Abstract

This study of multiple cases aimed to analyze the social support network of young mothers of children diagnosed with congenital syphilis in a municipality in Ceará with six participants. Information was collected through semi-structured interviews and analyzed using the cross-case synthesis analytical technique. The young women’s social network comprised family members, people outside the family, and social facilities. We identified heterogeneous bonds and social support as essential in the gestational and postpartum periods after the diagnosis of syphilis. The vertical transmission of syphilis is permeated by subjectivities identified from understanding the context involving social networks, interpersonal relationships, and support for mothers and their children.

Key words:
Adolescent Mothers; Syphilis; Congenital syphilis; Social Support

Introduction

Adolescence is defined as a phase between 10 and 19 years old, and the 15-24 years bracket is conceptualized as youth. The group of adolescents and young people aged between 10 and 24 years old is called the “young population” or “young people”¹1 Brasil. Ministério da Saúde (MS). Secretaria de Atenção em Saúde. Departamento de Ações Programáticas Estratégicas. Diretrizes nacionais para a atenção integral à saúde de adolescentes e jovens na promoção, proteção e recuperação da saúde. Área Técnica de Saúde do Adolescente e do Jovem. Brasília: MS; 2010.. It is a time marked by profound transformations and is considered a period of life with a higher incidence of sexually transmitted infections (STIs)²2 Genz N, Meincke SMK, Carret MLV, Corrêa ACL, Alves CN. Doenças sexualmente transmissíveis: conhecimento e comportamento sexual de adolescentes. Texto Contexto Enferm 2017; 26(2):e5100015.. Syphilis is an increasingly prevalent systemic, curable, and human-exclusive STI among young people. This disease can also be vertically transmitted during pregnancy, resulting in congenital syphilis (CS)³3 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Protocolo Clínico e Diretrizes Terapêuticas para Prevenção da Transmissão Vertical do HIV, Sífilis e Hepatites. Brasília: MS; 2019.^,44 Ceará. Coordenadoria de Promoção e Proteção à Saúde. Núcleo de Vigilância Epidemiológica. Boletim Epidemiológico - Sífilis. Fortaleza: Secretaria da Saúde do Estado do Ceará; 2022..

Congenital syphilis is a severe public health problem, and, despite efforts to prevent it, its incidence rate has significantly increased over the years. A progressive increase in this indicator was detected in Ceará, Brazil, up from 6.0 cases/1,000 live births, in 2010, to 12.9 cases/1,000 live births, in 2021⁴4 Ceará. Coordenadoria de Promoção e Proteção à Saúde. Núcleo de Vigilância Epidemiológica. Boletim Epidemiológico - Sífilis. Fortaleza: Secretaria da Saúde do Estado do Ceará; 2022..

Syphilis vertical transmission affects the mother, the child, and the entire family core, generating concern and anguish but mainly guilt and responsibility. The impact on women’s life becomes evident since the diagnosis of syphilis involves emotional reactions, family conflicts, harm to moral integrity, and social exclusion⁵5 Souza MHT, Beck EQ. Compreendendo a sífilis congênita a partir do olhar materno. Rev Enferm UFSM 2019; 9:e56.^,66 Silva JN, Cabral JF, Nascimento VF, Lucietto GC, Oliveira CBC, Silva RA. Impactos do diagnóstico da infecção sexualmente transmissível na vida da mulher. Enferm Foco 2018; 9(2):23-27..

In this context, the social support network, defined as a complex arrangement that involves human groups, systems, and organizations that are intentionally articulated with each other, stands out as a way of enhancing the initiatives of social stakeholders, promoting their development and capacity of protecting people’s health⁷7 Costa RF, Zeitoune RCG, Queiroz MVO, Gómez GCI, Ruiz GMJ. Redes de apoio ao adolescente no contexto do cuidado à saúde: interface entre saúde, família e educação. Rev Esc Enferm USP 2015; 49(5):741-747.. It is an essential resource for healthcare since the interpersonal connections in the social context of young people influence behaviors, and spread values, skills, and knowledge that can support youth leadership to promote their health⁷7 Costa RF, Zeitoune RCG, Queiroz MVO, Gómez GCI, Ruiz GMJ. Redes de apoio ao adolescente no contexto do cuidado à saúde: interface entre saúde, família e educação. Rev Esc Enferm USP 2015; 49(5):741-747..

