The Experience of Mothers Caring for Their Teenage Daughters' Young Children

The purpose of this study was firstly to explore and describe the experiences of mothers who are looking after their teenage daughters' young children. Secondly, to formulate guidelines (based on the results obtained) for psychiatric nurses in assisting these mothers to mobilise resources in order to promote, maintain and restore their mental health as an integral part of health. An exploratory, descriptive, contextual and qualitative design was used and Guba's model for ensuring trust­ worthiness in qualitative research was applied. The phenomenological approach was used to collect and analyse data from a sample of seven respondents who were purposively selected. Three independent themes emerged from the analysis of results: Meaning of the parenting role, lifestyle changes and support systems. The results further show that for these mothers the problem of teenage pregnancy and parenthood ends up being their problem. Their experiences in looking after these babies, although sometimes fulfilling and meaningful, are most of the time stressful. This has implications on their mental health. Guidelines are recommended in order to facilitate these mothers to mobilise their resources for mental health. "Teenage pregnancy and parenthood continue to haunt modern society into the 1990's. This is despite the availability of modern and effective technology for birth control/' Opsomming Die doel van hierdie studie was eerstens om die belewenis van moeders wat die jong kinders van hul tienerjarige dogters oppas, te ondersoek en beskryf. Tweedens om riglyne te beskryf (gegrond op die verkreë bevind ing s) vir psigiatriese verpleegkundiges om hierdie moeders te help om bronne te mobiliseer ten einde hul geestesgesondheid te bevorder, te handhaaf en te herstel as 'n integrale deel van gesondheid. 'n Verkennende, beskrywende, kontekstuele en kwalitatiewe ontwerp is gebruik, en Guba se model om vertrouenswaardigheid in kwalitatiewe navorsing to verseker, is aangewend. 'n Fenomenologiese strategie is gebruik om data van 'n steekproef van sewe respondente wat doelgerig gekies is, te versamel en te verwerk. Drie onhafhanklike temas het by die analise van gegewens na vore g etree : B e te ken is van die o u e rs k a p ro l, v e ra n d e rin g e in die le w e n styl en ondersteuningstelsels. Verder toon die resultate dat die probleem van tiener swangerskap en-ouerskap uiteindelik in die skoot van die tiener se moeder val. Hul belewenis van die versorging van hierdie babas, alhoewel soms vervullend, is meestal stresvol. Riglyne …


Introduction
Teenage pregnancy and parenthood continue to haunt modern society into the 1990's.This is despite the availabil ity of modern and effective technology for birth control.While the situation applies to both de veloped and developing countries, it is the latter countries that are hit the hard est (Ojwang & Maggwa, 1991:74).In African countries the rate of teenage pregnancy ranges between 10.5 to 51 per cent (Kooma in Sowetan, 1992:15).In South Africa there is also evidence that teenage pregnancy has taken on alarm ing proportions, particularly among col oured and Black communities (Preston-Whyte, 1991:7).A lot has been written on the problems associated with early childbearing.One of these problems is that the teenage mother, for one reason or another, is unable to play a parenting role.The onus then falls on the mother or mother figure to the teenage mother (particularly a m o ng B la cks) to ta ke o ver th is p a re n tin g role (B urm an & P reston-Whyte, 1992:231).
Research on the problems of teenage pregnancy and parenthood tended to focus solely on the teenage mother and her child(ren).The mother of the teen age mother is seldom focused on.This, despite her daily involvement in bring ing up her te e n a g e d a u g h te r's child (ren).The result of this systematic omission by researchers and the popular media, is the absence of m others of teenage 62 Curationis September 2000 m others as a target group in mental health care programmes.This despite the fact that studies have indicated a re lationship between parenting of young c h ild re n and stress (B e au tra is, Fergusson & Shannon, 1982;Baltenski & Cook, 1982;Boulton, 1983).This evidence from literature raised the following research questions:

^
How do mothers in a certain vil lage in the Molope region experience looking after their teenage daughters' young children while these daughters pursue their developmental tasks?

^
What guidelines can be devel oped by an advanced psychiatric nurse practitioner for a support pro gramme for these mothers in order to assist them to mobilise resources to facilitate the promotion, maintenance and restoration of their mental health as integral part of health?

