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Adolescent Pregnancy in Nicaragua: an Emic Perspective of Structural Influences

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Adolescent Pregnancy in Nicaragua: an Emic Perspective of Structural Influences Adolescent Pregnancy in Nicaragua: An Emic Perspective of Structural Influences Dissertation Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy in the Graduate School of The Ohio State University By Maryanne Bernadette Tranter, MS Graduate Program in Nursing The Ohio State University 2019 Dissertation Committee Rita Pickler, Ph.D., Advisor Barbara Piperata, Ph.D. Jennifer Kue, Ph.D. Copyrighted by Maryanne Bernadette Tranter 2019 2 Abstract Adolescent girls in Nicaragua are at risk for early pregnancy and motherhood and their infants are at greater risk for prematurity, low birth weight, child abuse and neglect, and poverty. Few studies specifically address the role cultural and societal values play in Latin America regarding adolescent pregnancy. However, researchers have identified critical cultural and social factors that were further explored in this study. Additionally, this study aimed to uncover new factors related to cultural values that may be important to the occurrence of adolescent pregnancy. The purposes of this qualitative study were to increase understanding of adolescent girls’ perspectives on motherhood and reveal perceived health determinants that contribute to adolescent pregnancy in Nicaragua. Based in Jinotega, Nicaragua where the adolescent pregnancy rates are among the highest in the country, data were collected using three qualitative approaches: a visual ethnography with photovoice, semi-structured interviews, and participant observation. Purposeful sampling for the ethnographic photovoice groups yielded 12 adolescents, one group with rural mothers 15-20 years old and one group with rural, never pregnant 18-20 year olds. The interview sample included 25 rural pregnant adolescents ages 15-20 years at the Casa Materna in Jinotega, a facility for pregnant teens located near the delivery hospital. Observations of places and events common in the lives of adolescent females occurred throughout the study with a focus on examples of machismo, marianismo, religion, and familismo. Data were analyzed for themes using a combined content analysis approach. Six themes were constructed from the data: (a) la maternidad es amor (motherhood is love), (b) la maternidad es responsibilidad (motherhood is responsibility), (c) machismo, (d) familismo, (e) personal agency, and (d) emotional isolation. The results of this study may be used to inform ii future interventions designed to reduce the adolescent pregnancy rate and improve the lives of adolescent girls and their children in Nicaragua. iii Dedication For my children, Sydney and Ethan, the adolescent girls in Nicaragua, and those who believed in me. iv Acknowledgments This dissertation would never have happened without the incredible guidance and input from my dissertation committee and collaborators or the love and support from my family and friends. First, I am enormously grateful to Drs. Pickler, Piperata, and Kue, my dissertation committee members for their continued guidance and support. Their expertise, insight, wisdom, and understanding throughout this journey helped me through the challenges and rewards of conducting qualitative research in a foreign country with pregnant adolescents. They have set an example for excellence and mentorship I will strive to follow. I am also appreciative of Drs. Laureen Smith, Jodi Ford, and Kim Arcoleo who were a part of my committee in the early stages of this research. Many thanks to the collaborators in Nicaragua and in particular to Jeorlin Mateez, my assistant nurse researcher in Nicaragua. She assisted and facilitated work with research participants thus allowing us to connect and speak with these girls to hear their voices. She also provided editorial assistance in checking the accuracy of the transcripts. I thank Drs. Andrés Herrera Rodríguez and William Ugarte Guevara from UNAN-CIDS for their expertise and guidance. I thank Dr. Magda Castrillo and Nurse Perla Zeledon for their help with translations, transcriptions, and perspectives. To Francisco Martínez Cubillo for his help getting settled and connected in Jinotega. I am grateful to Comunidad Connect, Nerys Blandon, and all the community health care workers of Los Robles who welcomed me into the community and provided strategic assistance in finding research participants. v This research could not have been completed without the financial support from Sigma Theta Tau Epsilon Chapter, the Ohio NAPNAP foundation, Meijer, and the over 100 people who donated to the research. Your goals in advancing nursing knowledge and giving a voice to these girls are evident through your research grant awards and donations used to facilitate this dissertation work. My friends and family have been a constant source of encouragement. Thank you to Leo Rivas for your patience, logistic support through each stage of the process in Nicaragua, and the inspiration to share the stories of these girls. Thank you to the Mak family for opening your home and hearts allowing the completion of this work. Thanks to my coworkers at Nationwide Children's Hospital, my Ph.D. peers, and friends for sharing the ups and downs of this process. I appreciate all of the people who encouraged me to begin this work, including Jeremy Carroll who is a constant support to our children. Thank you to my parents and siblings who continue to believe in me. Thank you to my children, Sydney and Ethan, for your love and understanding through all of your adolescent years that I worked on this degree. Finally, thank you to Barbara who was able to inspire and validate me while keeping professional and personal boundaries over a 9-year relationship; I am indebted. vi Vita 1994 B.S. Nursing, The Ohio State University 1997 M. S. Nursing, The Ohio State University 2002 – Present Nurse Practitioner, Nationwide Children's Hospital 2007 – 2011 Instructor, The Ohio State University 2011 – 2015 Graduate Teaching Associate, The Ohio State University Presentations at Professional Meetings “Adolescent Pregnancy in Nicaragua and Structural Violence.” Society for Applied Anthropology 74th Annual Meeting with co-sponsor Council of Nurse Anthropologists in Albuquerque, March 18-22, 2014. “A Five-Step Approach to Evaluating Research for Clinical Decision-Making.” Poster presentation with Nancy Ryan-Wenger, PhD, RN, CPNP, FAAN; Society of Pediatric Nurses Annual Conference, Nashville, TN, April 11-14, 2013. “Dietary patterns of rural children living in food insecure households in the Brazilian Amazon.” Poster presentation with Barbara Piperata, PhD; 2013 Human Biology Association Annual Meeting, Knoxville, TN, April 10-11, 2013. Fields of Study Major Field: Nursing Cognate: Anthropology Specialization: Global Health vii Table of Contents Abstract ........................................................................................................................................... ii Dedication ...................................................................................................................................... iv Acknowledgments........................................................................................................................... v Vita ................................................................................................................................................ vii Table of Contents ......................................................................................................................... viii List of Tables ................................................................................................................................ xii List of Figures .............................................................................................................................. xiii Chapter 1. Introduction ................................................................................................................... 1 Adolescent Pregnancy Rates ....................................................................................................... 1 Purpose ........................................................................................................................................ 3 Social Determinants .................................................................................................................... 4 General Study Aims .................................................................................................................... 5 Conceptual Framework ............................................................................................................... 5 How to Fill the Gap..................................................................................................................... 8 Research Aims and Questions .................................................................................................... 9 Summary ................................................................................................................................... 11 Chapter 2. Literature Review ........................................................................................................ 13 viii Known Social Determinants: A Review and Critique of Studies of Adolescent Pregnancy .... 13 Brief History of Nicaragua ........................................................................................................ 14 1910s-1980s. ......................................................................................................................... 14 1980s. ...................................................................................................................................
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