The social support network is vital in different periods of youth development, requiring new involvement that guarantees its social role as a support provider throughout life. Understanding the dynamics of young people’s social support network contributes to the knowledge of the socialization processes facilitated by each context for its members⁸8 Nunes TGR, Pontes FAR, Silva I. Juventude e apoio social: um olhar sobre as redes sociais de estudantes paraenses. Praxis Educ 2019;15:e20135341-21..

Young mothers with STIs experience a complex reality involving vulnerabilities that permeate their social context⁹9 Moura SLO, Silva MAM, Moreira ACA, Freitas CASL, Pinheiro AKB. Percepção de mulheres quanto à sua vulnerabilidade às Infecções Sexualmente Transmíssiveis. Esc Anna Nery 2021; 25(1): e20190325.. Children’s congenital syphilis diagnosis is part of this context, which requires investigating the support received by female adolescents to face this reality. Moreover, we should note that congenital syphilis is a hard-to-control disease. Thus, the study may also indicate essential perspectives to be addressed in the care of adolescent mothers.

This study’s guiding question was, “How is the social support network structured for young mothers of children diagnosed with congenital syphilis?” Thus, we aimed to analyze the social support network of young mothers of children diagnosed with congenital syphilis.

Methods

This qualitative multiple-case¹⁰10 Yin RK. Estudo de caso: planejamento e métodos. 5ª ed. Porto Alegre: Bookman; 2015. descriptive research allowed broad and detailed knowledge of the realities studied from the perspective of the researched units. It was held from August 2018 to December 2019 in a municipality in Ceará, Brazil, whose Health System comprises a healthcare network with services at different complexity levels.

Six young females aged 20 to 25 identified via the notification/investigation congenital syphilis form participated in the study through a survey carried out at the municipality’s Regional Health Coordination (CRES). The selected participants’ inclusion criteria were being in the age group between 10 and 24 years old, considered a young population¹1 Brasil. Ministério da Saúde (MS). Secretaria de Atenção em Saúde. Departamento de Ações Programáticas Estratégicas. Diretrizes nacionais para a atenção integral à saúde de adolescentes e jovens na promoção, proteção e recuperação da saúde. Área Técnica de Saúde do Adolescente e do Jovem. Brasília: MS; 2010. at the time of diagnosis of syphilis/CS, and having a child notified as a case of CS in 2017 and 2018.

The information collected in the Congenital Syphilis Notification/Investigation Forms identified 12 young people within the age range of interest in this research (young people aged between 10 and 24 years at the time of their children’s CS diagnosis). The managers of the reference teams of each health unit were contacted to locate the young women in their territories and then define the moment of meeting with the participants. Four did not accept to participate in the study, one was not found at the address registered in the notification form, and another lived in a municipality district, which hindered its localization and interview.

Information was collected through semi-structured individual interviews, one of the most crucial sources of information for a case study¹⁰10 Yin RK. Estudo de caso: planejamento e métodos. 5ª ed. Porto Alegre: Bookman; 2015.. Five interviews were held in the respondents’ homes and one in the PHC Unit (UBS) facility, at convenient and previously determined times, with a mean duration of 30 minutes. They were and audio-recorded with the participants’ authorization, led and transcribed in full by the researcher.

The Calgary Family Assessment Model (CFAM) guided the type of data to be collected and its organization. The CFAM comprises three main categories: structural, developmental, and functional. In this study, only topics related to the structural category were analyzed, consisting of the internal structure, family composition, birth order, and external structure, including data about the extended family and broader systems¹¹11 Wright LM, Leahey M. Enfermeiras e famílias: um guia para avaliação e intervenção na família. 5ª ed. São Paulo: Roca; 2012..

Thus, we obtained data to characterize the young women (age, marital status, schooling, income, occupation, number of children, age at first pregnancy), social support network elements (family members, friends, community services), and aspects of interpersonal relationships involved in experiencing illness from syphilis and CS.

