suggest that anxiety disorders interfere with quality of life and with interpersonal, professional, and social performance, and that individuals who are satisfied with family and social interactions (stronger social support) are more satisfied with life and less anxious.1818. Alden LE, Mellings TM. Generalized social phobia and social judgments: the salience of self- and partner information. J Anxiety Disord. 2004;18:143-57.,1919. Rodriguez MS, Cohen S. Social support. Encycl Ment Health. 1998;3:535-44.

In addition to what the literature shows, our results indicate that among the anxiety disorders we analyzed, GAD is the most strongly associated with the emotional and positive social interaction domains. It is known that GAD impairs social interaction,2020. Engster DTL. Transtorno de ansiedade generalizada [monograph]. Santa Rosa: Unijuí; 2013. which explains why individuals with this disorder tend to be lonely and to not feel the need to communicate.2121. Clark DA, Beck AT. Terapia Cognitiva para os transtornos de ansiedade. Porto Alegre: Artmed; 2012. However, it is possible that individuals with GAD are so involved with their own concerns that they end up not acknowledging the support received.

Despite the fact that anxiety symptoms are frequent during pregnancy, no studies so far have had investigated their association with social support in pregnant adolescents. The literature shows associations between anxiety symptomatology, anxiety traits, and social support in pregnant women of different ages, but not in adolescents specifically.11. Sabroza AR, Leal Mdo C, Souza PR Jr, Gama SG. [Some emotional repercussions of adolescent pregnancy in Rio de Janeiro, Brazil (1999-2001)]. Cad Saude Publica. 2004;20:S130-7.,2222. Benute GG, Galleta MA. Gravidez na adolescência: prevalência, ansiedade e ideação suicida. Rev Assoc Med Bras. 2002;48:198-9.,2323. Caputo VG, Bordin IA. [Mental health problems among pregnant and non- pregnant youth]. Rev Saude Publica. 2007;41:573-81. It is known that the role of social support at different life stages is important to minimize stress that occurs in the presence of psychosocial and physiological changes, such as occurs during pregnancy. It has long been established that social support can prevent different illnesses.2424. Cassel J. The contribution of the social environment to host resistance: the Fourth Wade Hampton Frost Lecture. Am J Epidemiol. 1976;104:107-23.

We found that older teenagers perceived to have less social support in the emotional, informational, and positive social interaction domains. The literature has shown that adult pregnant women receive more social support than do pregnant teenagers.2525. Wahn EH, Nissen E. Sociodemographic background, life style and psychosocial conditions of Swedish teenage mothers and their perception of health and social support during pregnancy and childbirth. Scand J Public Health. 2008;36:415-23.,2626. Figueiredo B, Bifulco A, Pacheco A, Costa R, Magarinho R. Teenage pregnancy, attachment style, and depression: a comparison of teenage and adult pregnant women in Portuguese series. Attach Hum Dev. 2006;8:123-38. However, a recently published study examining the effects of social support on Canadian women during and after pregnancy found that teenage mothers received more social support from the family during pregnancy than adult mothers.2727. Kim TH, Connolly JA, Tamim H. The effect of social support around pregnancy on postpartum depression among Canadian teen mothers and adult mothers in the maternity experiences survey. BMC Pregnancy Childbirth. 2014;14:162. The authors argue that because teenagers present more difficulties to connect with their peers, the family may end up providing more support. Despite the weak association, we can consider that older mothers have more experience in life, so that their family would not provide the same amount of support demanded by younger women.

A study in Mexico found that a higher household income predicts greater perception of support.2828. Lever JP, Martinez YIC. Pobreza y apoyo social: un estudio comparativo en tres niveles socioeconómicos. Interam J Psychol. 2007;41:177-88. Similarly, we found that adolescents with lower educational level were those who reported less social support in almost all domains. A study has shown an association between early motherhood and low educational attainment, with high school dropout rates when pregnancy occurs.2929. Martins RM, Pessoa SMF, Sousa RA. Perfil de um grupo de adolescentes que já experienciaram a maternidade. Rev Rene. 2002;3:65-70. It has been hypothesized that some teenage girls, notably in the poorest socioeconomic classes, may seek pregnancy as a way to improve their status, as if that were the only possible role for them in society.3030. Sciarra DT, Ponterotto JG. Adolescent motherhood among low-income urban Hispanics: familial considerations of mother-daughter dyads. Qual Health Res. 1998;8:751-63. For these women, pregnancy in adolescence might be a viable and valued project in a context devoid of options or choices for other life projects. Schooling is one of the main protective factors against early pregnancy, which means that more years of study translate into fewer early pregnancies.3131. World Health Organization (WHO). Global strategy for woman’s and children’s health, 2010. 2010 [cited 2014 Sep]. http://who.int/pmnch/activities/advocacy/fulldocument_globalstrategy
http://who.int/pmnch/activities/advocacy...