Purpose And fram ew ork
The purpose of this study was firstly to explore and describe the experiences of mothers who have to take care of the young children of their teenage daugh ters; secondly to describe guidelines for the advanced psychiatric nurse practi tioner to assist these mothers in mobi lising their resources to facilitate the pro motion, maintenance and restoration of their mental health.The Nursing for the Whole Person Theory was used as theo retical framework to reflect the results obtained from the research (Oral Roberts University, 1990-1992:136-142, Rand Afrikaans U niversity: D epartm ent of N ursing Science, 1992:36-41).This th e o ry view s the te e n a g e r and the mother of the teenager as spiritual be ings who function in an integrated bio psychosocial manner to achieve their quest for mental health (wholeness) by the mobilisation of resources.
Both their environments consist of inter acting dimensions, namely physical, so cial and spiritual, which determine their health status.Physical dimension refers to all bio-physio-chem ical processes.Psychological dimension refers to the carrier of all experience and behaviour and it includes all intellectual, emotional and volitional processes.Social dimen sion refers to the organisational struc tures among people and communities, in other words all human resources.The spiritual dimension refers to significant spiritual elements or occurrences in the

Reflexibility
Taking field notes.

Member checking
Follow-up interviews with participants.Literature control on parenting, its impact on guidelines.

Peer examination
The services of a colleague will be acquired.

Authority of research
The researcher has undergone previous training in research methods.Two doctors in psychiatric nursing, who have experi ence in research supervised this study.

Structural coherence
The focus will be on mothers' experiences.Results will be within Nursing for the Whole Person Theory.

Nominated sample
The sampling method will be purposive, no.prior selection.

Dense description
Complete design of methodology and literature control to main tain 'transparency'.
teenager and her m other's environ ment, which includes values, beliefs, norms and ethical principles, religion and meaning in life as well as relation ships with others and God.
The data gathered during the study is also reflected within this theoreti cal framework.

Research Methodology
An exploratory, descriptive and con textual design was utilised (Mouton & Marais, 1990:43-44;Burns & Grove, 1993:29).The research was con ducted in two phases.In phase I ind e p th , s e m i-s tru c tu re d phenom enological interviews were utilised to interview mothers of teen age daughters.A literature control was done to verify the results.Phase I provided the basis for deduction of guidelines and phase II consisted of the description of guidelines for the advanced psychiatric nurse to sup port these mothers in mobilising their resources in order promote their men tal health.These were also verified by conducting a literature control and discussing these guidelines with ad vanced psychiatric nurse practition ers.

Data collection
Data was c o lle c te d th ro u g h p h e n o m enological, semi-structured in-depth interview s, using a tape recorder to record the interviews (Burns & Grove, 1 99 3:5 7 8-58 1; M in ic h ie llo , A ro n i, Tim ewell & Alexander, 1991:87-129).The aim of these interviews is to allow the participants to speak freely and "in their own terms" about a set of concerns (Ferreira in Mouton & Marais, 1990:212).
The participants were visited in their homes at least twice before data collec tion.The first visit was to obtain informed consent and to build rapport.The sec ond visit was again to build rapport and to arrange a date for data collection.A few participants were visited again dur ing data analysis for the purpose of vali dating some of the interpretations made by the researcher.A central question was asked: "Please tell me how you experience looking after your teenage daughter's young children".The researcher used facili tating communication techniques such as minimal response, clarification and re phrasing to encourage the mothers to speak openly and freely about their ex periences (Minichiello et al. 1991: 167-131).The interviews were audiotaped and later transcribed verbatim.The re searcher made field notes following the interviews to describe her own observa tions and experiences during the inter view (Minichiello et al. 1991:256). andTesch's (in Creswell, 1994:153) de scriptive methods of data analysis were used.In addition, the processes of bracketing (suspending preconceived ide as a b o u t the e x p e rie n ce s of parenting) and intuiting (focusing on the description given by the respondents) as su gg este d by S p ie lb e rg (in Ornery, 1983:53) were applied.The steps fol lowed in data analysis were: reading through all the transcripts carefully in order to get a sense of the whole; pick ing any transcript, reading through it, jotting down some ideas as they come to mind and also identifying the major c a te g o rie s re p re se n te d in the universum; reading through all the tran scripts while underlining units of mean ing related to the identified major catego ries; putting the units of meaning into m ajor categories; identifying sub-cat egories w ithin the m ajor categories; identifying relationships among the ma jo r and sub-categories then reflecting these as themes.A consensus discussion was then held with an independent coder (who is an advanced psychiatric nurse and also has experience of qualitative research).A lit erature control was conducted to iden tify the similarities and differences be tween this study and previous research.Results were then reflected as patterns of interaction in the respondent's envi ronment within the Nursing for the Whole Person Theory (Oral Roberts University, 1990-1992:136-142, Rand Afrikaans Uni versity: Department of Nursing Science, 1992:36-41).