The CFAM also proposes using an ecomap, an instrument that aims to portray the relationships between the internal and external structure members and broader systems¹⁰10 Yin RK. Estudo de caso: planejamento e métodos. 5ª ed. Porto Alegre: Bookman; 2015.. The central circle is called “family or home”, and the outer circles represent people, bodies, or institutions. Lines are drawn between the family and the outer circles that indicate the nature of the links. Straight lines indicate strong relationships, dotted lines are tenuous ties and slashed lines indicate stressful relationships¹¹11 Wright LM, Leahey M. Enfermeiras e famílias: um guia para avaliação e intervenção na família. 5ª ed. São Paulo: Roca; 2012.. GenoPro®¹²12 GENOPRO(r). Versão 3.0.1.5: GenoPro(r) [Internet]. 2019 [acessado 2021 jan 13]. Disponível em: https://www. genopro.com/.
https://www. genopro.com... and Microsoft PowerPoint 2010 program were used as resources for the graphic elaboration of this tool.

The participants represented the index people, and ecomaps were prepared for each case to represent the social support network and its particularities, using them as evidence for studying the family structure and relationships. It is noteworthy that the initial design of the ecomaps occurred during the interviews and was improved after the transcription of the testimonials through the systematized collected information.

Evidence was analyzed using the analytical cross-case synthesis technique¹⁰10 Yin RK. Estudo de caso: planejamento e métodos. 5ª ed. Porto Alegre: Bookman; 2015., applied to multiple-case studies. This method translates by examining, categorizing, and recombining data to direct a discovery, and we adopted the description of cases as a strategy.

Furthermore, through guiding questions, we aimed to understand the young women’s attitudes towards this situation and the impact on their social network, and we could identify the resources and supporting sources employed to tackle the issue. We intended to apprehend information about a specific context of the participants’ lives (a period that included pregnancy, diagnosis of maternal syphilis and SC, childbirth, and puerperium) since the social support network is dynamic and undergoes changes over time.

Bardin’s content analysis method was also used to support the individual analysis of the qualitative information obtained, focusing on the thematic analysis technique¹³13 Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2016., which aimed to delve into more personal issues that emerged from the participants’ statements.

Thematic categories emerged from the content analysis of the interviews: “Organization of the social support network for young mothers in the context of syphilis/congenital syphilis”, “And where does social support for young mothers come from?”, “Furthermore, interpersonal relationships weave the young mother’s social support network”. Subsequently, a cross-case synthesis was performed to compare the data, observing whether they had characteristics that replicated or contrasted.

The study followed Resolution No. 466/2012 of the Ministry of Health. The Research Ethics Committee (CEP) approved the project to which this research is linked under Opinion No. 3.377.307. All participants signed the Informed Consent Form, and the letter J, plus an Arabic number, was used to represent each participant in preserving the anonymity and confidentiality of the young women.

Results

Characterization of the participants

The participants were between 20 and 25 years old (at the time of the interview). Two were single, and four were in a common-law marriage relationship. Two had completed high school, three had completed elementary school, and one had not. Two participants had a paid occupation. Household income ranged from less than one minimum wage to three minimum wages. Four young women were Catholic, one was Evangelical, and another considered herself Christian. Pregnancy was unplanned in three cases. The age of the first pregnancy was between 14 and 23, as the number of children ranged from one to three. The diagnosis of maternal syphilis and congenital syphilis occurred when they were aged between 17 and 23.

Representing the cases

The ecomaps of the individual cases are shown below, which express the most relevant characteristics of the young women’s social support network, including the internal family, the extended family, the broader systems, and the emotional and interpersonal relationships of each context.

The internal family structure was diversified. We identified settings with different compositions. A family composed of the couple and children (J1, J3, and J4), mother and children (J2), and the couple and children with other members of the family of origin, such as the mother-in-law and sister-in-law (J5) and the mother, children, and grandparents (J6).

The components listed by the young women as constituents of their social support network were determined from the connections established between members of the internal family, with the extended family and broader systems, and consisted of family members (partners, children, mothers, grandparents, sisters, uncles, and cousins), people outside the family, such as friends and the services that assisted the young woman and her child during pregnancy. We have also components related to illness from syphilis, represented by nurses and community health workers (ACS), other community institutions (churches, educational and social institutions), and other systems (neighborhood and work), shown in Figures 1, 2, and 3.