We also found that pregnant women who did not live with a partner reported less social support in the affectionate and positive social interaction domains. Social support received before and during pregnancy, mainly offered by a partner, seems to be decisive for the mental well-being of pregnant women.3232. Freitas GV, Botega NJ. [Prevalence of depression, anxiety and suicide ideation in pregnant adolescents]. Rev Assoc Med Bras. 2002;48:245-9. Studies show that the absence or lack of support from a companion was more frequent among single teenage mothers or those who did not live with a partner.2525. Wahn EH, Nissen E. Sociodemographic background, life style and psychosocial conditions of Swedish teenage mothers and their perception of health and social support during pregnancy and childbirth. Scand J Public Health. 2008;36:415-23.,2626. Figueiredo B, Bifulco A, Pacheco A, Costa R, Magarinho R. Teenage pregnancy, attachment style, and depression: a comparison of teenage and adult pregnant women in Portuguese series. Attach Hum Dev. 2006;8:123-38. In the United States, a study with pregnant women found that married women had more support than those unmarried and that partner support and marital stability are important factors for health and well-being.3333. Cohen K, Capponi S, Nyamukapa M, Baxter JK, Worly BL. Social determinants of partner support in pregnancy. Obstet Gynecol. 2014;123:S142. Partner support is an important protective factor throughout pregnancy and conception and our study corroborates these findings.

Non-primiparous teenagers perceived less support in the affectionate, emotional, informational, and positive social interaction domains. Primiparous teenagers demand more support, especially to face the challenges of motherhood and to overcome the difficulties imposed by changes, doubts, anxiety feelings, and fears, which can be minimized by having a social support network. In addition, pregnant teenagers who did not plan the pregnancy reported less social support (informational domain). It is known that adequate guidance for young women can prevent pregnancy.3434. Carlos AI, Pires A, Cabrita T, Alves H, Araújo C, Bentes MH. Comportamento parental de mães adolescentes. Ana Psicologica. 2007;25:183-94. The absence of dialogue, acceptance, and understanding make young women vulnerable, with several undesirable consequences, including an early and unwanted pregnancy.3535. Danieli LG. Adolescentes grávidas: percepções e educação em saúde [dissertação]. Santa Maria: UFSM; 2010. In addition, pregnancy imposes risks to adolescents, who are still physically and psychologically immature, increasing the risk of gestational complications, lack of prenatal care, and absence of social support networks.3636. Amorim MM, Lima Lde A, Lopes CV, Araújo DK, Silva JG, César LC, et al. [Risk factors for pregnancy in adolescence in a teaching maternity in Paraíba: a case-control study]. Rev Bras Ginecol Obstet. 2009;31:401-10. An environment surrounded by aggressions, fear, and poor communication, with lack of affection, assistance, and guidance can lead to pregnancy complications, whereas a supportive environment during pregnancy decreases pregnancy risks.3131. World Health Organization (WHO). Global strategy for woman’s and children’s health, 2010. 2010 [cited 2014 Sep]. http://who.int/pmnch/activities/advocacy/fulldocument_globalstrategy
http://who.int/pmnch/activities/advocacy...

We also found that pregnant teenagers who used tobacco reported less social support in the affectionate and material domains. A longitudinal study in Australia showed that tobacco use during pregnancy was significantly higher among women who had financial problems, low social support, and who were victims of violence.3737. Powers JR, McDermott L, Loxton DJ, Chojenta CL. A prospective study of prevalence and predictors of concurrent alcohol and tobacco use during pregnancy. Matern Child Health J. 2013;17:76-84. Another study conducted with Hispanic pregnant women found that smokers had problems like anxiety, low self-esteem, and low support.3838. Maxson PJ, Edwards SE, Ingram A, Miranda ML. Psychosocial differences between smokers and non-smokers during pregnancy. Addict Behav. 2012;37:153-9.