Results and Discussion of Results
The three main themes that emerged from the respondents' accounts of their e xpe rie nce s w ere: M eaning of the parenting role, life-style changes and support systems.These themes were further categorised and sub-categorised as depicted in Table 2.

* Meaning of the Parenting Role
Two major categories emerged from this theme: (i) parenting as a stressor, and (ii) parenting as doing one's duty.

(i)
Parenting as a Stressor All seven respondents expressed dis tress in looking after the young children of their teenage daughters.The realisa tion that looking after young children is stressful is supported in the literature (Brailey, 1985:47;G ordon, 1990:57;Kamerman, 1980:128;Leifer, 1980:230;Liddell, 1989:134-143;Stern, 1989: The village in w hich these re spondents stay is 45 kilom etres from town.According to Puskar & Martsolf (in Fawcett, 1993:212), rural areas are known for their lack of specialised health care services, transportation problems, poverty and high unemployment.The lack of specialised health care services and transport was apparent from field notes.All seven respondents utilise the local clinic for health care needs.Treat ment for children under five years of age and the aged is free.However, four re spondents stated that the help they get from the clinic is not always enough for meeting their health needs.They some times have to pay for transport to get to hospital.They also have to pay private doctors.At other times they use tradi tional doctors and have to pay for an cestral rituals additionally.
One respondent said: "Last time I had to pay R250 for traditional health con sultation."Another one said; "I had to slaughter a goat for the ancestral heal ing for the baby's sickness." Traditional and folklore medicine is still considered a va lu e d p ra c tic e a m o n g B la cks (Tshotsho, 1994:24-25).Indigenous healing beliefs and practices still form a core part of culture even among Black Americans (Wilson & Kneis, 1992:917).

(b)
The question of income and em ployment is another factor impinging on the financial burden experienced by these mothers.Figley, 1983:56).

(ii) Parenting as Doing One's Duty
All seven respondents expressed this theme.They see the role of taking over the paren ting role fo r th e ir teenage daughters as a given or as a natural con sequence.This brings in a normative aspect to the practice of childcare.In our society the duty of raising young children is a wom an's responsibility.Several authors al lude to the 'gendering of responsibility' fo r ch ild care in our so cie ty (H ollen, 1982:309;Unger & Crawford, 1992:424;Kamerman, 1980:66;Gordon, 1990:49;Boulton, 1983:22).
Referring to the 'motherhood mystique', Unger & Crawford (1992:431) assert that in our society "being a mother is the ulti mate fulfilment for a woman".It is there fore not surprising that these women seem not to question this added role.
The three subcategories that emerged under the category of " parenting as do ing one's duty" are: a sense of fulfilment, mother-child attachment and motivation 65 Curationis September 2000

* Life Style Changes
This is a second independent them e emerging from the respondents' experi ences.This theme was categorised as: (i) a sense of being trapped; (ii) accept ing less than an ideal standard of life, and (iii) job reorganisation.

(i)
A Sense of Being Trapped Six of the respondents expressed a sense of being trapped in one way or another.This sense is conveyed in the following account:

"I 'm cut off from my friends. My life is restricted a lot. Let's say I want to go and visit my friends and enjoy a bit, I can't. Maybe some times one of your friends has a party. You are sitting there and drinking cold things. Som etim es you drink and drink. The next thing when you come home, there is no cooked food. So it means I have to be here all the time."
Other areas in which respondents felt restricted were: attending church serv ices (2); time to visit boyfriend (1); going to town (3) and being with other people (3).