The participants’ narratives portray how the young mothers’ social support network is set up in the context of syphilis/congenital syphilis beyond the structural aspect, allowing us to understand it from the established relationships and the interaction of the young women with the constituent elements of this network.

Organization of the social support network for young mothers in syphilis/congenital syphilis context

In the mothers’ social support network, relevant contact with members of the internal structure was identified. However, when asked if the interaction is greater with the members of the internal family, a situation in which the young woman expresses the feeling of not belonging to the current family context was evidenced. These findings are shown below:

As for the external organization, regarding the extended family, close contact with some members (mother, sisters, and uncle) was noticed, and conditions that reveal distancing:

Concerning broader systems, we found a setting with a restricted social support network, but, for the most part, the young women recognized several community institutions and people outside the internal structural context and the extended family belonging to this network. This finding can be evidenced both in the ecomaps and in the participants’ statements:

Furthermore, where does the social support for the young mother come from?

Social support was a fundamental aspect in the experience of young women with complex circumstances during pregnancy, childbirth, syphilis infection, and vertical transmission of the disease. In this sense, mothers reported support from people in broader systems, the extended family, health services, and partners:

The participants also pointed out social support fragilities since they felt helpless in some situations:

The interpersonal relationships that weave the young mother’s social support network

The nature and peculiarities of the established bonds were revealed from the interaction among the social support network members of the young women in this study. We could identify the meaning of these relationships and how they interfered with the context experienced by these mothers. From this perspective, the participants signaled how the relationships between the internal family and the extended family, with the partner, among internal family members, and with broader systems occurred. Internal family:

Regarding the extended Family, we highlight the following:

Discussion

Family is defined as a community that aims to achieve the personal fulfillment of its members, becoming the first group of the social support network with which, the individual interacts. It is a dynamic unit of affective, social and cognitive relationships immersed in the material, historical, and cultural conditions of a given social group¹⁴14 Barroso PO, Pedroso JS, Cruz EJS. Redes de apoio social de famílias com crianças acolhidas institucionalmente: estudo de caso múltiplo. Pensando Fam 2018; 22(2):219-234..

The internal family comprises members who live together in the same household. However, Wright and Leahey¹¹11 Wright LM, Leahey M. Enfermeiras e famílias: um guia para avaliação e intervenção na família. 5ª ed. São Paulo: Roca; 2012. ponder “that the family is whom its members say they are”. Two subcategories are listed regarding the external structure. The first refers to the extended family, which includes the family of origin and the family of procreation, and the current generation. The second is called broader systems and consists of social institutions and people with whom families have significant contact with¹¹11 Wright LM, Leahey M. Enfermeiras e famílias: um guia para avaliação e intervenção na família. 5ª ed. São Paulo: Roca; 2012..

This study evidenced diversified links in family relationships and broader systems. It highlighted gaps regarding the interpersonal relationships of young women with their partners, characterized by conflicting connections and distrust, after the discovery of STI/syphilis (J1, J2). This negative repercussion is pointed out in the literature as the basis for the “betrayal” hypothesis and, therefore, a breach of trust between the couple¹⁵15 Busnello GF, Hoff GA, Kolhs M, Frigo J, Zanotelli SS. Infecção pelo papiloma vírus: conhecimento das mulheres infectadas frente ao diagnóstico. Rev UNINGÁ Rev 2016; 25(3):25-30..

Disclosing an STI to partners will not always interfere with the marital relationship, and, in many cases, understanding this condition contributes to the partners’ perception regarding the need for care¹⁵15 Busnello GF, Hoff GA, Kolhs M, Frigo J, Zanotelli SS. Infecção pelo papiloma vírus: conhecimento das mulheres infectadas frente ao diagnóstico. Rev UNINGÁ Rev 2016; 25(3):25-30.. There is an agreement with this investigation since two young women preserved their relationships harmoniously (J3 and J5) and others (J1 and J2). Despite the negative impact, they shared the diagnosis with their partners and submitted to the treatment.