The results of this study should be interpreted in the light of its limitations. First, as in any cross-sectional study, we were not able to evaluate causality. Secondly, we must consider that we did not have a control group of non-teenage pregnant women. However, this study also has some strengths. First, we used a broad sample of pregnant adolescents. Secondly, the use of a validated structured clinical interview to evaluate the psychiatric diagnosis increases the reliability and reproducibility of our results. In addition, our findings have important implications for public health. Considering that anxiety disorders can affect both the mother's health and the offspring, identification of potential risk factors for prenatal anxiety disorders may be helpful for the design of preventive interventions for mothers and infants.

In conclusion, we were able to establish that perceived social support has a positive effect on the mental health of pregnant teenagers, minimizing the possible difficulties of an early pregnancy. This work thus shows that social support must be taken into consideration in the design of adequate health interventions for pregnant teenagers.

Acknowledgements

This work was supported by research grants from Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Programa de Apoio a Núcleos de Excelência (PRONEX - CNPq/Fundação de Amparo è Pesquisa do Estado do Rio Grande do Sul [FAPERGS] - Project IVAPSA).

References

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    Sabroza AR, Leal Mdo C, Souza PR Jr, Gama SG. [Some emotional repercussions of adolescent pregnancy in Rio de Janeiro, Brazil (1999-2001)]. Cad Saude Publica. 2004;20:S130-7.
  • 2
    Reis ABF, Silva JLL, Andrade M. Assistência das adolescentes gestantes na estratégia saúde da família. Promocao Saude. 2009;5:23-5.
  • 3
    Kessler RC, Petukhova M, Sampson NA, Zaslavsky AM, Wittchen H-U. Twelve-month and life time prevalence and life time morbid risk of anxiety and mood disorders in the United States. Int J Methods Psychiatr Res. 2012;21:169-84.
  • 4
    Wittchen HU, Jacobi F, Rehm J, Gustavsson A, Svensson M, Jönsson B, et al. The size and burden of mental disorders and other disorders of the brain in Europe 2010. Eur Neuropsychopharmacol. 2011;21:655-79.
  • 5
    Reyes A, Nunes A, Quevedo L, Ribeiro R, Castelli R, Oses JP, et al. Ansiedade em gestantes adolescentes. In: 18° Congresso de Iniciação Científica da UCPel. Pelotas: Universidade Católica de Pelotas; 2009.
  • 6
    Dessen MA, Braz MP. Rede social de apoio durante transições familiares decorrentes do nascimento de filhos. Psic Teor Pesq. 2000;16:221-31.
  • 7
    Cramer D, Henderson S, Scott R. Mental health and desired social support: a four-wave panel study. J Soc Pers Relat. 1997;14:761-75.
  • 8
    Antunes C, Fontaine AM. Percepção de apoio social na adolescência: análise fatorial confirmatória da escala Social Support Appraisals. Paidéia (Ribeirão Preto). 2005;15:355-66.
  • 9
    Wethingston E, Kessler RC. Perceived support, received support, and adjustment to stressfull life events. J Health Soc Behav. 1986;27:78-89.
  • 10
    Nunes MJC. Qualidade de vida: influência das variáveis psicossociais [dissertação]. Coimbra: Instituto Superior de Altos Estudos Miguel Torga; 1999.
  • 11
    Cruz EBL. Estudo da relação entre a qualidade de vida relacionada com saúde e o bem-estar psicológico: a satisfação com a vida e o apoio social [dissertação]. Coimbra: Instituto Superior Miguel Torga; 2001.
  • 12
    Griep RH, Chor D, Faerstein E, Werneck GL, Lopes CS. Validade de constructo de escala de apoio social do Medical Outcomes Study adaptada para o português no Estudo Pró-Saúde. Cad Saude Publica. 2005;21:703-14.
  • 13
    Stevenson W, Maton KI, Teti DM. Social support, relationship quality, and well-being among pregnant adolescents. J Adolesc. 1999;22:109-21.
  • 14
    Cobb S. Presidential Address-1976. Social support as a moderator of life stress. Psychosom Med. 1976;38:300-14.
  • 15
    Martini J, Petzoldt J, Einsle F, Beesdo-Baum K, Höfler M, Wittchen HU. Risk factors and course patterns of anxiety and depressive disorders during pregnancy and after delivery: a prospective-longitudinal study. J Affect Disord. 2015;175:385-95.