Curationis September 2000
This sense of being tied to the home was also mentioned by mothers in a study of w om en w ith p re -s c h o o l ch ild re n (Boulton, 1983:91).Lack of freedom for yourself, lack of time with spouse and lack of time with other adults were men tio n e d by w om en in W e inb erg and Richardson 's study (1981:689).

(ii) Accepting less than an ideal stand ard o f life
Three respondents complained of this change in their life-style.This is because all available resources had to be re channelled towards childcare.(1990:74), women reported the follow ing : "not having time to tackle big projects around the house as much as they would like to and not being able to spend as they would like to." (ii) Job reorganisation Four of the respondents had to re-organise their jobs in order to accommodate the young children into their daily work schedule.One changed from day to night duty.Two had to leave paid em ployment.
Weinberg & Richardson (1984:686) as sert that "the birth o f a ch ild encom passes a range of experiences over time, including ... the concom itant need for parents to reorganise their ongoing life structure regarding simple life mainte nance, s o c ia l co n ta cts and jo b d e mands." • Support systems This is the third theme that emerged from the respondents' experiences.It was categorised into types and sources of support received by respondents while looking after their teenage daughters' young children (see Table 3).
Types of support received were further categorised into: (i) financial and mate rial aid; (ii) health care and family plan n in g; (iii) p h y s ic a l a ssista n ce ; (iv) strength and sustenance and (v) conflict resolution.
(i) Financial and material aid All seven respondents raised financial concerns.These were discussed under the section on financial distress.From Table 3, it seems that other children in the family are the major source of sup port.
One respondent had this to say regard ing this form of support: "It's difficult because even this child who gives me money gets very little salary.His job is also not stable .

.. My mother also is not on pension ... I 'm not working. "
Noted by its absence is support by the ch ild 's father.Four of the teenagers' boyfriends are still attending school.Of the nine teenage mothers in this study, only five boyfriends admitted responsi bility for fathering the children.

(ii) Health care support
According to Table 3, the most men tioned source of health care support and family planning is the local clinic.How ever, as already mentioned, this is sel dom enough.

(iii) Physical assistance
Again, respondents rely on other chil dren in the family for this assistance.This assistance comes randomly rather than being enduring.Such assistance de pends on the availability and willingness of the other children.One elderly re spondent who is looking after four young children, said; "Today this one is sick, I have to take him to the clinic.Then it's another one ..

. I have to look after the baby, too. When I ask the two boys to stay away from school to help me, they refuse."
Noted by their absence in rendering sup port are the husbands.In research done elsewhere, however, women mentioned husbands as their major source of sup port in daily childcare (Hollen, 1982:309;Kamerman, 1980:108).In another study (W einberg & R ichardson, 1981:689), women reported problems with sharing responsibilities of child care with their spouses as one of the fourteen dimen sions of stress in raising small children.This is a matter of concern on the part of Black women in this part of the country.

(iv) Strength and sustenance
Four respondents mentioned relying on God when the going becam e tough.One respondent said; "It was difficult ... It was dark.Today this baby has grown.All because of God."This sug gests that even though the respondents experience difficulties, they are still able to transcend their situation.

(v) Conflict resolution
Several areas of conflict emerged from the respondents' accounts: • Teenage mother for not doing her part in caring for her own child, contributing to the child's ill-health through engag-67 Curationis September 2000 ing in prescribed acts, disregarding pa rental advice, manipulative behaviour and becoming too attached to the baby.
• The boy's parents for not rendering material support.
• The baby's father for failing to show parental responsibility.
• Husbands for not rendering financial assistance.
• The respondents' in-laws for interfer ence.
• Supportive neighbours for becoming, in turn, an added burden.
Although all seven respondents admit ted to experiencing conflict at times, only three mentioned dealing with it.The rest seem to avoid dealing with it at all.An other interesting observation is that all the respondents seem to expect from their husbands is financial-, not physical assistance.