Another explicit weakness concerns the difficulty in establishing dialogue and sharing the events experienced with people close to them. J1 is not accustomed to talking to her mother about specific subjects. At the same time, J5 feels uncomfortable sharing with her partner’s family members the situation of illness due to an STI/syphilis. The abovementioned can be interpreted as fear of the family members’ reaction. The concern about facing “assigned classifications” and not being accepted are reported reasons for the omission of many women regarding this condition in their social environment¹⁶16 Fernandes MA, Bezerra MM, Moura FMJSP, Alencar NES, Lima FFF, Castro AED. Infecções sexualmente transmissíveis e as vivências de mulheres em situação de reclusão. Rev Enferm UERJ 2016; 24(6):e27774..

We should point out the young women’s distant relationships with members of the extended family and those of closeness and union. Wright and Leahey¹¹11 Wright LM, Leahey M. Enfermeiras e famílias: um guia para avaliação e intervenção na família. 5ª ed. São Paulo: Roca; 2012. underscore that the existing links between its components are not always perceived, but they are influential forces in the family structure and independent of geographic distances.

We identified a restricted network of broad systems (J1). However, for the most part, this consisted of many community institutions and people outside the family (J2, J3, J4, J5, and J6). Close/strong, harmonious, very strong, severed, and distant/weak relationships stood out.

The close relationship with the nurse who accompanied the prenatal care was significant (J1, J6). In the nursing appointment, the young woman is received and, at this stage, techniques and procedures must exceed the biologicist nature to create bonds and establish a relationship of trust with the pregnant woman and her family, which contributes to the dialogue, and when there is a diagnosis of syphilis, to guidance on treatment, finding partners, and perform follow-up tests with to prevent congenital syphilis¹⁷17 Nunes JT, Marinho ACV, Davim RMB, Silva GGO, Felix RS, Martino MMF. Sífilis na gestação: perspectivas e condutas do enfermeiro. Rev Enferm UFPE 2017; 11(12):4875-4884..

The relationship with the health units was classified as distant/weak. There was a rare contact with the UBS, and the search happened mainly in case of illness in the family. This limited relationship was also evidenced in a study where pregnant adolescents had weakened relationships with health units and lacked interest in attending these places and establishing a bond¹⁸18 Lago PN, Sousa AAS, Rodrigues DPR, Siva MRF, Mesquita NS. A atenção primária em saúde como fonte de apoio social a gestantes adolescentes. Enferm Bras 2019; 18(1):75-84.^,1919 Pillay S, Tooke LJ. Symptomatic congenital syphilis in a tertiary neonatal unit in Cape Town, South Africa: High morbidity and mortality in a preventable disease. S Afr Med J 2019; 109(9):652-658..

However, despite the weak link with the UBS, they have emerged as a reference for young women in health care during pregnancy, the puerperium, and monitoring of gestational syphilis and congenital syphilis, and follow-up after treating these diseases.

Social support was and, in this study, occurred during the gestational period, childbirth, in the puerperium, and after the diagnosis of syphilis, translating into support in prenatal care, the treatment of syphilis, performing household chores, and caring for the children. The network also found weaknesses, while a lack of support was reported.

The partners supported in the prenatal care and performing tests when requested during pregnancy. In other studies, the partner’s role as an active participant in the support network emerged as a crucial figure when interacting positively with the pregnancy²⁰20 Matos GC, Soares MC, Escobal APL, Quadro PP, Rodrigues JB. Rede de apoio familiar à gravidez e ao parto na adolescência: uma abordagem moscoviciana. J Nurs Health 2019; 9(1):e199106..

Partners were influential in other moments related to motherhood. In this sense, the paternal role extends to caring for the children, such as preparing food, changing diapers, and bathing, as revealed in the young women’s statements. We observed the effective participation of parents in the care of newborn children. We stress that, in many settings, partners are the only or main reference of the puerperae in their home lives²¹21 Silva EM, Marcolino E, Ganassin GS, Santos AL, Marcon SS. Participação do companheiro nos cuidados do binômio mãe e filho: percepção de puérperas. J Res Fundam Care 2016; 8(1):3991-4003..