  • 16
    Amorim P. Mini International Neuropsychiatric Interview (MINI): validação de entrevista breve para diagnóstico de transtornos mentais. Rev Bras Psiquiatr. 2000;22:106-15.
  • 17
    Associação Brasileira de Empresas em Pesquisas (ABEP). Critério de classificação econômica no Brasil [Internet]. [cited 2013 Oct]. http://www.abep.org/
    » http://www.abep.org/
  • 18
    Alden LE, Mellings TM. Generalized social phobia and social judgments: the salience of self- and partner information. J Anxiety Disord. 2004;18:143-57.
  • 19
    Rodriguez MS, Cohen S. Social support. Encycl Ment Health. 1998;3:535-44.
  • 20
    Engster DTL. Transtorno de ansiedade generalizada [monograph]. Santa Rosa: Unijuí; 2013.
  • 21
    Clark DA, Beck AT. Terapia Cognitiva para os transtornos de ansiedade. Porto Alegre: Artmed; 2012.
  • 22
    Benute GG, Galleta MA. Gravidez na adolescência: prevalência, ansiedade e ideação suicida. Rev Assoc Med Bras. 2002;48:198-9.
  • 23
    Caputo VG, Bordin IA. [Mental health problems among pregnant and non- pregnant youth]. Rev Saude Publica. 2007;41:573-81.
  • 24
    Cassel J. The contribution of the social environment to host resistance: the Fourth Wade Hampton Frost Lecture. Am J Epidemiol. 1976;104:107-23.
  • 25
    Wahn EH, Nissen E. Sociodemographic background, life style and psychosocial conditions of Swedish teenage mothers and their perception of health and social support during pregnancy and childbirth. Scand J Public Health. 2008;36:415-23.
  • 26
    Figueiredo B, Bifulco A, Pacheco A, Costa R, Magarinho R. Teenage pregnancy, attachment style, and depression: a comparison of teenage and adult pregnant women in Portuguese series. Attach Hum Dev. 2006;8:123-38.
  • 27
    Kim TH, Connolly JA, Tamim H. The effect of social support around pregnancy on postpartum depression among Canadian teen mothers and adult mothers in the maternity experiences survey. BMC Pregnancy Childbirth. 2014;14:162.
  • 28
    Lever JP, Martinez YIC. Pobreza y apoyo social: un estudio comparativo en tres niveles socioeconómicos. Interam J Psychol. 2007;41:177-88.
  • 29
    Martins RM, Pessoa SMF, Sousa RA. Perfil de um grupo de adolescentes que já experienciaram a maternidade. Rev Rene. 2002;3:65-70.
  • 30
    Sciarra DT, Ponterotto JG. Adolescent motherhood among low-income urban Hispanics: familial considerations of mother-daughter dyads. Qual Health Res. 1998;8:751-63.
  • 31
    World Health Organization (WHO). Global strategy for woman’s and children’s health, 2010. 2010 [cited 2014 Sep]. http://who.int/pmnch/activities/advocacy/fulldocument_globalstrategy
    » http://who.int/pmnch/activities/advocacy/fulldocument_globalstrategy
  • 32
    Freitas GV, Botega NJ. [Prevalence of depression, anxiety and suicide ideation in pregnant adolescents]. Rev Assoc Med Bras. 2002;48:245-9.
  • 33
    Cohen K, Capponi S, Nyamukapa M, Baxter JK, Worly BL. Social determinants of partner support in pregnancy. Obstet Gynecol. 2014;123:S142.
  • 34
    Carlos AI, Pires A, Cabrita T, Alves H, Araújo C, Bentes MH. Comportamento parental de mães adolescentes. Ana Psicologica. 2007;25:183-94.
  • 35
    Danieli LG. Adolescentes grávidas: percepções e educação em saúde [dissertação]. Santa Maria: UFSM; 2010.
  • 36
    Amorim MM, Lima Lde A, Lopes CV, Araújo DK, Silva JG, César LC, et al. [Risk factors for pregnancy in adolescence in a teaching maternity in Paraíba: a case-control study]. Rev Bras Ginecol Obstet. 2009;31:401-10.
  • 37
    Powers JR, McDermott L, Loxton DJ, Chojenta CL. A prospective study of prevalence and predictors of concurrent alcohol and tobacco use during pregnancy. Matern Child Health J. 2013;17:76-84.
  • 38
    Maxson PJ, Edwards SE, Ingram A, Miranda ML. Psychosocial differences between smokers and non-smokers during pregnancy. Addict Behav. 2012;37:153-9.

Publication Dates

  • Publication in this collection
    04 Aug 2016
  • Date of issue
    Jan-Mar 2017

History

  • Received
    01 Sept 2015
  • Accepted
    17 Feb 2016
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