Conclusions and Recommendations in the form of Guidelines
The results of this study show that the respondents require assistance from the formal and informal health care delivery systems.In fact, in the village in which the study was undertaken, nurses are the only formal group of health care pro fessionals.Nurses also form the largest group of health care providers in South Africa.For this reason, they can contrib ute significantly to the promotion, main tenance and restoration of the mental health of mothers who take care of their teenage daughters' young children.It is usually the teenager's mother who ends up taking over the parental role of her grandchild.In addition to the de mands associated with the developmen tal tasks appropriate for her stage of development, she now also has to face childcare demands.These dem ands influence the patterns of interaction be tween the internal and external environ m ent of th e m o th e r of th e te en ag e mother, who fulfils the parental role in respect of the teenager's child.Depend ing on this pattern of interaction, the mother can experience either a sense of fulfilm ent or distress (physical, mental and spiritual).The whole process in Figure 4.1 is dy namic and cyclic.This means that one strategy can influence many areas in the Similarly, each strategy can be used in conjunction with other strategies.For example, the holistic approach can be used as a stra te g y in w o rk in g w ith groups as a means of competence build ing.In addition, the strategies can be applied at any level of promotion, main tenance and restoration of mental health as an integral part of health.These strat egies will now be briefly discussed.

* Holistic approach to nursing prac tice
In the im plem entation of the nursing process, the nurse can use a theory that considers a client in totality, that is body, mind and spirit as well as the external environment and patterns of interaction between the internal and external envi ronment.An example of such a theory is the N ursing fo r the W hole Person Theory (Oral Roberts University: Anna V aughn S c h o o l o f N u rs in g , 1990-1992:136-142, Rand Afrikaans Univer sity: Department of Nursing Science, 1992:36-41).
A client-centred approach is used so that the nurse-client interaction is negotiated and the nurse attempts to understand the client's explanatory model of health and illness (Wilson & Kneisl, 1992:960).This is important as folk medicine was frequently utilised by respondents in this study.

• Competence building
This is a strategy that seeks to (i) in crease the individual's or group's aware ness of issues and events related to health and illness; (ii) increase in one's understanding of the dimensions of po tential stressors, possible outcomes and alternative methods of doing things; and (iii) increase one's knowledge of where and how to acquire the necessary re sources (Stuart & Sundeen, 1991:257).
Methods that can be used for com pe tence building are: • education regarding stressors asso ciated with parenting; • cost-saving measures, such as nutri tious yet low-cost baby foods, market ing of second-hand baby clothes, the practice of breast-milk expression, tend ing door-size vegetable gardens and anticipatory guidance about the needs of infants, toddlers and pre-school chil dren (Liddell, 1989, chapters 11-13).

• Group work
The nurse organizes groups of women who are taking a parental role in the lives of the young children of teenage moth ers.The aims are: (i) to maximize the impact the nurse can make; (ii) to pro vide an opportunity for group partici pants to share experiences, discuss common problems, share solutions, ex press emotional distress and reduce iso lation and loneliness expressed by re s p o n d e n ts in his stu d y (K u ip ers & Bebbington, 1990:55).

• Effective referral system
The nurse should establish a network and keep a file of names and addresses of all potential resourceful persons, such as psychiatric nursing specialists and consultants, agencies and organizations in the region, province and country.When the need arises, the mothers who are taking care of their teenage daugh ters' young children can be referred to these persons, agencies or organiza tions for support.

* Domiciliary care
Wherever possible, nurses should make home visits to mothers who are taking care of their teenage daughters' young children.This is important because some of the respondents in this study are eld erly and sickly and, therefore, may not benefit from group work.The main ob jective here is to increase contact be tween the client and the health care sys tem, and to reduce isolation.During home visits, the nurse can conduct edu cation sessions, monitor the health of the family system, and hold family problem solving sessions (Kuipers & Bebbington, 1990:67).