Among the support relationships subsidized by other women, the young women indicated, as elements, the friends, the nurse, and the health unit’s ACS, also reported in the literature that identified that the representations of the social support network of pregnant adolescents consisted notably of a female character, including family members and external people²²22 Demori CC, Soares MC, Cremonese L, Barreto NB. De mulheres para mulheres: rede social de apoio às adolescentes grávidas. Rev Enferm UFSM 2018; 8(2):247-262. in this field.

In a study carried out with adolescents, the health unit represented by the professionals was a place of social support¹⁸18 Lago PN, Sousa AAS, Rodrigues DPR, Siva MRF, Mesquita NS. A atenção primária em saúde como fonte de apoio social a gestantes adolescentes. Enferm Bras 2019; 18(1):75-84.. However, they also revealed that the support provided by the health service was restricted to biomedical care, with no deepening of social and psychological issues, so essential in the motherhood process¹⁸18 Lago PN, Sousa AAS, Rodrigues DPR, Siva MRF, Mesquita NS. A atenção primária em saúde como fonte de apoio social a gestantes adolescentes. Enferm Bras 2019; 18(1):75-84..

The social network was fundamental in supporting young women after the discovery of syphilis. Family members offered emotional support, reassuring women at diagnosis and seeking information about the disease. A friend of one of the participants guided her to understand what syphilis is, the partners underwent treatment, and health professionals aided according to the established protocols.

Support from family members at this time can help women overcome the challenging experience of having an STI. They recognize that they need this support to share the test result and ease their anxieties and doubts regarding the situation, understand her feelings, and adhere to treatment and follow-up²³23 Silva VST. Os (Des)caminhos da sífilis congênita no município de Botucatu, São Paulo [dissertação]. Botucatu: Universidade Estadual Paulista; 2016..

The diverse cases studied were also related to the quality of relationships and support within the young mothers’ networks. Thus, the lack of support from the social network was also identified in some young women’s statements and justified by the father figure’s non-acceptance of the pregnancy, the geographical distance from the family of origin, and because its members already have their responsibilities of work, home care, and with their own families, which hindered any attempt to offer the necessary help.

Premature pregnancy can lead to social abandonment, such as by family and partners. An investigation with adolescents found the fragility of the family support network, which resulted in representations of pregnancy and childbirth based on loneliness, insecurity, and fear of experiencing the process²¹21 Silva EM, Marcolino E, Ganassin GS, Santos AL, Marcon SS. Participação do companheiro nos cuidados do binômio mãe e filho: percepção de puérperas. J Res Fundam Care 2016; 8(1):3991-4003..

In this regard, we should note the probability of an individual participating in a social network and not receiving social support or thinking that they do not receive it since this is associated with interactions that are perceived as positive; that is, they represent qualitative aspects of relationships, thus, of a subjective nature. As a result, individuals should identify the resources available on the network²⁴24 Nunes TGR, Pontes FAR, Silva I. Juventude e apoio social: um olhar sobre as redes sociais de estudantes paraenses. Praxis Educ 2019; 15:e20135341-21..

Final considerations

The social networks were diversified and, in general, characterized as broad. The social support was satisfactory. Interpersonal relationships were heterogeneous, and the most significant for the young women were those that represented strong affective bonds and support and those that revealed conflicts and lack of support.

Normal, close, harmonious, severed, distant, and indifferent relationships stood out with the broader systems. We highlight a weakened bond with the health units, the social and emotional support to young women after the diagnosis of syphilis, and the impact of this disease on the social network, especially concerning marital relationships. Moreover, we observed the limited role played by some families regarding the support to the mother-child binomial, which can contribute to fear and insecurity in the maternity process and illness.

The limitations of this study focus on the fact that only one member of the family core was approached, hampering the perception of this network and its relationships from another viewpoint. Listening to the other elements would be necessary for deepening the established social relationships, the existing resources to address issues, and the available community support.

We consider that the vertical transmission of syphilis is permeated by singularities that can be identified from understanding the context that involves social networks, interpersonal relationships, and social support of mothers and their children. These results can sustain strategies to control congenital syphilis and reinforce the need for further investigations considering these subjectivities.

References

Publication Dates

History