• Advocacy
The nurse can stimulate community ac tion as well as influence governm ent action by playing an advocacy role on behalf of mothers of teenage mothers.
The objectives are to make society aware of its responsibility in respect of teenage pregnancy and parenting, by impress ing upon it the impact thereof on the mental health of mothers of teenagers; to change com m unity attitudes about child-rearing practices and to inform women about their rights.
The nurse and women can make repre sentations to the Reconstruction and Development Program (RDP) forum in their village regarding the needs of moth ering.The need for child care facilities, such as publicly subsidized day care centers and public school-based kinder garten and preschools.This will leave mothers free to follow their developmental tasks appropriate to their stage of development and the necessary time off to rest.
Since respondents in this study derive a sense of fulfillment from the parenting role, a partnership can be formed be tween a publicly subsidized child care system where they can form a group of child minders and be paid for part of their services in cash or in kind.The nurse can also press fo r representation of this group of mothers in the RDP forums.
The nurse can play an advocacy role by pleading with the system, arguing and recommending a change that will ben e fit th e c lie n ts (L e d d y & Pepper, 1989:379).One way of changing the sys tem is to advocate for a team of mental health nursing specialists, m ultidisci plinary teams and private doctors to visit the village on a weekly basis (Fawcett, 1993:219).
• Anticipatory guidance C o n d u c tin g a n tic ip a to ry g u id a n c e classes for pregnant teenagers can also help their mothers indirectly.One of the areas that caused co nflict for the re spondents in this study was the teenage m others' lack of parenting skill.The mothers of teenagers can also benefit from these classes, as it will enable them to anticipate likely problems and develop solutions before their teenage daughters become pregnant.

Conclusions
This study arose from three observa tions.Firstly, that in m ost cases and amongst Blacks in particular, the young c h ild re n o f te e n a g e m o th e rs are parented by their grandmothers.This has become necessary to allow the teen age daughter to become equipped for a career/education.The second observation is the absence of program s to support these grand mothers in the stressful role of parenting.Perhaps this can be attributed to the assumption that grandmothers are ex perienced parents.Related to this lack of program s for grandm others is the third observation, namely the apparent lack of research studies on grandmoth ers as a target group, as well as silence on the part of the popular media.
One re s p o n d e n t said: "Things cam e to a standstill... My building project had to stop as the little money available now goes to caring for this baby." In a study of women's perceptions of their current life circumstances since the arrival of a new b ab y by E ck e n ro d e & G ore

Figure 4 .
Figure 4.1 elicits how the advanced psy chiatric nurse can assist mothers to mo bilise resources in taking care of their teenage daughters' young children, by taking a holistic approach.

Figure
Figure 4.1 : Psychiatric Nurses' assistance of mothers looking after teenage daughters' young children

Table 1 : Strategies to ensure trustworthiness*
Initially spend time with respondent before interview to build rapport.Again allow time for respondent to verbalise experiences.

My life is difficult ... the way this child (teenage mother) burdens me with her child ... A child needs a lot of things, food, clothing, e tc .... My husband gets pension, but I don't know what he does with this money. "
158;  Tam & Chan, 1994:212; Valman, 1993:3).The distress experienced by respond ents was further categorised as: finan cial, physical and emotional-spiritual.

Sometimes I have to carry her on my back in order to do housework ... today this one is sick, tomorrow is another one ... by night time I 'm so tired ... my body is sore and I can 't sleep." Physical
Only one respondent in this study works for a salary, only two have working husbands, only one is get ting old-age pension (although three qualify).The rest live in abject poverty.Other writers have also alluded to the fe m in is a tio n o f p o v e rty (U n g e r &Crawford, 1984:456; Washington in Birns  & Hay, 1988:206).

If she can't look after this baby. After all, I, too, did not raise my first child ...m y mother did it. She will be wiser with h er second child." one
"It's alright respondent said.Another one said; "

Her mother left her when she was a small, little, frail thing. I struggled to raise her. God was with me. Look at her tod ay... I 've made it."
sense of pride and fulfilment.One re spondent said: "Oh, this child is mine.She has nothing to do with the mother ... she is mine." In certain cases bond ing between the child and the biological m o th e r w as a c tu a lly d is c o u ra g e d ."What happens if she gets married by another man ... This child is m ine." another respondent said.

The mother is such a fool. You can't risk leaving the baby with her ... she can't even feed her properly. The other day the baby drank
paraffin..." Deficiency of parenting skills on the part of the teenage mothers has been high lig h te d in the lite ra tu re (Loening in Burm an and P re ston -W hyte, 1981; Sommer, W hitm an, B orkow ski et al, 1993:391; B ro o k s -G u n n & C hase-Lansdale, 1991:471.